REHABILITATION

OF THE SPINE
A PRACTITIONER'S MANUAL

Editor

CRAIG L1EBENSON, DC
Los Angeles, California

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Williams & Wilkins
A WAVERLY COMPANY

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HONG KONG. MUNICH SYDNEY TOKYO' WROCL\W

1996

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Contents

Seclioll I. Basic Principles

1. Guidelines for Cost-Effective Management of Spinal Pain

,.',
\ ..:1 .

.. . . . . . . . . }

CRAIG UEBENSON

2. Integrating Rehabilitation into Chiropractic Practice (Blending Active and

.
13
Passive Care)
.
CRAIG UEBENSON

3. Training and Exercise Science

.......... .45

JEAN P. BOUCHER

Sectioll ll. Assessment of Musculoskeletal Function

4. Pain and Disability Questionnaires in Chiropractic Rehabilitation

57

HOWARD VERNON

C)
5.. Outcomes Assessment in the Small Private Practice

...................73

CRAIG UEBENSON and JEFF OSLANCE

6: Evaluation of Muscular Imbalance

II

()

,~

97

VLADIMIR JANDA

7. Diagnosis of Muscular Dysfunction by Inspection

............... .113

LUDMILA F VASILYEVAand KAREL LEWIT

................ 143

8. Evaluation of Lifting

oJ}

()

LEONARD N. MATHESON

Sec/ion 111. Patient Education

9. Back School

153

PAUL D. HOOPER

()

10, Patient Education '

I~

()

Appendix IO.l How to Care/or Your B(J(:k "lid Neck: A Sec/ioll Addrc.'i.\"cd J(J the
Patient __ . . . . . . . . . . . . . . .
. . . . . . . . . . . . . .. .

\ ()

1~

CRAIG UEBENSON and JEFF OSLANCE

169

Section IV. Functional ReslOrarioll

ll~

Role of Manipulation in Spinal Rehabilitation

195

KARELLEWIT

)l;iii

CONTENTS

12. 'Spinal Therapeutics Based on Responses to Loading

.225

GARY JACOB and ROBIN McKENZIE

13. -Manual Resistance Techniques and Self-Stretches for Illlproving Flexibilityl

253
Mobility
CRAIG L1EBENSON

14: Spinal Stabilization Exercise Program

. . .21.)3

JERRY HYMAN and CRAIG L1EBENSON

Appendi.\' 14.1 Ex.ercise Checklist

. ..............316

15. Sensory Motor Stimulation

319

VLAOIMIR JANDA and MARIE vA vRovA

16. Postural Disorders ofthe Body Axis

329

PIERRE MARIE GAGEY and RENE GENTAZ

17. Lumbar Spine Injury in the Athlete

341

ROBERT G. WATKINS

18.- Active Rehabilitation Protocols ..................................... 355

CRAIG LIE BEN SON

Sectioll

\~

Psycho.weial and Sociopolitical Aspects of Rehabifiwrioll

19. Psychosocial Factors in Chronic Pain.......

.,

391

GEORGE E. BECKER

20. PatientIDoctor Interaction

A05

WILLIAM H. KIRKALDYWILLIS

21. Place of Active Care in Disability Prevention ......................... All

VERT MOONEY

Index

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i- - - - , - - - - - - - - - - - - - - - - - -

AI9

I
BASIC PRINCIPLES

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1 GUIDELINES FOR COST-EFFECTIVE

MANAGEMENT OF SPINAL PAIN
CRAIG L1EBENSON

MISDIAGNOSIS AND MISMANAGEMENT OF

THE PROBLEM
Em'crging evidence indica(c~ the problem of low bad:
pain has been mismanaged on a gr;md scale. From overprescription of bed rest to overuse of surgical intervention and advanced imaging techniques. the costs related
[0 low back pain afC unccilwincd. The U.S. govcrnmcnl reccntly issued federal guidelines on .acme low back pain
aimed at promoting a quoJlit)' care modeL I RC<lssurancc. activity modification, manipulation. over-the-counter medications. and exercise were recommended as the key clements of
such a model. I
Epidemic
From 60 to 80% of the general population suffer lower back
pain at some time in their lives.I.I> Most of these individuals
recover within 6 weeks, but 5 to 15% arc unresponsive to
treatment and have continued disabili ty 7-'O (Fig. 1.1). The
minority of patients who do not recover within 3 months ae
count for up 75 to 90% of the total expenses related to this
health care problem,1l-17 which exceed $60 billion per
year in the United Slates. 11 The 7.4% of patients who arc
out of work for 6 momhs account for 75.6% of the 101'11
cost lll (Fig. 1.2). The majority of these costs (60%) are attributable to indemnity. with only 40% related to treatlllcm ll . 15
(Table 1.1).
Among those patients whose symptoms resolve. recurrences arc COllllllon. In some studies. recurrence rates were as
low as 22 to 36%.I'}-21 BerquistUllman and Larsson found
Ihat 620/c; of patiellls with acute back pain suffered at least one
recurrence during I year of follow-up. 10 A longterm study revealed that 45% of patients had at least onc significant recurrence within 4 years. 22
The incidence rate. cost of chronicity and disability,
and high recurrence ralC add up lO a problem of epidemic
proportions. In his Volvo award winning paper. \VaddclJ
stated. "Convcmional medical treatment for low-back pain
has failed. ~md lhe role of medicine in the present epidemic
musl be critic::llly eXtllnined:~.\ The cause of this epidcmic
involvcs a number of f"ctors. The reasons for this fail
ure or treatment .md potcntial solutions .are presenteu in
Table 1.2.

Ovcrcmphasis on a Structural [)iclgnosis

Artcr ivtixtcr and Barr's, discovery that compn::ssiol1 of a
nerve root by a hcrnialc<1 disk could cause sciatica. thl' medical profession has belicved sirongly in thc pathoanatomic
basis for back and leg pain.;J,::; Structur.ll cvidc;lcc of a disk
hernia is present in Illore than 90% of palicnt~. with appropriate symploms.:{o-~'J Unforlunalely. even whe;n using. such
.ldvanced imaging lechniques .lS mydogr<lphy CT :,canning.
or magnetic resollance.; imaging. lhe same posilin~ findings
<In.: <llso prescnt ill 28 to 50% of normal. asymplUmatic inuividuals. 2h-\fI Thus. imaging tests have high s'~nsiti\'ity (few
false negatives) hut low sped/icity (high false-positivc rate)
for identifying disk problems. Even \vhcn (he diagnosis of
disk hernia is rckvant. such pathologic change tcnds to resolve without surgical inh.:rvention. Bw;;h et ;,11. reported. "A
high proponion of intcrvertebral disc hcrn!atiolls haye the
potential {() resolve spolltaneollsly. Even if patknt:, have
marked rcduction of straight leg raising. positive neurologic
signs, and a substantial intcrvcrtebral disc herniation (as op
posed to a bulge). there is potcntial for making. a natural recovery. not least due to resolution of the intt.vertl.."bral disc
herniation."'1
Other structural pathologic chang.es havc abo been ovcrrated as causes of hack pain, Linle correlation ;:xists bctween
r~ldioJogic signs of degeneration and clinical sympto11ls..r~-JS
Nachcmson said. "Even when strict radiographic criteria arc
.ldhered 10. 'disk degeneration' is dClllonstralcd with cqu:.tl incidence in subjects wilh or wilhout pain.".'" III a :'tlIdy of cadaveric specimens. Vidcman c{ al. found no correlation be
{ween structural pilthologic fIndings 311U a hislOry of low back
pain:m Spondylolisthesis is an exception: patients with this
abnormality havc an increased incidence of episodes of low
back pain.~tc Segmcntal ins(<Ibility and isolated disk resorption
;,irC other diagnoses that cannot bc validated as C.llisatiyc fae
lOTS of low back pain.'"
An interesting silllation exists with rcspeci to two popular
diagnoses-the facct and sacroiliac syndromes. Although it is
known lhat these structures arc pain sensitive. it i~ notoriously
difficult to conlirnl the diagnosi~ of either <..'ondition.u ..e
Schw.lri,:er el .ll. used .. combinmion of scrcciling and <:onfirmalory anacsthcli.... zygapophysc;ll joint blocks along with
typical cX~lI11in;'llioli procedures (i.e.. extension \'-'ith rotation)
.lIld could not correlate injection response with any single
3

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

cause of their symptoll\s.Jb For this re<\son, most such cases

;.tre classified with the label "nonspecific back pain:'
According to Frymoyer. "Most commonly. diagnosis is
speculative and unconfirmed by objective tesling."-Il The
Quebec Ta~k force states that "before we b~coll1e I1lcsllH.:rizcd
with the dcveloping diagnostk tcchnology. such lcchniques
must be adjudic~\tcd rigidly ;as to their cost/bcndil. risk/hcnclit. ~md cost/cfft::cti\'t:::~~~;s r:lliOS,"11l Perhaps with diagnostiL:
blocks paving the way. other h:ss expensive lests Illay bc
found to compare favorably to this potcntially important
"gold standard."

PERCi)H
70

6O~

50

'0

30

20

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OF .e.9SEIICE

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FRO~

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WOR!': !::mnth:;)

Fig. 1.1. Likelihood of injured worker:> returning to active employment as work absence increases. Quebec, 1981. (From Spitzer

WO, Le Blanc FE, Dupuis M, et al: Scientific approach to the as~

sessment and management of aclivity-related spinal disorders: A
monograph for clinicians. Report of the Quebec Task Force on
Spinal Disorders. Spine 12 (SuppI7):Sl. 198'/.)

PERCENi

70

60

50

'0

O\'crprescription of Bed Rest

"Because of the failure to pinpoint lhe specific pain gcncr~llors
in low back pain, bed rcst and analgesics have become the
typical treatment. The self-limiting course of mosl low back
pain episodes has given justificatio!l to this pracl ice of symptomalic lrcatm';;:nl. As it turns ouL this seemingly benign prescription of prolonged bed rest has been shown in be one of
lhe most costly errors in musculoskeletal carc. Allan and
\Vaddell said, "Tr'lgically. uespitc the best of imcntions to
relieve pain. our whole approach 10 b'ickachc has been <associated with increasing low back dis<tbility~Despite a \vide
mnge of trcntmclllS. or perhaps bL:C;;IU~C nonc of the them
provide a lasting cure. our whole slrategy of management
has been negative. bascd on rest.., We have aClUally prescribed
low back disabiliIY!"~' The Qucbt:c rcpon Slated. "Bcd rest is
nor necessary for low back pain witholH signilicam radial ion.
When prescribed. il should las\ no longer than 2 days,

30

Table 1.1. Percentage of Costs by Type of Treatment

and Compensation

20
10

Back Pain Costs

Percent

Percent

Medical costs

0
< I

OU;i.:.TlW OF ASSENC:: fROM

\oiO~K

tc.or.~f'1s1

Fig. 1.2. Compensation costs for back injury in groups wilh different durations of absence from work. Quebec, 1981. (From Spitzer
WO, Le Blanc FE, Dupuis M. et al: Scientific approach to the as
sessment and management of activity-related spinal disorders: A
monograph lor clinicians. Report of the Quebec Task Force on
Spinal Disorders. Spine 12 (Suppl 7):51, 1987.)

Physician's fees
Hospital costs
Diagnostic tests
Physical therapy
Drugs
Appliances

33
11
11
4

2
2

Oisability
Temporary
Permanent

67

22
45
100

Tolal costs
Adnplcd wilh permissIon from Pope MH, Frymoyer JW. Andersson G

(~cls):

Occupational low Back Pain. New YOlk, Pracgcf. 1984. p 107"

set of clinical features (history or cX~lInin:.ltioll}.'l.\ In contrast. a study ill\"olving chronic ncek pilin patients who had
suffercd whiplash revealed that double <lncstht:tic blocks
could identify painful joints in 40 10 68% of p:.ltiCIltS.~1 In an~
other study in ....olving the usc of diagnmaic blocks. investigators reported that between 13 and 30ck of p:.llienls with
chronic low back pain experienced pain generah.:d from the
sacroiliac joinLJ~
Most patients witlt low back pain do not ha\"t: structural
pathologic conditions that call be clearly determined as the

f--

Table 1.2. The Low Back Pain Epidemic

Thc Problem

Overemphasis on slrucu!ral

The Solulion

10 deconditioning syndrome

diagnosis
Overprescription of bed res!
Overuse of surgery

Early, aggresive conservative

lherapy
Ac!ive care lor subacute cases

Ignoring abnormal illness

Early JD of disability predictors

behavior

l,;HAt-' I t:K 1 : uU'UtLII\lt:~

FOR COSTEFFECTlVE MANAGEMENT OF SPINAL PAIN

Prolonged lx:d resl may be counleq)roduc(ivc."l~ Dcyo and

colleagues p~rformcd a controlled clinical lrial comparing
] d'lys ;.lg;lin:-:l ::! weeks or bed n.::.;(. They concluded lhal nol
only was 2 days of bed fC.'a as crfc.:ctivc as 2 wc.:eks. but also
the negmivc effecls of prolonged immohilizatioll wcre also
lil1litcd:~'~

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Overuse of Su rgcry
The t)\'crus.... ()f surgery has he..... 1 perl laps tllc single lliost damaging medical intervention for b'H:k pain sufferc.:rs. Bigos and
Baltic said. "Surgery seems helpful for ,It most 2~~ of patients
with back problem:;. and its inappropri:'ltc IJSC can have .1 greal
impact on increasing the chance of chrOllic back pain disability.l'ln his Volvo award rape.!'. W..lddcll said, "Such dramatic
surgical successes unfortunately only ;:\pply to approximately
l'lc of palit;llls with low back disorders. Ou.r failure involves
the remaining 999'0 .. for wholll the problem has become
progressively worse."=' Saal and Saal supervised care for a
group of patiClllS referred by neurologists for surgery. They
<.Htcmplcd rchabilil ..uion for these p.llients .lIld made the following obSe(valions: "Surgery should be rcser\'cd f~r tho:;e
patients for whom function C,lIll\ut be s'llisfactorily improved
by a physical rehabilitation progr<.tlll .. F;:tilure of passive
nonopcrativc treatmCI1l is not suflicicnt for lhe decision to
opcr<lte." l"
In 1970. Hakclius performed ;I study that revealed that the
majority of sciatica paticllls responded to consef\'ative e;:lrc.:-n
In 1983, Weber reported that. cvcn in properly selected
patients, there is no diffcrc!l(c in outcome betwecn surgically and conservatively trcated p;.tticnts at 2 yeurs.~l Saal and
Saal and their collci.lgues disco\'en.:d. ''The premise th<lt operative patients fare better in the lirsl year is cOlllrary to our
rcsults:'~!j In 1992, Bush stated that, "86% of patienls with
clinicnl scialica <lnd r'ldiologic evidence of nerve root entrapment were treated suc;.;essfully by <lggrcssivc conservative
managcment." II
The flotion that surgery is necessary in a patient with <l
large disk extrusion is not supported in the literature.
According to Saal and Sa.li. "The presence of disk extrusion
docs not adversely clTcl.:l the outcomc of nonopcrativc trcatment <lnd should not be used as ovcn....helming evidence thal
surgcry is nccessary."~') Blish ct al. found that, "Indeed, the intervertebr:J1 disc pathomorphology that might secm best
suited to surgical re:;ectioll is in fact thm which shows the
most significant incidence of nalur...1 regression ... These n::suits confirm that if the pain can be controlled. nature can be
allowed to run its course Wilh the parti;:11 or complete resolution of the mechanic.1I ractor .... Lumbar herniated nucleus
pulposus can be treated Iltlnoper.Hively with a high degree of
success..l l
Surgery clcarly has its place in the treatment of lumbar
spine disorders. COllscrv;'ltivc care pr'lctitioners must be able
to select lhe paticnts who satisfy the criteria for surgical intcrvention. These criteriOl ;Irc morc strict than ."reviollsly be
licved. Bush said, "(n :;ol11e cases, :;ymptollls may have been

more promptly relieved by surgery, but this has a significant

morbidity and rarely mortality. Surgery is not invariably successful.11 Allen nnd \Vaddell, using the strongest possible
Innguagc, blamc their colleagues. "The rnpid and enthusiastic
expansion of disc surgery soon exposed its limitations and
failures. It was nceused of leaving morc trngic human wreck~
'Ige in its w'lke than any other operation in history."~5
Frymoyer describes a particularly difficult patient group on
which !O pdform surgery: "One place where treatment has an
adverse effect is surgical management of patien!s with COIllpensation:'H Schneider and Kahanovitz echoed these same
remarks. noting that even in patients who had an apparently
successful operation for sciatica. if their problem is compensable. they are still at significant risk for recurrence and disability.52

Overemphasis on a Psychogenic Diagnosis

According to Dworkin.~\ "Pain report often occurs in the
absence of pathophysiology or any discernible peripheral
somatic changes. This finding implies the need to reexamine our limited understanding of pain. rather than leaping to
the conclusion that such p<lins must be psychogenic."
LaRocca commented on this problem in his Presidential
Address to. the Cervical Spine Research Society Annual Meeting in Decembcr of 1991: "An assumption is
made that there is a pathological entity operating in the
spine to produce pain which, if eliminated or controlled.
should result in pain relief in evcry instance ... The clinician,
having spent his resources, is conditioned to resolvc the
m.ltter by deciding that a psychological explanation is the
only alternmive . . . The error here is the automatic leap
to psychology. It assumes that all organic factors have been
considered. when in reality the c1inician's appreciation of
the complexity of such factors is often severely limited:'5~
According to Merskey, "Slater and Glithcro~5 showed that
60% of patients diagnosed by distinguished neurologists
as having hysteria did suffer from. or develop, rckvant
physical disease that might account for their symptoms ... "~Ii
Mcrskcy goes on to conclude that most regional pain syndromes arc not psychogenic in origin and arc oflen mislabeled
as such.j'~~"
This is not to say that pain behavior docs not accompany
pain sensation. Dworkin says. "Fin<\lIy. there is no inconsistency in accepting the likelihood that chronic pain patients experience distress in the form of depression. anxiety, and multiple nonspecific physical symptoms, without having recourse
to the diagnosis or classification of their pain condition as
psychogenic:'H Pain behavior is common and should be rcc
ognizcd and addressed. Although acute pain is directly related
to painful stimuli. nociceplion, and tissue injury. chronic p<lin
is attributable only in part to physical evcnls.~"}..{') Chronic illness bch'iVior and disability arc only partially related to nociceptive innuences,',I.'-"-H, Psychosocial illness behavior. including depression. inaclivity, and pain avoidance, are the
rule with chronic pain suffercrs.;,i-71

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

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Because most patients do not have a diagnosable structural cause of their symptoms, a functional disorder should bc
assumed. Pain in the locomotor system should be viewed as a
sign of impaired function. Nonspecific or idiopathic back pain
most likely has to do with muscle or joint dysfunction with rc. sultant soft tissue irritation and pain generation. Treatments
designed for injury states or disk lesions inevitably fail. thus
Cll:-.!:ig r~p:-~(,"!0rt. desp~ir. and illness bchavior.n-JI:>
Abnonnal illness behavior was dehllct..i by PiI0wsk~.'Jl as a
patient's inappropriate or maladaptive rcsponse to a physic<ll
complaint (Table 1.3). This situation typically occurs when no
organic cause for a patient's back pain can be identifkd.
Descanes' view of pain as a warning signal of impending
harm has led to the advice to "let pain be your guide." which
is helpful in acute situations when nociceptive factors prcdominate. In chronic cases. howevcr, bchavior should be encouraged that focuses on functional reactivation and not on
pain avoidance. In fact, it is necessary for chronic pain patients to focus on. increasing their activities in spite of {hcir
pain.

on quantilicalion of fUIll..:tional delkits. cxal."i~e. education.

and psychologic intCfvcntion havc proven th~ir succcss with
chronically di~3hk<1lnw-h;Kk pain sufferers or recurrelll p;tin
patients (T<lblt: \.4).
Prhm.ll') Prcn~ntiol1

Because lirst-lilll~ had, pain p;l\iell(s ;m..~ likdy to sutler recurrcnces. slll,:ce~~ful primary pre"cnlion would he ut" gre;1l
.'alue ill reducing this epidemic disorder. Unfortun;l!e!y. little
scientific literature <1ddresscs this topic. Those eng<l.ed in
repetitivc liftin~ or prolonged sitting occupations may be at
highcr risk. but few sludics have c"alu.\tcd whether trcatmcnt
C<ln lowcr these risks. Twu of thc hcst studies performcd to
dalc involvc nur:-;~s nnd llurse's aidcs. 1',.sH Gundcwcll et al.
showed that ex~rciscs Colll impan a prcn:nti\"c bellclit. and
Vide man ct a1. showed that skilliraining c:an reduce future illjurics.7~'Jln Skill training. ergonomic: l1louilicaliol1s. and improved Illness art: all prob;lblc ways to prevcnl lirsl-time occurrences of back pain.

Primar.y Conservative Care

QUALITY CARE: COST CONTAINMENT STRATEGIES
FOR MANAGING SPINAL PAIN
Feuerstein J~ has modeled how rehabilitation deals with assessment and multidisciplinary managcment of medical status
(internal, neurologic, musculoskeletal). physical capabilities
(functional capacity, work capacity). work demands (biomechanical. psychophysical), and psychosocial /behavioral resources (coping skills, job satisfaclion. family situation).
A quality care .approach begins with primary prevention
and thc aggressive trcatment of any acute pain cpisodes.
Manipulation is a proven cost savcr in this regard. l
Overutilization of expensive imaging techniques to make a
structural diagnosis should be avoided. UM Strict crilcria for
prc..c;cribing bed rcst or surgery should be maintained. After
studying a group of patients with operable disk lesions. Blish
et ai. commented thut "Even if paticms have markcd reduction of straight leg raising. positive neurologic signs. and a
substantial intervertebral disc herniation (as opposed to .1
bulge).... if the pain can be controlled, nature can be allowed
to run its course with the partial or complete resolution of the
mechanical factor:''!
Paticnts with subacute pain should be educated about the
benign nature of p<lin and the dangers of dcconditioning. and
be encouraged abolll the benefits and safety of becoming
more active. Functional restor<ltion programs concentrating

A pro-activc disnbility managcment program '.lggn:ssi,dy

(reats acute pain t:pisodes with conservative carc. The Quebec:
report Slated that. "Management strategies should be directed
at maximizing lh~ number of workas rClUrning to ''''ork before I month and minimizing the number whose spinal disorder keeps them idle for longer than 6 lllomhs"""1 Most Ir.lditionally minded physicians arc still ignoram of the dangers of
bed rcst and immobilil.lltion. l They are too pi.lssivc in their .11'proach to lower back p<lin. Troup said. 'The first attack is the
ideal time for active and pcrlli.lPS ;.lggressivc trc.lllllcnl. But
if it is tacilly assumed that the vast majority of patients recover from back pain whether or not they arc treated. then the
opportunity may be missed."1I1 The natural history of lower
b<lck pain is toward resolution in 80% of patients within
6 weeks. The 20% who <lrc re~istant to this generally f:lvorable natural history. however. Iwve .1 50% ch'Ull:e of becoming pennancntly disabled if their symptoms persist for
6 months (Fig. 1.3).
Linton and co-workers demonstrated th.lt early aggressive
treatment (patient education. cxcrcisc instruction. physical
therapy) was superior to tr<lditionaltreatment approaches (rcst
and analgesics without physical therapy for 3 mOlllhs).
"Properly administered Early Active Intervcntion may therefore decrease sick leave and prevent chronic problems. thus
saving considerable rcsources. "Ie This study is particularly
powcrful in that the risk of developing chronic pain W'1S eight

Table 1.3. Abnormallllness'Sehavior

Symptom magnification syndrome
n~!~?vo!d",O(:~ behavior
Psychologic distress
Calaslrophizing as a coping strategy
Anxiety
Treatment dependency

Table 1.4. Quality Care for low Back Pain

Primary prevention
Primary conservative care lor acute episodes
Secondary functional restoration lor subacute and recurrent cases
Tertiary multidisciplinary functional restoration for chronic. disabled
patients

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"',

CHAPTER 1 : GUIDELINES FOR COSTEFFECTIVE MANAGEMENT OF SPINAL PAIN

ulations over a I-month period. s" Certain studies excluded

from the meta-analysis were those such as Meadc's, which
included other therapies. the effects of which could not
be disentangled from those of manipulation.&4s5 The study
by Meade and co-workers was one of a select few that
suggested manipulation was beneficial for chronic low
back paill. R5 Triano et at reported recently that in patients
with low back pain over 7 weeh, an avemge of 10.)
treatments with chiropractic manipulation resulted in improved function and significantly reduced pain.l Erhard
and Delitto demonstrated that patients receiving manipulation and exercise outpcrfonned those receiving ex.ercise
alone.'u

PROBABILITY OF RETURNING TO WORK

tI

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12
1B
TIME OuT OF WORK (MONTHS)

24

Fig. 1.3. The probability of recovering from low back pain. (From
Frymoyer JW: Epidemiology of spinal disorders. In Mayer TG,
Mooney V, Gatchel AJ (eds): Contemporary Conservative Care
for Painful Spinal Disorders. Philadelphia, Lea & Febiger, 1991.)

times lower in the Early Active Intervention group than in the

traditional group. Many doctors consulting in managed care
situations today wrongly conclude that care should be minimized for back pain sufferers because most will get better regardless of carc.

MANIPULATIVE THERAPY RESULTS IN LESS DISABILITY AND

INCREASED PATIENT SATISFACTION

Manipulative therapy has clearly established its cost cfrcc~

tivcncss in patients with acute and subacute low back
pain.'~-'~"~ Jarvis and colleagues found. in comparing medi..:al
versus chiropractic treatment for identical diagnoses, that
"COSI for care \Va... significantly more for medical claims. and
compensation costs were lO~fold less for chiroprac~
tic claims."S(J Authors of a recent meta-analysis looked at
studies comparing spinal manipul<.ltion to other conservative treatments for acute low back pain and found signific3mly bet(er rales of recovery for those individuals
treated with maniplllation.~J In fact, they concluded that
manipulative therapy has demonstrated a 34% better rate
of recovery at Ihe 3~weck mark than other conservative
. therapies. lt)
Patient satisfaction is a critical aspect to reducing disability and treatment costs. Chiropractics (which offers over 90%
of the spinal manipulatlons) has shown higher levels of patient satisfaction than family practitioner visits for back
pain.S7~ti" This level of satisfaction may be auributable in parl
to the thorough explanations that chiropractors give their patients regarding the nature of their symptoms (facct. rnyofascial. disk. etc.}.R'1
Shckellc noted that the expert Rand panel rccommcn~
dations for spinal manipulation included about 12 manip-

EARLY RETURN TO WORK IS A KEY

Aggressive care gives the best chance for early return to

work. Litigation neurosis is easy for disabled workers to acquire. Promoting bed rest and prolonged inactivity only in- .
creases the likelihood of prolonged disability. Treatments that
mobilize the patient and auempt to return them to work
quickly are advantageous. Communication between doctor
and employer is essential because certain job modifications
may be necessary to ensure worker safety on return to work.
Deyo and associates said, "Our data support a recent trend toward earlier mobilintion of patients with back pain .... early
return to work may help to prevent the emergence of chronic
back pain syndromes, with their enormous human and monetary costs."~s Cats-Baril and Frymoyer also said. "It would
seem that people who 3re able to work through the acute
phase of a low back pain episode or those who go back to
work even if the pain has not disappeared after a period of rest
arc unlikely (0 become disabled .... keeping people al work
is vcry effective thcrapy."n Waddell succinctly stated that,
"Prolonged time away from work in itself makes recovery
and return to work progressively less likcly."~J

Secondary Functional Restoration

Prolonged passive care in an attempt to ameliorate the suffering of back pain patients can lead to patient dependency. In
the acute stages of an injury. such care is nccessary; however.
when the chemical signs of innammation arc missing. a more
active. patient participatory type of care is required. Oland
and Tveiten said, ". . . resources from the health services
should be used in the subacute stage to enhance diagnosis,
treatment, and rehabilitation and to inform the public of the
benign. self-limiting course of low~back pain and the positive
effect of physical training."'))
Secondary functional restoration care that focuses on specific functional goals and patient education should be the
mode of care for subacute or recurrent pain, paticn(s~
Comprehensive rchabilitation involves functional capacity
testing. physical training. education about biomechanics and
ergonomics. and identification of psychosocial predictors of
disability (Table 1.5).

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

Table 1.5. Functional Restoration

Functional capacity evaluation
Rehabilitation of the motor system
Patient education
Identification of psychosocial factors (disability predictors)

FUNCTIONAL CAPACITY EVALUATION

Functional reactivation requires .lsseSSll1cnt of the fUllctiom,1

status of the patient's 010101' system, EvalmHion of posture and movement or static and dynamic function is essential and should include assessmcnl of joint mobility. muscle strength. coordination. cndUl<lIlC:C. and f1cxibiiilY,
Postural analysis and job or activity skills should also be
assessed:
An objective functional capacity cv.\luation can be perfanned inexpensively and helps thc doctor understand cxactly
what areas need improvement. Many of the function<ll tests
also provide ideal outcome asscssment measurements. which
provide the patient \vith visual feedback of their baseline
functional capacity :.lIld lets thcm see their progress ovcr time.
It is also crucial for communication with third-party payers or
for documentation in medicolegal cases, "Low-tech" tcsts
have proven reliability,9~ Such tests correlme better with disability than do dynametric tesls.l).'i Overuse of technically advanced tests can lead to increased expense, and therefore such
methods should be lIsed only if necessary_
ACTIVE CARE VS. PASSIVE CARE

In a comparative study of pa.<;sive physical therapy versus rc

habilitation. Mitchell and Cam1cn found. "Active exercise to
provide mobility. muscle strengthening. and work condition
ing has shown superior results, , , substantial savings have
been realized in the number of days absent from work and
savings in the dollars expended for compensation benefits.
There was an initial increase in health care costs resulting
from the intensity of the treatment, but these costs were more
than offset by savings in wage loss C05t.'"')(' Lindstrom et al.
compared a group of patients treated with exercises and education to a control group that received more traditional trc:atment. They documented earlier return to work and decreased
re-injury in the rehabilitation group.'H
The notion th<lt active cxercise c<ln be harmful in an individual with back pain i~ incorrect. Guided exercise by a
properly trained rehilbilitation specialist is the optimal treatment program for the subacute population. A key is exercising to a:.pIe::.c.s.tahlli.!!~Lquota.rather than to a pain limit.7~,n
Waddell stated. "There is no evidence lhat activit\' is harmful
and. contrary to Common beli'cC itdcles n(;t necc~sarily~~-~el1
aggravate the pai~_:'~~~ Saal and Saal treated a group of patien(s that had back and leg pain and were referred for
surgery, They concluded, "All patients had undergone an
aggressivc physical rehabilitation program consisting of
back school and stabit!7.ation exercise training, .. 92% return
work ratc."~" Active rehabilitation is csseJ\lial for all

to-

patients, including tho:,c for whtHl1 surgery is being consid

cred, Again, Saal .11ld 5;l;1l said the failure of passive nonop'
erali\'c trcmmcllt i~ 1\(1t "ufticicl1t support of the decision to
opcrale.~"

In one: notahk stud~ l.'\lHLcrning thc tn:aUllcnt of unCOlllplicatcd. ,H.:utc bal.:k pain paticlHs, Fa.ls ct al. reported that
exe:rcise was no hCIl\.'r (h;1I\ llSU;t! L';\l"l': hy a gcneral practitioner:" One oh\'i\\u" \.'ritiL'i~m or thi~ ~tud)' is that exercises were givcn l\l1 a "gcneric" basis r"ther than being
customized to the need" of eat.:h p<l1ient. This investigation
call be t.:ontrastcd with l'ight other cOlltrolled studies. all or
which show'cd suhslanti;l! bendit from exercise that lasted
for <II 1e,lst 6 l110mhs to 2 years:::.'"1 Il-' In a well-controlled
sludy looking at cxerci...e in failed bat.:k surgery patients.
Timm found thaI "I~wlech" cxercises (stabilization and
McKenzie) gave" greater bcnefit than "high-tech" exercises
(Cybcx),lIu
Moonc)' said. "Prolon~cd rest and passive physical thcr
apy modalities no longer have a place in the trcatmCnl of the
chronic problem."'O\ According to Waddell. "The main theme
of m.II1agcment mU,,1 change from rest to rchabilitiltion and
restoralion or rulIl,,;{ioll.'
PATIENT EDUCATION FOR DISABILITY PREVENTION

P<lticnt cduc;.uiol\. L'''pc-cially rcg'lrding skill training and

as well at,; I;clfcarc methods. has shown promise in reducing the cn.. h associated \vith disabling lower
back pain,ll~.,.llII Berqui'IUllmilll and Larsson showed th<lt.
when compared to'1 control group, patients with acute lower
back pain who rct.:ci\cd a 4-hour b'lck school returned to
work sooner <lIld had few rccurrelH.:es in the following
year,H-' A recent study concluded. "Differences between back
school participants and .1 comp<lrison gr;)up indicated significantly fewer injuric\ among the back school participants in the {)-ll1onth post-intervention period,"'N Participants had one h:tIf a" many re-injuries as nonparticipants.
They also demonstrated liignificant rcullctions in lost work
time costs, Although thi.:"ic results un.: impressive. some
studies havc questioned Ihe long-term results of back
schools,III.I!.\

ergonomic~

IDENTIFICATION OF PSYCHOSOCIAL FACTORS

{DISABILITY PREDICTORS,

It is the responsihility of the rehabilitation specialist (0 be on

the lookout for carly ..igns of :.l disability prone patient.
According to Frymoycr. "if a patient is identified early in the
course of thc low hack p<lin cpisode to have a high risk for
disability. early, 'Iggrcssive rclmbilitativc efforts 111ay be more
successful ~md cost effectivc than permitting the patient to
have a longer period of disability with its resultant economic.
social and medical consequences,.. ~)
The problcm of chronicity or "deluyed recovery" occurs
when disability is disproportionate to impairl11cnt.lI~ Many rescarchers believe psychologic charm:tcristics may be more

CHAPTER 1 : GUIDELINES FOR COSTEFFECTIVE MANAGEMENT OF SPINAL PAIN

important than biomechanical ones.68--rn:7-l1.75 Frymoyer said.

'There is increasing evidence from the general field of
disability, and specifically low back disability, that a 'disability prone profile' can be identified and used to predict polential disability before the condition becomes truly
chronic....., Job dissatisfaction is one of th~ only proven
predictors of disabling back pain. m According to Cats-Baril
and Frymoycr,Il6 other predictors of low back disability include work status and job satisfaction~ injury being viewed as
compensable: past hospitaIi7...,tion; and the patient's educational level.
Recent studies indicate that it may be possible to idcmify
acute back pain patients with psychologic predispositions to

becoming chronically disabled. ll7 m In the Minnesota

Mulliphasic Personality Inventory (MMPI), responses indicating increased catastrophizing as a painMcoping strategy as
well as emotional distress appear to be promising discriminator5.111-122 D~prcssion. anxiety. hypochondriasis, and hysteria
arc related to poor surgical outcomc. n .1l6 The "bio-psychosocial" model has been proposed by Waddell to address the disability problem in patie",s with low back pain"(Table 1.6).
Tertiary Multidisciplinary Functional Restoration

C}

CONCLUSION

\Vith consensus-based guidelines emerging as the best chance

to cut costs associated with diagnosis and treatment of low
back pain. it is incumbent on us to be aware of the direction
in which new findings lead. Quality care will result in bcHer
patient satisfaction and reduced costs. Manipulation and exercise both appear to be of value if our beliefs arc based on
[he scicntitlc literature. Future studies will hopefully nush out
which patients respond better to what type of care and what
arc appropriate timelines for transfening from passive to active care.

Table 1.7. Multidisciplinary Functlonat Restoration

Quantifiable, functional capacity evaluation
Physical reconditioning of the impaired "weak link
Work hardening
Behavioral disability management
Ongoing outcome assessment using objective criteria
M

REFERENcr~

Tertiary treatment of the chronic. disabled patient with multidisciplinary junctional restoration has demonstrated its cost
effectiveness. A combination of technically advanced functional capacity evaluation. exercise training. iid psy.::liVsocial intervention are essential to the program's succcss.
With a functional restoration approach. Mayer et al. allowed
87% of chronically disabled people to return 10 work compared to only 41 % of a comparison group.12) Hazard et al. rcported that 81 % of the treatment group returned to work compared to only 21 % of lhe conuol group.I~4 \Vhen Sachs et at.
used less psychologic intervention. 73% returned to work
compared with 38% in the control group. This approach was
less costly than that used by Mayer or Ha7.md and their colIcagues.l~j Oland and Tvciten aUemptcd a modified program
in Europe. but they had difficulty achieving similar results. 9 .'
Alaranta et al. compared a multidisciplinary functional
rcslOration program to a primarily passive care approach and
documented improved function, pain, and disability Icvcls.I~('
In contrast to most other multidisciplinary approaches, their
approach lnvalved the use of low cost. "low-tech" functional
capacity measures.
Multidisciplinary functional restoration includes the components described in Table 1.7.

Table 1.6. Blopsychosocial Approach to low

Back Disability
Restore function
Promote return 10 work
Decrease pain
Reduce distress
Reduce abnormal illness beh~'::;:::

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- _..----_ _._---._--

u
i (~

..

'.

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

I
!
i

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FOR COST-EFFECTIVE MANAGEMENT OF SPINAL PAIN

75. Stcmh<lch RA. Timll1CmlanS G: Personality changes associated with

reduction of pain. Pain 1: 117. 1975.
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as :In improved basis for surgical decisions in low back disorders. Spine
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1989.
81. Troup JOG: The perception of musculoskeletal pain and incapacity
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83. Shekcltc PG. Adams AH. Chassin MR. ct al: Spinal manipulation for
lowback pain. Ann 100em Mcd 117:590, 1992.
&4. Shckelle PG: Spine updalC: Spinal manipulation. Spine 19:858,
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85. Meade lW. Dyer S, Brownc W. et al: Low back pain ofmcchanical origin: Randomized comparison of chiropraclic and hospital outpatienl
treatment. Br Med J 300:1431. 1990.
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with identical diagnostic coocs. J Occup Mcd 33:847,1991.
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1989.
&8. Cherkin DC: Family physicians and chiropractors: What's best for thc
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89. Curtis P. Bove G: Family physicians. chiropr.J.ctors, and back pain. J
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91. Erhard RE. Delino A: Relative effectiveness of an extension program
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1994.
92. Cats-Baril WL, Frymo)'cr JW: Identifying patients at risk of becoming
disabled becausc of lowback pain. Spine 16:607. 1991.
93. Oland G, T\'cilen GT: t\ lri:ll of modem rehabilitation for chronic lowback pain and disability. Spine 16:457. 1991.
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fonm.ncc tests: Rciiability and nonnative data. Scand J Rchab Mcd
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95. Rissanen A, Alaranta H, Sainio P, ct OIl: Isokinelic and nondynametric
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96. Mitchell RI, Camlcn GM: Results of 3 multiccnter trial using an intensive active cxercise program for the treatment of acute soft tissue and
b.:lck injuries. Spine 15:514, 1990.
97. Lindstrom A, Ohlund C. Eel. C. ct :1.1: Activation of subaCUle low back
paticnts. Phys Ther 4:279.1992_
98. Faas A, Chavannes AW, van Eijk J Th M. et OIl: A randomi1.ed, placebocontrolled trial of exercise thcr.lpy in patients with acute low back pain.
Spine 18:1388, 1993.
99. Catchlove R, Cohen K: Effccts of a dircctive return to work approach
in the tratmcnt of workmens' compensation patients with chronic pain.
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100. Fordyce WE, Brockway JA, Bergman lA. et al: Acutc baek pain: A control group comparison of behavioural vs. lradilionallllanagement meth
ods. J Behav Med 9:127,1986.

101. Mayer TG. Gatchel RI. Kishino NO. et at: Objective :lSsessment
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with comparison group and one-ycar follow-up. Spine 10:482.
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102. Linton SJ. Dndlcy LA.Jensr.n I. el al: TIlc secondary prevention of low
bad: p3in: A controlled study with follow-up. Pain 36: 197, 1989.
103. Kdlct KM. Kellett DA. Nordholm LA: Effccts of an exercise program
on sick Ic<lve duc to back pain. Phys TIlcr 71:283, 1991.
104. limm KE: A randomizcd-control study of acti\'e and pas.o;,ivc treatRlent!'
fOf I.:hl'Ouic iow back pain iollowing l..:) lallllllcclOmy. J Occup .sports
Phys Thcr 20:276, 1994.
105. Mooney V: Whcre is thc pain coming from'? Spine 12:754. 1987.
106. Brown KC. Sirlc.'> AT. Hilycr JC. cl 31: Cost.. d fectivene55 of a back
school intervention for municipal employees. Spine 17: 1224, 1992.
107. Moffcll JAK, Chase SM, Portek I. et al: A controlled, prospective study
to evaluate tlte effectiveness of a back school in the relief of chronic
low back pain. Spine 11:120. 1986.
108. Versloot JM. Schilstra N, Tolen FJ. et 31: Back school in industry. A
prospective longitudinal controlled study (3 YC3rs). ISSLS Meeting,
Miami. FL, April 13-17.1988.
109. Nordin M. Frankel V. Spengler OM: A prc\'enti\'e back care program
for industry. Presented at thc International Lumbu Spine Meeting.
Paris, May 1981.
llO. Rl~rwick OM. Budman S. Fddstein M: No c1inic<t1 e(fc~~ of back
schools in an HMO. Spine 14:8, 1989.
III. L:lnkhorst GJ, van de Stadl RJ. Vogciaar TW. et :II: The eITccl of the
Swedish back school in chronic idiopathic low baek pain. Scand J
RehabiJ Med 15:141. 1983.
,
112. Lindquist S. Lundberg B. Wikmark R, ct al: Infomlation and rcgimen
on low back pain. Stand J Rehabit ~ted 16:113, 1984.
113. Genaidy AM: A training programme to impro\'c hum:tn physical capability for manual h3ndlingjobs. Ergonomics 34:1. 1991! !t D::r::bcry VJ, Tullis W: Delayed n.-covcl) in the patient with :I. work
compensablc injury. J Occup Moo 25:829, 1983.
115. Bigos SJ, Dattie MC. Spengler DM. ct al: A prospectivc study of work
perccptions and psychosocial factors affecting the report of back injul).
Spine 16:1, 1991.
116. C:l.ts-Baril WL, Frymoyer JW: Idcntifying paticnL'> at risk of becoming
disabled because of low-back pain. Spine 16:605, 1991.
117. Waddell G. Newton M, Henderson 1, el al: A fcar-avoidance beliefs
qucstionnaire and the role of fear-avoidance beliefs in chronic low back
pain and diS3bility. Pain 52: 157.168, 1993.
118. 1c1.1,i A, Adams HE, Swkcs GS, ct "I: An identific<ltion of low hack pain
groups using biobchavioral \ariables. 1 Occup Rehab 2: 19. 199:!.
119. Reesor KA, Craig KD: Medically incongruent chronic b3ck pain:
Physical limitations, suffering and ineffective coping. Pain 3:!::l;l.. 1988.
120. Turk DC. Rudy TE: Toward an empirically derivcd taxonomy of
chronic back pain patients: Integrntion of psychological assessment
data. J Consult Clin Psychol 56:233. 1988.
121, Feuerstein M, Thebargc RW: Perceptions of disability and occup'lIional
stress as discriminatoni of work disability in patients with chronic pain.
J Occup Rehab 1:185, 199\,
122. WiRing FG. Klonoff H, Kokan P: Psychological. demographic and orthopaedic factors :\ssociated with prediction of outcome of spinal fll~
sion. Clin Orthop 90: 153. 1973.
123. MayerTG, Gatehel RJ, Maycr H, ct OIl: A prospective two-year siudy of
functional Testor-nion in industrial low hack injury. JAMA :!SS:1763.
1987.
124. Hazard RG. Fenwick JW. Kalisch SM, et al: Functional rcstor.l.tion with
behavioral support. Spine 14:157, 1989.
125. Sachs BL, David JF. Olimpio D. el :11: Spin:!.l rehabilitation b)' work tolerancc bascd on objectivc physic;11 ctlpacity assessment of dysfunction.
Spine 15:1325. 1990.
126. Alaranta H. Rytokoski U, Rissanan A. ct ,,\: Inten"i\'c physical':lOd psychosocial training program for patients with chronic low back pain.
Spine 19:1339, 1994.

'--*'------,-------------------------I
I %J

..

_--_._._----------------

Integrating Rehabilitation into Chiropractic

Practice (Blending Active and Passive Care)
CRAIG L1EBENSON

Rehabilitation and chiropractic (manual medicine) are perfect

partners in the delivery of high quality neuromusculoskeietal
health care. Disorders of the locomotor systc;m onen resolve
spontaneously, but high recurrence rates dictate a more pC".
active approach. Manipulation and exercise arc the two mcth~
ods that have become the standard of care, especially in the
costly aren,a involving tow back pain. New treatments must
prove their value against these "gold standards. Combining:
passive and active care is a new art that requires certain Fun
darncnlal skills. which arc outlined in this chapter.
It

,
~

,~

,, <J

,!

j
~

I,1. (}
1J
,"'-~

,,t
~

()

!
;j

t"'s;.

-;j

i::...:.--fI'

FUNCTIONAL PATHOLOGY OFTHE MOTOR SYSTEM

Clinically significant structural abnonnalitics. such as disk
syndromes, are present in less than 20% of patients with low
back pain. In the absence of trauma or relevant pathoanaromic
change. the primary goals of care should be restoration of
function and prevention of disability, including the chief functions of the locomotor system; strength, endurance, flexibility.
coordination. and balance. Patients should be educated about
the negative effects of immobilization and deconditioning and
the safetylbenefits of early mobilization and controlled activity. Rehabilitation is guided by evaluation of the functional
capacity ano work demands of the individual. This evaluation
also provides ideal outcome measures of quality care.

Dcconditioning Syndrome

I,, -:,,)

Rehabilitation attempts to address physical. and if necessary

psychologic. deconditioning that accompanies most persistcnt
pain syndromes. Muscular disuse leads to weakness. incoordination. atrophy, and loss of flexibility. Joint immobilization leads to bone demineralization. capsular adhesions, and
decreased ligamentous stress tolerance (including annular
weakncss). Cardiovascular fitness is diminished. Deconditioning affects not only peripheral anatomic structures, but
also afferent systems, such as proprioception involvcd in balance as well as ccntral neuromotor control of movemcnt and
pOsture.
Although a specific pain generator often is diff1eult to
pin down, the deconditioning syndrome can be identified in
most patients with chronic or recurrent back pain by the pres
ellce of immobility, musclc weakness. and pain-avoidance behavior. It encompasses many of the typical physical and psy
chologic signs associated with back pain patients. The various

~<i

l t)

1
~

I,
:~

}
(~

'l)

j (~

II

interconnections between Ihese clinical signs are shown in

Figure 2.1.
The o\'eremphasis 011 trcutmellt of ('(mjeclIIrell struclIIj"al
pathologic change (disk. facct, etc.) has resulted in (l failure
to identify or focus on intrinsic fwu.:tit~"(ll losses. pSydlO,'Wcial factors. and extri"."ic ellvirollmelllal streuor,'i (\1'ork de
nIa"ds). This failure to recognize the limited reach of clinical
diagnosis has especially plagued the medical community.
whose overconfidence in the diagnosis of disk syndromes has
promoted an overly passive approach involving rest and
medication. The overcmphasis of this noomanagement philosophy is typically grounded in the belief that llle natural history of most b~lck pain episodes leads to resolution.
Unfortunately. by encouraging inactivity. this approach results in immobilil.3tion of tissues and leads to deconditioning
of thc musculoskeletal system. Dc)'o encourages maintaining
function as the mainstay of treatment when a specific diagnosis is elusive.
Chiropractors or myofascial specialists who concentrate
exclusively on passive intervention (i,e.. spinal adjustments.
trigger point therapy) to treat a specific pi.lin generator (joint
or soft tissue) arc also placing patients at risk for dcconditioning. Unles,\" the pariefll is educated to control em'irollmental stressors and trained to recondition !ullctio1l(lj' lh:ficits.
pai" recurrences and treatmefll dependency will be rhe !"IIle
rather ,II('" rile exceptio".
NEGATIVE EFFECTS OF IMMOBILIZATION

Prolonged immobilization results in compromise of the

musculotendinous, ligamentous-articular. osseous. cardiovascular, and central nervous systcms2-~. (Figs. 2.2 and 2.3;
Table 2.1).
'Prolonged immobilization after an injury can lead to scar
tissuc foonation and lowered fatigue tolerance of injured tissues, Soft tissue healing has three phases: inflammation. re
pair, and remodcling. Some form of local (issue immobilization is usually advisable during thc inflammatory phase.
which usually peaks around the third day after injury. Toward
the end of the inflammatory phase. fibroblasts are fouild in increasing numbers in the injured area. These fibroblasts contribute to scar formation. In a study of calf contusions in
rats, Lehto and colleagues found that connective tissue scar
formation will persist and become fibrotic rather than be
13

_% (3
1- - - - - - , - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 ,,-~

I,
~

;;

\;#

r"

<$.~1

nt:.nt\OILII ...... 'VI~

ur

nCo

.,r"~l::

...... rnl-\I,.,

1lllVI~cn

.:::> IVIAI"-U...... L

recurrent pam

Fig. 2.1. Pathophysiology of deconditioning

syndrome. (Adapted with permission from
Liebenson C: Pathogenesis 01 chronic back
pain. J Manipulative Physiol Ther 15:303.
1992.)

muscle

illness

!
,.-..~ ~ /
I \
\ ! \
pain avoidance

hypertonicity \

beh.,ior

& disuse

joint
sliffness

- - . . depression /

behavior
/
/

loss of
ca:d:ovascular
fitness

muscle
weakness

incoordination

atrophy

~ static & dynamic muscular performance

Immob,I,utio"

Ad~DI~I,on

c~o~ul~r

10 non",><:

mental depression

tinue,

OCCI,rO~I'o"al

a"d

Enzyme defect
acquired disease
viral infection

S''..nk'''90 1

g~tltl'C

helO"

Inactivity

/~

Decreased

Muscle pain

content of
mitochondria

,>

Exercise
Fig. 2.2. Biochemical changes associated with reduced physi
cal activity. (From Troup JDG, Videman T: Inactivity and the
aetiopathogenesis of musculoskeletal disorders. Clio Biomech
4:175, 1989.)

absorbed if the acute inflammatory reaction is allowed to persisl.~~ These authors suggest early. aggressive management of
injuries 10 limit enlargcment of thc injurt:d arca.~~
During the repair phase. passive and active m~tion of the
tissues positively affects the injured tissut:s. Classic work on
knee cartilage by Salter and co-workers. showed that/after 3
weeks of immobilization. intra-articular i.ldhesions complicate
the repair phase of sofltissue hcaling.l~ Either intermittcnt ae-

intolerance

--~

Fig. 2.3. Effects of musculoskeletal immobllization. (From Troup

JDG, Videman T: Inactivity and the aetiopathogenesis of muscu~
loskeletal disorders. Clin Biomech 4: 175. 1989.)
live motion or continuous passive motion prevented SUl,'h adhesion forlllation.Y
The remodeling phase involvcs lysis of adhesions and r~
orientation of coll,lgcn fibers along the lines of impos.~d
stress. Again, prolonged immobilil.ation is. a negative fal,'(or in
proper healing. In studies of rhesus monkcys. Noyes studied
the effects of 8 weeks of immobilization on ligament stiffness
and failure ~~!e.;' Ligmncnt stiffness was reduced (0 69(';'".. of

d
0:

'"
Table 2.1. Negative

J::ffer.t~

nf Immobilization

Joints
Shrinks joint capsules:.)
Increases compressive loading'
Leads to joint contracture~G
Increases synthesis rate of glycosaminoglycans"';'
Increase in periarticular librosis'o-':
Irreversible changes after 8 weeks immobilization')"
Ligament
Lowers failure or yield poinFH> '5-"
Decreased thickness of collagen libers 'l'I_~
Disk biochemistry
Decreases oxygen~'
Decreases glucose~l
Decreases sullate 2 '
Increases lactate concentralion~.l'
Decreases proleoglycan cooteot n

Bone
Decreases bone density:n-3'
Eburnation"
Muscle
Decreased thickening of collagen fibers 18 .3.l'
Decreased oxidative polential1.... 3~
Decreased muscle mass::'2.3C>-3?
Decreased Sarcomeres'o
Decreased cross-sectional area t l -4)
Decreased mitochondrial contenr"
Increased connective tissue librosis"~
Type 1 muscle alroph~2.,o."T
Type 2 muscle atroph~e. ~
20% loss of muscle strength per weekUl
Cardiopulmonary
Increased maximal heart rate~'
Decreased va: max,"l
Decreased plasma volume'"'
(From liebensoo C: Pathogenesis of chronic back pain. J Manipulative
Physiol Ther 15:303, 1992,)

nonnal after 8 weeks. After 5 months of reconditioning. stiffness was reduced to only 7% of nonnal levels.} Five months
of reconditioning improved the tissue failure rate to 80% of
normal. and after 12 months of reconditioning, the ratc was
completely nonnal.}

FUNCTIONAL DEFICITS ARE PROSPECTIVELY CORRELATED

WITH LOW BACK PAIN

Patients typically become inactive when they cxperience

pain, and this inactivity promotes dcconditioning. \Vith deconditioning comes greater susceptibility to typical postural
or occupational repetitive strains. A chronic cycle of recurring
pain is easily established unless function is restorcd./lf pain
relief is the only goal of treatment. and functional restoration is ignored, painful recurrences arc more likely". Spons
medicine specialist Stanley Herring says, "signs and symptoms of injury abate. but these functional deficits persist. ' . ,
adaptive patterns develop secondary to the remaining
functional dcficits,"~ Focusing on function helps patients
to develop control over their symptoms and to prevent
recurrences.
In many retrospective studies, investigators have documented that various functional changes in musculoskeletal
performance arc associated with episodes of bnck pain. al-

though tht:y C:l 11 1l0t dctcrminc if (hcse changcs are a cause

or :1 rc:,uh of lhc pain. Prospcclivc studies come closer to
id"'lltiryin~ clioll\gic factors. Thc goal of such research is to
idctltify what factors are causally linked to low back pain
epi:'Olks in a prcdictivl: manner. The following studies arc all
pnlspCl:liw,
i\<l<tny (csc;lrdlcrs have found that muscle strength is
prospectively correlated with future incidences of disabling
ha... k pain. Chaninlir~a dcmonstratcd in 1973 a correlation betwccn der..:rcased 111llSCuiar strcngth and increased incidcnce of
lo\v bar..:k pain::" Cady ct a1. found decreascd isomctric lifting strength and endurance in firemen who later developed
lirst time episodes or low back pain,SoI Rowe found decreased
abdominal muscle strcngth in 50y.~ of those who later developed symptoms. ~~
Losses in muscle strength have also been found to corre
late with the increased likelihood of recurrences in an individual once they have suffered a disabling back injury.
Biering-Sorenson found that individuals with lhe greatcst
number of recurrcnces of lower back pain had decreased isometric trunk muscle strength in flexion and extension,}6Troup
et a1. reponed that dccreased dynamic trunk nexion strength
is a good predictor of recurrences or persistence of lower
back pain. ~7
In olle study, physically fit nursc's aides had shorter recoveTj' periods after injury than those who were less fit.~8
Gundewall c( al. demonstrated that nurscs and nurse's aides
who spellt 20 minutes per day for 13 months exercising their
backs had fewer injuries than those who did not exercisc,~;J
These (wo groups were divided randomly and the exercises
included trunk extension strcngth and endurance as well as
pushing and pulling, Vide man ct at round that back injuries
could be reduced by increasing the patient handling skill of
nurses,toO
The correlation between losses in normal flexibility and
the likelihood of developing a disabling episode of back pain
is not as clear,',) although decreases in normal flexibility do
relate to a higher thall normal rate of rccurrcncc.~7,61 Troup
and co-workers found a decreasc in saginal nc~ibility, especially in extcnsion. in those persons who later developed
symptoms,:;7
Deyo and Bass reported that decrc~sed physicnl activity.
along with smoking and weight factors. were predictive of future episodes of lower back pain,62 The American Academy of
Orthopedic Surgeons stated that "functional deficits become
the dominzlIll physical impairment associ~ted with disability
in the patient wilh chronic back problems,"63 Table 2.2 summarizes the functional losses prospectively correlated with
episodes of back pain,
Biomcchanical Fclclors
Musculoskeletal structures (ligaments, joints, disks. muscles.
etc,) are constantly subjected to biomechanical forces such as
tension, torsion, compression. or shear. When functional
capacity is less than work or activity demands. microfailure

 .. _._

Table 2.2. Intrinsic Functional Losses Correlated

Prospectively with Back Pain Episodes

'III.:: VI""U'IIC:. J-\

r'HAl,; IITtONER'S MANUAL

High

Muscle strength~~
Isometric lilting strengthlendurance~
Abdominal strength~~7
Isometric flexion/extension strenglh~
Physical fitnessS-O s,
Job skill(,O
Extension mobility!>7
Physical a,ctivily~9.6~

(fatigue) and eventunl injury arc the result (Fig. 2.4). The
stress! strain curve explains the mech:Jnics of the relationship
between extemalload (~aress) and lissue deformation (strain).
The applied or elongming force is termed slress. The amount
or percent of elongation is the strain. Stress is measured in
newtons and strain in percent (%) elongation.
Loadittg of biologic tissues produces a characteristic
stress/slrain curve demonstrming the amount of stress (load~
iog) required to produce a set amount of strain (percent cion
gation or deformation)I"- (Fig. 2.5). Thc initial concave portion of thc curvc is lhe "toc" region, which corresponds [0 the
initial tissue distraction involving a structural changc from a
crimped. wavy fibril organization [Q a morc straightened, par
alleI arrangement.~ In the toe region, little force or energy is
required to lake the slack out of the tisslle. but the tissue
quickly becomes stiffer, resisting further dong..Hion. If greater
forc\"~ arc prescnt. tissue dcform<ttion occurs with ac(:vlIlpi.t
nying microfailurc. Only 4% deformation is necessary to
cause microfailurc. M
After prolonged or repeated loading-sometimes. just 15
minutes-tissue (:reef) will occur, resulting from thc "gradual
rearrangement of collagen fibers. proteoglyc~ms and water in
the ligaments or capsule being slressed:'j.i Once a tissue is
stressed. ir tends to havc difficulty returning (0 its initial
length. The encrgy lost aftcr prolonged or repetitive loading is
callc~ ilysleresi!i. and is represented by the differcnce between
lhe new and old stress/strain curves (Fig. 2.6). Hysterisis only
occurs when loading exceeds the point at which ~11I crimp is
removed from the tissues (4% elongation). According to
Bogduk and Twomey. "the further ..I structure is stressed beyond its toe phase, tlte more bonds arc broken and the grc.Hcr
the hysteresis and sct:(..1
'Mild strains can causc microdmnagc. <1nd if repe~lted. they
frequently result in tissue deformation.:; According to
Bogduk and Twomey. "what proportion of collagen fibers
need to fail before mucroscopic failurc of a ligamclll or c<.tpsule is not known ... "(..I At a certain point 'Ifta loading has
led to tissue fatigue and microinjury. tissucs begin to fail and
frank rupture of structural clements occurs. Under conditions
of cxpos~re to prolonged cycles of repctitive stress, less cxternal 1000Id is required to cause tissue failure. Bogduk .1Od
Twomey conclude that hystcresis makes fatigued tis;ucs more
vulnerable to injury. "after prolonged !'train, ligaments. capsules and intervertebral dises of the lumbar spinc muy creep.
und they may be liable to injury if ~i.;dden forces arc UIlCX-

Injury

Non-injury

Low ""-

Deconditioned

Highly
trained

Functional capacity

Fig. 2.4. Relationship between exte.rnal demand and functional

capacity.

STRESS

MacrO- failure

Microlailure

. Slack' and

crimp
removed
CliniC a \

O,,'?-

\1>('

,
)

STRAIN ('X. Elongation)

Fig. 2.5. Stress-strain curve lor a ligament. (From Bogduk N,
Twomey LT: Clinical Anatomy of the Lumbar Spine. 2nd Ed.
Melbourne. Churchill Livingstone. 1991.)

pectcdl)' applied oul'ing their vulncrable. recovcry pk,~~."M

According to Andcrsson ... It is generally believed thai r~pe!i
tive loading causes failure becausc of faligue of the various
tissues: I .\ Brinckmann and Pope condudc
under repetitivc loading. the yield strc~s of thesc l1lillcriilb .tIld the
strength of struclllres buill from these matcrials i:-: n:duccd
with respect to the stress or strength obscrved under a single
load cyclc..f .... (Fig. 2.7). l?educillg ('xjJo.mre 10 high /t.\.e/.\" of
load-sllch as trunk flexioll wilh eilher CO/1//u(!.uiofl or rota-

.,

;;

tion-is Ol/e! of 1he 1110.\1 i/1/{Jorlwll le/1('I.\" (~r pre vclIIioll oj 1011'
.~

11

250

STRESS

200 -19\ -------LOAO 150

INI

CONTROL

100
50

oO~-:-l--:2--'30'--'-4--:;;--'6:-'
OEFORMATION (mm)
Fig. 2.8. The strength of rested tissue deteriorates dramatically
compared 10 normal tissue. In this medial collateral ligament of a
rabbit knee thai rested for 9 weeks, two thirds of the strength has
been lost. (From Mooney V: The subacute patient: To operate or
not to operate. In Mayer TG, Mooney V, Gatchel RJ (eds):

Initial length

Set

Contemporary Conservative Care for Painful Spinal Disorders.

STRAIN

Final length

Baltimore. Williams & Wilkins. 1991.)

Neuroph)'siologic Factors

Fig. 2.6. Stress-strain curve illustrating hysteresis. When unloaded. a structure regains shape at a rate different to thai at
which it deformed. Any dillerence between the initial and final
shape is the ~set." (From Bogduk N. Twomey LT: Clinical Anatomy
of the Lumbar Spine. 2nd Ed. Melbourne, Churchill Livingstone.
1991.)

Injury

As tbc activc component of our locomotor system. muscles

arc often called on consciously or by reflex to protect othcr
tissues' under stress. Compcns3lOry adaptations (facilitative
;llld inhibitory) typically follow any strain, whether or not it is
painful. \Vhat may begin as a segmcntal, reflex muscular
'Idaptalion to pain may become "programmed" in the form of
<l new movement pauem stored in the central nervous system.
Injury. inflammation. joint nociceptive activity, sensitization
of dorsal horn neuroncs. or pain perception can all trigger
muscular reactions. These adaptations arc an essential part of
the deconditioning syndrome.
tS THERE A PAtN CYCLE?

Repetition
Fig. 2.7. A fatigue curve illustrates the importance of repetition
and load to fatigue failure. (From Andersson GBJ: Occupational
biomechanics. In Weinstein IN. Wiesel SW (eds): The Lumbar
Spine. Philadelphia, we Saunders. 1990.)

back pain. Similarly. frequent microbrcaks. t~lkel1 as often

as every 20 minutes. C'ln help reducc thc chance of injury
.Iner exposure to repetitive overloading. Frequent microbreaks can prcvclll the instability that arises after tissue
creep has occurred. Such breaks can prevent repetitive strain
injuries noted after prolonged stalic loading such as from
sitting or repetitive overuse from sports or occupational
activities.
The more impaired lhe sort tissllt:. the less stress required
to reach the soft tissue fatigue or f:.lilure p~int. Im/1/obilized
fisslle.f; are more I'IIlllcrable t"OI/ I/orll/al (issues to similar
WJl01U1ts oj/1/cc!ul1lical stress (Fi,t:. 2.8).' Pre\'elllin,~ the negative effects oj ilJl11lobilizmioll is O1W of the primary goals of
relwbililllirm for 11I11scuioskeleUlI complaints.

Th~

existence of a pain-spasmpain cycle has been a \vellacccpted concept of physical therapy and chiropractics. As a
criteria for therapeutic decision making. it is one of the most
il\lluel\tial "" priori" assumptions of many practitioners. espc
dally aillong those who lise extensive passiv~ techniques
and/or soft tissue manipulation. Its validity is unproven. howcver. and currently. it is often ignored. The litemture docs
show thm prolonged or intense pain can lead to both psychologic (abnormal illncss behavior) and neurologic (dorsal
horn sensitization) consequences. Either or both of these
behavioral and physiologic dysfunctions arc at the heart of the
transition frolll :.111 .\cutc to a chronic pain syndrome.
Significant external loading that exceeds intrinsic functional
capacity leads to tissue fatigue and altered biomechanics. To
maintain spinal stability following biomechanical changes,.
such as can occur after creep and hysteresis, type I and type
II affcrcllls arc stimulated to maintain accurate proprioception
Crable 2.3). The initial firing from the joint mcchanoreceptors, muscle spindle affcrents. ilnd Goigi tendon organ afferCllts allows ad'lptation to occur so the fatiguing tissues can
avoid failure. Because these receptors arc adaptive. they do
not continue to discharge if the biol1lechanical changes :lr~

Table 2.3 Nerve Types and Functions

FAST
MYELINATED
LARGE

SLOW
UNMYELINATED
SMALL

Low Threshold/Adaptive

High Thresholdl
Nonadapting

II
g~mma

A alpha

A beta and

Golgi tendon,
primary
muscle
spindle, al
lerenls to
skeletal
muscle

Secondary muscle
spindle, gamma
efferent to intrafusal muscle
spindle

III

IV

Adelia

Acute
pain

Chronic pain,
postganglionic
autonomic,
dorsal root afferents

present for a long period of time. As a result, repetitive strains

eventually exhaust the adaptive capacity of the body's dc
fenses and lead to painful injury.
Once tissue failure occurs, inflammation, mediated by
bradykinin. substance P, and prostaglandin E2, lead to stimulation of nonadaptive, types III and IV nociceptive affcrcnts.
Various changes in the muscular system occur automatically
when injury occurs. For instance, muscle inhibition follows
acute low back pain or knee injury/inflammation. 67.(,~
Additionally, increased neuromuscular tone also results from
strong nocic.:.ip;iVt .Hiiiiulation,!,9-71 Protective mechanismsnonnal illness behavior-to immobilize an injured area are
usually appropriate in the acute stage. If they become memo
rized as a "pain-motor program," however, they can lead to a
chronic state. Abnormal illness behavior, such as excl!ssive or
prolonged stress, fear, or anxiety, will affect the neuromuscu
lar system behaviorally via canditialling alld ph.lfSiologicalJ.v
from the limbic center, thus providing an ideal terrain for
chronic pain.
Testing with evoked potentials of patients with chronic
back pain revealed lower pain thresholds and higher than normal evoked responses at thresholds than are noted in normal
subjects. 72 Magnetocnccphalographic study with sub, supra,
and standard intracutancous electric shock stimuli in chronic
back sufferers also revealcd a higher than normal pain-evoked
magnetic field. n It was concluded that this heightcncd response was attributable to central nervous system hyperresponsiveness in the primary somatosensory cortex.
Acute pain involves biomcchanical insult (i.e., injury,
repetitive strain), biochemical mediation (inflammation), facilitation of algesic pathways, and finally neuromuscular
adaptation. If repetitive biomechanical insult is not avoided;
abnormal illness behavior is present; or deconditi~ning occurs, resulting in inadequate neuromuscular adaptation, then
chronic pain with central nervous system involvement (corticalization) can be expected.
To prevent the transition from acute to chronic pain, three
things should ocq~r once the initial acute, inflammatory
phase has passed: ( 1) patietll educaricm about how to idenllfy
v

and limit external SOlfl"ces of [);o/lll'chan;nt! ovcrlo(ld; (2)

early idelllificatioTl of psychosocial j{zctors (~r abnormal iff
Iless behavior; and (3) idellfijicatio/l and rehabilitatioll (~ftlu'
functional pathology of the motor system (i.e., dl'COlldit;ollill~
.~~vlldro/llc). This third aspect involves looking for specific
joint and muscle dysfunctions so that patient reactivation can
be promoted and deconditioning prevented. Figure 2.9 shows
how chronic pain can arise from dccol1ditioning syndrome.
, Pain is dcrived from the Latin term "poena" mcaning
penalty or punishment... Unfortunately, pain docs not always
serve as a good early-warning system, but/oftell arises only
after damage is done,. Pain alone is just a symplOm-the COIlscious perception of nociceptive aClivity. If [Jain relilf is the
01l/Y goal of care, thell decollditiolling afld variollsfulIctiOfwl
pathologies will remain as precursors to future bio/llccJ/(mical failures. Functio/lal re:"'toratio/l ill additio" to paill reliel
are appropriate goals because prevellfion of recurrent or
chronic pain is the ultimate goal of a cost cOlllainmelltoriellled approach. In as much as we can identify specific
functional pathologies that are causally linked-trigger points
or overactive muscles, weak muscles or abl1of!lIal movement
patterns, and joint dysfunction-we can then not only provide
symptomatic (pain) relief, but also restore function. Evcn in
the absence of uncovering a clear chain of functional patllologic changes. identifying deficits in functional capacity can
drive the reactivation of the patient by rcrnediating pain
avoidance behavior.
MUSCULAR PAIN, TENSION, AND INHIBITION

Muscles are often ignored while joints or disks receive the

majority of recognition as potential pain generators. For

THE PAIN CYCLE:

INJURY

REPETITIVE STRAIN

Swelling &
Inflammation

~ Soft Tissue

~~('oPain ~
Gradual

'VO/

Muscular

M~ru,,,~ ~09'""'~:
Joint Stiffness
Fig. 2.9. The pain cycle.

\,.,on""r

~---"'t.

~'

I t:.M .:: .

In 1 cur"'", I 11\l1I

19

Ht::HAtjllllAllUN INTO CHIROPRACTIC PRACTICE

years. skCplics have enjoyed pointing out thc unproven nature

of such clinically popular concepts as myofascial trigger
points. RC\'it:wing the lilc:ratllrc on muscle p~lin. however. rcveals the error or this omission.
Traumatic injuries overload the structural components of
muscles and lead In frank lissue disuplion and failure. Under
lhese circum~tances. incre'lscd muscle pain is predominal1lly
a result ()f neurochemical events. "Tr~lumatized muscles rcIeasc various chcmi(,;;'lls capable of aCliv;'lting no..:iceptl\'e
pain gcncr;nors.;J These chemicals can also activate nociceptive pathways via (HHaSsiulll. br;.ldykinin. or histamine
extravasation.
Increased mll~c1c (one or "spasm" has been widely used
as a descriptor for palients with p;'llpable stiffness in their soft
tissues. Unfortunately. viscoelastic connective tissue and neuromuscular factors arc rarely differentiated. Additionally,
terms such as increased muscle tone. muscle tension. tightness. stiffllc~s. shortening. hypertonicily. spasm. fibrosis. and
others arc llsed loosely and without ~dcquate definition.
Scicntific work in this field has been l~cking. but researchers
arc beginning to redress Ihis situation.74.7~
Although it is admiuedly unproven. muscle tension is
widely believed 10 go hand in 'hand with p~in. Muscles as the
active components of the locomotor system are responsible
for both reflex and centnllly mediated adaptations to repclitive strain. injury. or pain.
The significance and \'alidity of p~lIpable increases of soft
tissue tension or stiffness have been called into question by.
among other things. the poor reproducibility of electromyography (EMGI and lhe poor reliability of palpation. Nonetheless. as Paillard expl'lins. muscle tone is a key aspect of mOlar
control: "Muscle tone. once widely used as a basic semiological dimension of clinical neurology. is now almost totally
ignored by neurophy:-:iology. It (;'crtainly de:-:efvcs new COI1sider;,uions as a potent contextual dimension of motor pcrform;mce. "7f,
The organ of muscle lOne is thought to be the muscle spindle. which sels the sensitivity of the muscle to streIch. Boyd
refers to the muscle spindle <.\s " ...1 marvel of control engi
ncering. incorporating many of the features of an engineering
'servo-control' systcm."n In theory. muscle tone is greatly influenced by the amount of gamm<.l activit>, present: the greater
thc background gamma activity. the larger the intrafusalspindie response to any given change in muscle length (Fig. 2.10).
The gamma syslcm is under the coolrol of descending impulses from the cX.Ir'lpyramidal motor pathways. These higher
cortical centers (i.e.. the limbic lobe) arc more active under
conditions of emotional stress.
Many examples of increased soft tissue tension arc unequivocal. such as cases of acute lumbar strain. tonicollis,
acute appendicitis. peritonitis. and whiplash. To What, degree
st!ch ncuromuscular changes "lrc attributable 10 rencx, central,
or other mechanisms is unclear. It is also unproven to what
extent the muscle spindle or gamma system participlltes.
Increased EMG <Iclivity in muscles has been shown, as in the
case of the loss of the lumbar "ex ion relaxalion rcsponse. in

Afferent

impulse

frequency

High gamma

/ !/LOW

___ }

gamma

Muscle length
Fig. 2.10. Inlluenee of muscle length on spindle impulse freQuency al two different levels of gamma motoneuron activity.
(From Korr 1M: Proprioceplors and somatic dysfunction. J Am
Osteopath Assoc 74:638, 1975.)

patients with low back disability.'" In addition. sustained

EMG activity has been found in the nidus of trigger points.'9
It has also been noted that when pressure is applied to an aclive trigger point. EMG activity increases in musclcs in thc referred pain zone.l;O
Static overstrain. such as from prolongcd sitting or slumping, has often been suggested as a high risk activity for individuals with a back problem. Sustained contractions of only
4% of thc maximum voluntary contraction possible have been
shown to lead to negative cffccts.(,~111 Metabolites are produced that stimulate groups 1II and IV aUerents and increase
gamma motor neuron activity. It has also been shown that increased interstitial potassium concentrations sensitize the
groups III and IV muscle afferents. ,n resulting in an increase
in the sensitivity to stretch of muscles with convergent afferent inpu(Sj (Figs. 2.11 and 2.12).
Study of muscle fibers has shown that conditions of constant 10,1'1 affect the ability of a ltlusde to achieve efficient rclaxation.'4 As a result. tension and pressure build up in the
muscle.'J The more the muscle contracts. the greater the energy expenditure. Local ischemia is another key factor involved in increased muscle tone. Under conditions of ischemia. groups III and IV muscle affcrents become more
sensitive to strelchX-l (Fig. 2.13).
Ischemia itself is not painful; however. if II muscle
contracts under ischemic conditions. pain develops wilhin
I minute.lI~ Br~ldykinin is released during ischemia and is
therefore thought to be associated wilh ischemia-produced
pain."lJ Under eccentric muscular conditions. mild overload may swell muscle fibers without inflammation.!((;
Heavy eccentric exercise leads to swelling and necrotic inflammation. 1I7
Joint receptors. if stimulated. cause both facilitation and
inhibition of muscles. Low intensity stimulation of joint afferents in the knee have been shown to influence the sensitivity to stretch of Illuscles around Ihe kncc.w.llt-91J Also. rellcx inhibition of muscles has been noted when joints and ligaments
;,ue <Irthritic or swollen;r,7.'ll,J~ vasilis mcdialis inhibition is the
mOSl famous eX<Jlllplcyl Muscle fatigability resulting from in-

......-_._-_...

_----_.

 ._."

vr- Inc: .:)rll\lC: "'"

t'HAl.; 1IIIONER'S MANUAL

/'\J$Ck' reccplOfS

(stmAi: metabolilt's

l.'le<:lrolyles J
1lI,IV

H!

F'R'H!JlY "-'SUE

tVsch? spindlr

~t;t~';;:;;'Mt'\

,
i

(}yn.:mc W'Sit';ty\

SECCNJARY "-ISQE

Fig. 2.11. Pathophysiologic model for mechanisms possibly involved in the genesis and spread of muscular tension in occupational muscle pain and chronic musculoskeletal pain syndromes.
(From Johansson H, Sokja P: Pathophysiological mechanisms involved in genesis and spread 01 muscular tension in occupational
muscle pain and in chronic musculoskeletal pain syndromes. A
hypothesis. Med Hypotheses 35:196,1991.)

Fig. 2.12. Increase in muscle tone with chronic irritation of the small nociceptor afferents from skeletal
muscles. (From Dvorak J: Neurological and biomechanical aspects of back pain. In Buerger AA,
Greenman PE (eds): Empirical Approaches to the
Validation of Spinal Manipulation. Springfield,
Charles C Thomas. 1985.)

III.IV

AH.r.nts

alphaMolor
A.lI::on

"

,.'

CHAPTER 2 : INTEGRATING REHABILITATION INTO CHIROPRACTIC PRACTICE

Leclon
. -->-.

i.

Fig. 2.13. local vicious cycles in damaged muscle

as a possible peripheral mechanism for chronic muscle pain. The right-hand cycle is assumed to be
started by a tissue lesion that releases vasoneuroaclive substances (path A). The centrallactor of the cycles is ischemia, which can be produced by venous
congestion, local contracture. and tonic activation of
muscles by descending motor pathways (path 8).
(From Mense S: Nociception from skeletal muscle in
relation to clinical muscle pain. Pain 54:241.1993.)

IA

Rc le4se o[
v4soneuTo~ctive

substances

LOCo'll

Fa Hure o[

I
I

Col++

I
I

OedemA

ischo'lemia

pu:~p

Contracture

Jt'
I
I

21

Venous
conqcstion

18

1~

I
I

I C)
~

I {.
<"1:\

\y

'..y

ii

()

i~

-"-.Ji

C~

II

;;

~
.~'~

'-..>;.JI

I
I

(,)
~;--""

-J.;.J}

!-~ (}

! f}

I
I

Increase in
muscle tonc

via descendinq
pathways

hibition of certain muscles required for a task is a likely contributor to overload injury or pain.9.,.I1~
Hides et al. documented/unilateral wasting of the multifidus muscle in patients with acute low back pain/"~ With realtime sonography. they measured cross-sectional area (CSA)
of the muscle and determined that the wasting was isolated to
one vertebral segment. The wasting occurred rapidly in a 10'
calized area and was thus not considered to be the result of
disuse atrophy. The authors were abk to correlate the area of
wasting with a dysfunctional segment identified on clinical
manual examination (i.e.. motion palpation)....ln patients with
chronic back pain. CT scanning demonstrated generalized atrophy but a relative increase in the CSA on the symptomatic
side~~ Such a relative increase in the CSA could be explained
by Ihe findings of increased paraspinal muscle activity% and
hi..ologic evidence of type I fiber hypcl1rophy on the symptomatic side and type II fiber atrophy bilaterally in persons
with chronic back pain.!H
BullockSaxton et al. described gluteus maximus and
medius inhibition during gait. and their subsequent facililation after a brief course of propriosensory retraining."ll Janda
also reported r~ciprocal inhibition of the abdominal muscles as a result of stiff. overnctivc erector spinae musclcs.r~)
He showed that the abdominals became spontaneously
stronger following inhibition and stretching of the erector
spinae. Headley successfully demonstrated inhibition of the
100ver trapezius muscle during shoulder Oexion or abduction when active trigger points in the upper trapezius are prescnt.lI~ Simons also reported inhibition of the deltoid muscle
during shoulder flexion when infraspinatus trigger poilHs arc
prescnt.!!!)

TIIP ;/lirhtl muscular reactioll to pain alld injury has trat/itional/y been as.mlllct/to be im:reased tell-fie", ami slijJ"ess.
Data ill Ihe lilerlllure indicate ilihibiliull is at least as significallt. Tissue immobilization occurs secondarily. which leads
to joint stiffness and disuse muscle atrophy. Such changes become a habit. mediated by central motor regulatory pathways
as a new "pain-motor program" forms.
The combination of trigger points. muscle inhibition, and
joint dysfunction arc kcy peripheral components of the functional pathology of the motor system. If sustained over a period of time. these components 1ll.1Y outlive the elimination of
what caused them in the first place. This f<lct is of concern in
cases of cumulative trauma (rcpctilive strain) disorders and
prevention of recurrences after acute injury.
JOINT DYSFUNCTION AND PAIN

According to Schaiblc and Grubb. "The major sensation th'..lt

is ascribed to the joint is pain:" l ,(] The joint is involved in
pain, proprioceptive. reOcx muscul~\r. renex sympathetic, and
other neurobiologic events. Thcsc events arc depicted in
Figure 2.14. Although joint afferenls participate in movement
and position sense, proprioceplion is primarily a muscle
sense.IOlJ.11J1
/fyperstmsitjvit)' (increased or abnormal paill respo/1se)
ofjoints to movemellf is a key factor ill the developmellf ofthe
dec:omlitioning symlrome. Groups III and IV afferCnlS can develop "long-lasting 'sensitization' to mcchanical stimuli after
the onsct of joint inflammation.... many of them have been
fOllnd to exhibit ongoing uisclwrgcs whcn the joint is kcpt in
its resting position."II~' Mcch.mo-inscnsitivc affercO!s arc also

 _ ....... '

Enhancement olthe
ellecliveness 01 descending
inhibilory inHuences

Increase 01
nculopeplide ..-'"
PrcduCliOn\)
_

,~r-

, ............ ,,<;;. M.

r'"t'1,",,1.,..11 t IUNt:.H::;

MANUAL

Increased a!1Clcnl ,nllow

(group II. Ill. IV sensory MIleS)

l_.__

Release 01
transmitters and
modulators

Release 01
neuropcplldes
from allelcO( ................
fibres

Increased synthesis
of neuropeplidcs
Gene expression

Hypercrcilability
01 spinal neurons
wilh articular input

\
\

Synthesis 2M
release 01
inll<1mmar:;rj

Ascending fibres
e.g. spinothalamic tracl

medialc:!.

Fig. 2.14. Overview of neuronal events in the course 01 an inllammation in the joint. (From Schaible HG. Grubb SO: Afferent and spinal
mechanisms of joint pain. Pain 55:5, 1993.)
;

prCl\ellt. These "silent nociccptors" also can become pain

prodlicers when sensitized by inflammation. II.)
Joints as a source of pain are ,111 too frequcntly ignored. In
a study of318 consecutive patients with intractable ncck pain.
examined by provocation diskography and/or zygapophyseal
joint blocks. 26% of the patients had symptoms aSl\ociatcd
with a joint. whereas 53<;(: had symptoms related 10 a disk.lU~
In a similar study. 56 patients with neck pain a"od no l\igns of
nerve root involvement of at !C;'lst 6 months dural ion were ex
amined. The results shO\vcd 23% had a symptomatic joint.
20% had a symptomatic disk. and 41 % had symptoms rel;'ltcd
10 bOlh a disk and a facet joint. lU.\
Referred pain is often ascribed to nerve root irritation. bUl
joints arc also a likely source. Activated joint affcrcnts arc C<lp<lble of giving rise to referred pain. Cat spill<ll cord neurons
with knee input had clHl\"t~rgent input from muscles in the
thigh and lower leg and the skin. )(J.I Cutaneous reccptive fields
were found as distant as in the foot.
Johansson et a1. reviewed the motor rcnex effects of joint
afferent excitation.(~} Under non-noxious stimuli. joint afferellis excile significanl amounts of reflex galllll1<.\ motoncuron
activity,6Q which probably <Issists tnthe regulation of stiffness.
Longlasting noxiolls stimulation results in activation of thc
nexioo reflex (Fig. 2.15).loints me also supplied with efferent sympathetic nerve fibers. which .arc cap;'lblc of consistent
rencx discharges. wo ,
As mentioned prcviowdy, joint inflammation call give risc
to fcnex inhibilion of lllusc!CS.{7.'.11.'}2 The knce was the modcl

in these sllldic~. hut spinal joim dysrullI,;tion has hecn com:>

latcd with mll\dc \vasting in paticlIis \\ illt aL'utc low h'lck
p;lin ;IS wei I.""

,
J

SUBLUXATION. REFERRED PAIN. AND NEUROPATHIC PAIN

lllc chiropractic suhluxation involves biOl1lcdlal1ical alter;'Itions such <I" viscoelastic "tillness in addilion 10 neufuphysiologic,i1ly mcdi'ltcd dorsal horn scnsitiz'ltion. Such sensitization has .1 nCl!foanatorni<.: basis in primary 'llfercnts and
secondary dors.t1 llllrn neurons. ikcausc of ncuroplasticity. a
rcduced pain threshold fmll1 primary affcrellls coupled with
an exaggerated p;tin rc~ponsc 1c;tds 10 hyper;llgesi,1 and referred pain. Tod;ly'S pain \cicl1tists call thi" sensation "neurolXlthic pain:' Previous rC'Icard\ W.IS led hy ostl'opalhs who
termed this neurolllcchanical phcnomcn;t thc "facilitated segment." Pmtcrson says of Ihe facilitated segment thm " ... be
C;IUSC of ;;Ibnonnal affcrem or crferellt sensory inputs to a par
ticul<lr area of the ~pinal cord. that area is kcpt ill ;1 state of
constallt increased excitation. This l"'lcilitation allows nor
mall)' inefl"cctual or sublimirml slimuli to becomc dfc<':livc in
producing cfferclH output from the bcilitatcd scgmcllt .. _.. It~1

(Fig. 2.16)
As long ago ;IS 1883. Stlll"gc suggested th"\1 an injury
could trigger a dwngc in the ccntr;:11 nervous system such
that lIormal inputs would evoke ~1Il ex.lggcrated rcsponse. HI~
[n 1893. ;vbcKcllzic proposed that referred p'lin ..:ould fC
suIt after sensor)' impulse" from injured tissue IW\"l~ created

.,,

,
}'

vNr\1"' I tH ;.: : ; IN I tUHAIINl,;i REHABILITATION INTO CHIROPRACTIC PRACTICE

23
Fig. ~. i 5. .suggesteo nelworK of lac
tors contributing to fixed flexion of a
damaged joint. (From Young A. Stokes
M. lies JF: El1ects of joint pathology on
muscles. Clin Orthop 219:21.1987.)

IMMOBILIZATION . . . . - -

,I
J

<--~

!,

<~

\)

~ FlJxI:::/

()

CONTRACTURE

<)
--w?

!
J

an "irritable focus" in specific spinal cord segments, II", Perl

cl al. lOi and Kcnshalo and co_workcrs lt1lt made the initial
experiments that showed that noxious sensory :-;tlmuli pro

()

duccd heightened sensItivity 01 dorsal horn neurons to future

stimuli.
A new concept called "ncu1"Opmhic pain" iJ being pitt for.

ward to explain the common clinical prescuwlioll of persis

[e/lf pain. hY{Jer.w!ll.'iitil'jry, alld poor motor cOlltrol ill the ab-

,,}

::('II('e of a pallia-til/atomic or Ileurologic expJlIIull;01l.

Bcc<lusc of the poor correlation between presenting symp

toms and objectivc physical signs, the pain experienced by
these patients is commonly misl~lbelcd psychogenic. Ac
cording to MCP.'kcy. "There is increasing cvidence lhal signs
and symptoms tlwt were wkcn to be proof of hystcria-or
of behavioral disorder-such as a failure of complaints to
observe anatomical boundaries. may have ;:; physical
b;:ISis."I(~I.11O @.cgional pain syndromes and regional loss of
sensitivity can have a. pathophysiologicalorigin-r:C"Gtcdto
expansion' 6r-rcceptm- fi-eld~ th'ro~ugh the responses lo peripheral injury of spinal cord ncurons." l lJ'J.llli According 10
Nachemson. "various pool501' ncrve cells in the dorsal
columns can be hypersensitized and thus c;:ln sigrml.a pai~ful
condition oven though there is-vcry lillie-peripheral inpl}l."'lll
The implications of Ihis research in v;:llidmi'ng the com
plaints of millions of pain sufferers is remarkable. The sub
luxation hYl'othe.\ix backed stead/waf), by rhe c:hiropractic
l'/'(~fcssion appears to be Oil rite \,(!(t:e of scielltific validatiOf/-if/ a modljied form-by (1/1 independellt group of neuroplrysiologists .\wdyillg poi" fl/ec!wninlls ami behavior. That
this group of scientists 1ll.lke no mention of chiroprJctic nnd
ollly occasionally refer to the physical medicine theories of
rnyof<.lscial pain by Travel! and Rinzlcr and of zygapophyscal
pain by Bogduk .Illd Twomey is intrigllillg.'~Il~)"~ What is

.c':~

\J

1,)
~

{')
-;-J

t0
B

()

i,

(}

()

!
I {J
-~

'0P

:t

it'
,~

I
~

fJ
>

r~

L.

most exciting is lhallhcy Me attacking the notion {hat pain 1';1tienls with few objective signs have psychog.enic pain.
Ncuropathic pain is considered cOlllmon in causalgia.
rcOex sympathctic dystrophy. posl-herpelic ncuralgia.
stroke. syrillgolll)'cli~l. syringobulbia. multiple sclerosis. and
spinal cord injury. Ncurop:.lthic pain C;1l1 also result from
a rcpclilive strain initiating strong affcrclll nociceplivc
b<lITagc to dorsal horn ncurons. eventually leading to sen
sitization of those neurons bec.lUse of central nervous system plaslicity. As (f re.vu!t (~r sensitizatio/1 (~{ secondary
donal hom l1eurons or II dt'crellsed thr(!s!lo/d for prinulI:r
peripht'ral (~{/('re1l1s-illdlldillg I/ormally [Jai,,- i"sellsith'e
groups I and f( ({{erelll.'i. i1lput/rom I/ormal m('chwlOreCt!fHor
ufferelll!i {'(III be interpreted as lIoc;;ceprive. 11.\ Sensi[iwtion rc
suits in allodynia. deep hyperalgesia. poor motor l..'ontrol. and
an cxpansion of the receptor field.
Neuropathic pain is relnted 10:
Allodynia-Lowering of pain thrc"ihold (c:",:n [() 110nno~iolls stimuli) and pail'!... thai ;:Irises front activali.illL
_~of$cnj,:.orv channels l~l;lrULw~)f\:cd~\Tn<e.g.. low
Ihrcsllold l1lcchanOrcccplors ILTMj,.
Tnt: Scnsitivity to non-lluxious stimuli ;IS in light p,t1patiotl or
percussioll of noninjurcd lissues and pain wilh physiologic
joint 11l00'cmcnL
Hypcnllgcsiu-lncrcOlse ill rcspollse to ~upr;llhreshold (i.c.. IlOX
ious) stinlllii. fI,<techanic;ll hypcralgcsi<l is pain during movcments in lhe working range or pain Oil g('lIll(' pressurc.
Closely n:[alcd 10 persistent pain.
Test: Posilivc jump sign (p;lli('lI( wilhdra\\'~ll) with son liS$UC'
palp,lIiun or Iloninjurcd rissllc. Withdrawal with passive m'crpressur~ at lhe end or Ihe physiologic r;:mge (l( joint movement.
CutallCHlls H~'(lnc<;thcsi:l-[)ecn:::lscd sensalion ()[" :,cllsitivity.
Tnl: DecrcOl:'cd ~cn~atioll III pin prick.

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

De'!.cend,nQ
sysl~ms

I
-

Small d'OmeTer ,npvl

To osccnd,nQ
syslem!>

(ommon pool or

COnnC(lor neurons
With thruhold
K

lUres. Stimulation of viscera docs not .tlways produce

pain. btU \'isccral aftcn::nts projecting into the dorsal horn
do lypic<lliy converge Wilh skin <lnd/or deep somatic
:->lructures. I ).I.117
COl\\'crgcm::e and (elllral neural plasticity provide the
ncuroanatomic basis for pain rdefr<ll. It hus been reported thut
lll;lIlY :.lllercnt units. whcn noxiously stimulated. elicit pain in
two distinct rcceptin:: fields (RF).Ill'1 Branching of the "ffcrent
fiber 1ll:'1r its termination point is thL: likely anatomic ex pia nillioll. According to MCllse. this convergence would. "reduce
the spatial resolution of the nociceptive system ilntI thus could
contribute to the diffuse nature of deep pain."n It has been
~:.llown that dorsal hom neurons are able to change the size.
J\ulllbcr. and sensitivity of their RF under thc innuence of
noxious slimuli.lI<,l'~1l
When noxious stimuli arc applied experimentally. referred pain into new RF typic'llly takes a few minutes to
OCCUr.1~ Ncuroplaslicity seems to be QI?filting as ncw central
ncrvous connections are formcd after peripheral injury. It hilS
j been shown lh~llvi~~ceral pain, such as from a coronary .in. farct, can be referrcdJ9. ;U.n.Ys..-cJi::.J.!ku~~...1!c'oralis!!!'.lj9r.ll~
The muscula.r l<lrget for rcferred pain may also show signs of
Ilype-r.algesTa~m--

Fig. 2,16. Physiologic mechanism 01 the ~irritable focus in the

grey maHer of the spinal cord. (From Grieve GP; Simulated visceral disease. In Grieve GP (ed): Modern Manual Therapy of the
Verteberal Column. Edinburgh, Churchill Livingstone, Edinburgh,
1986.)
H

Poor 1'..lotor Contro'-lncoordin~lIi{ll1()r POD( balance.

Test: Incoordinatcd !novcmClH pallcrns or gait; ro~ilj\,c
Rhombcrg or Hamanl tcst
Referred Pain or Sccondur)" H),JlCnllgcsia-Sprc:ld of p<lin or
hyperalgesia 10 uninjured or normailisslic in ,I dcnnatom.Ll or
nondemm(omal distribution.

Test: Trigger point cvalu<ttiol1, pain I1mppillg.

Sympathetic Symptoms-Vasomotor effect".
'1esl: Moisture. thermal ch.mgcs in tissues.

Neuropathic symptoms have been shown to be rel,lted

in part to convergent input in the dorsal horn from skin
and/or deep somatic (visceral and nonvisccral) struc;.

- Thepr~ncc of nondcrmatomal referred pain and hyperalgesia implies thnt ccntrill changes independent of convergence arc operative. ,~~ An example is the situation in which
referred pain spreads to the site of iln old injury. An angina at
wck has been shown to refer pilin directly to an old vertebml
fractllre.l~1 il Iws also becn demonstrated that I wcek after
dental surgery. pin prick of the nasal mucosa Ciln produce referrcd pain to the treated tceth. ,~~ Distant referral of pain to a
nondermmomal arca can also occur. such as in cardiac pain
referring to the ear.12~ It has also been shown that a decrease
in the fkxion withdrawal reflex threshold is present in women
aftcr gynecologic surgery.'l
What is Sensitization? Sensitization is a change in the
stimulus-response profile of dorsal hom neurons so that the)'
respond to mech;:moreccptivc ilfferents as if they were nocicertors, 12f,.I~~ \Villis explains that a nociceptive barrage leads
to central sensitization of dorsal horn neurons:I~(J "If these
lH>ciceptivc neurons have convergent input from mcchanorc
ccptors. their responses to both innocuous and noxious mechanical stimuli will then be increased.... Sensitization then
causes formerly subthreshold responses to rench threshold
and trigger disehargcs."'u, According to Mayer and colleagues. "Overwhelming evidence suppons the conclusion
that a change in the central processing of input from lowthreshold mcchanorcccptors is responsible for secondary hyperalgesia to light touCh."I~lI Silent nociceptors that arc
mechano-insensitivc also can become mechanoscnsitive once
sensitized. 1flo Table 2.4 lists the neural changes associated
with sensitization and Figure 2.17 depicts the p::Hhophysiology of sensitiz'ltion.

,
j

How Do Mechalloreceptor A[[ereflts Cause Pain? The

Neurochemistry of Neuropathic Paill. The p:'lthophysiology
of neuropathic pain involves peripheral ilnd central neural

Ji;

25

CHAt-' I cH Z : 11'1 I I::UNAllNli Ht:HAI:ULlIAIIUN INTO CHIROPRACTIC PRACTICE

Repetitive strain

Hysteresis and deformation

tc

(")

() ,

I -

~~-)

Decreased tissue fatigue/failure point

Sustained aHerent barrage in types III and IV

Mechanoreceptorslnociceptors

()

Sensitization of dorsal horn neurons

1
r,

Fig. 2.17. The pathophysiology

Neufopathic pain

()

of sensitization.

10

10
0

c\'~nts.

Sustained activity in types III and IV (small diameter)

primary affcrcnts leads to a rclcflse of excitatory amino acids
(gl~t<lD]_aJc) ,and _neV~...P.21iQe.s, ,(sllbs,t,al1:~~~Pt:i.I.l~~lredorsal
h.orn. Increased concentration of these neurochemical media
tors lowers the firing threshold for primary sensory affcren Is. 116.127 In the presence of certain neurotransmitters, secondary dorsal horn neurons may become hyper-responsive
because of cxcitatory amino acids acting at N-methyI4o-aspartate (NMDA) receptor sites and activating dorsal hom nociceptive neurons::t>,;!.7 Secondary neuron hyper-responsiveness after repeated stimulation is called "wind-up" and is
often short term. Inhibitory amino acids such as GAB A arc
present to dampen this exaggerated response. but. over time.
segmental inhibition is deactivated by the flood of cxciuttory
<Imino acidsy'I.I.'O Long-lasting changes appear to be the result of oncogene activation by strong nociceptive input. 11f'
Oncogenes such as c-fos enter the nucleus of the neuron and
regulate lHher gene activity. According to \Villis. "The implications of this chain of events arc still unclear. but a potential
result could be long-term changes in the responsiveness of
nociceptive ncurons.I~r;
Pathoanatomic Changes in Neuropathic Pain. Peripheral nerves can sprout after peripheral nerve injury so that low
threshold I11cchanoreceptors C..1Il extend to tcrminate within
the superlici"ll dorsal horn and make direct connection with
nocicepwrs.I.'l.I.Dl According to Dubner. peripheral nervc damagc Icads to an expansion of the low lhreshold portion of wide
dynamic range (WDR) neurons bcciluse of a loss of sur-

1
! ~.)

10
I

-.

I ()

I~

10
i ;)
,~

,
,,

't,

()

l'

.(~

\,j)

-,J

I ()

I ()

'~

I ()
!

1~ 0
,j

{#

Table 2.4. Results of Sensitization ll2

J.)

Increased spontaneous activity of types III and IV primary afferents

Prolonged after discharges of afferents to repeated stimulation
Decreased threshold to afferent input
Expanded receptive fields of dorsal horn neurons

,i ()
~

ii

\J

it (}
1

'"

t,
l'

~'~

\Wi'

()
t''?J

h-

rounding inhibition.I''' Increased c.xcilability Icads to ex

The most sensitive neurons ilrc small
local circuit inhibitory neurons. 1.'1' ~vlorphol()gic changes have
been demonstrated in thc r..1t dorsal horn after p;lnial nerve
injury.I.'o.l.I.I

CilOlOxicity_I~!I.I.\I.1I:

CORTICALIZATION OF PAIN ANO CENTRAL MOTOR

REGULATION

The locomotor system has peripheral (sensory and motor) and

central (programming) components. The peripheral components (somatosensory. vestibular. visual) pro\'ide input and
feedback (afferent) as \\'ell as carry out the instructions (efferent) of [hc central motor regulatory centers (cortex, cen:bellum. basal ganglia. etc.) (Figs. 2.18 and 2.! 9). Prolonged
or intense noxiolls. sensory stimulation call !e;IO lo dorsal
horn sensilization. reorganization of somatotopic maps. limbic dysfunction. and reprogr'.lI11ming" of movcmelll patterns.
Abnormal illness behavior in response to subacute pain
encour<1ges ehronicilY. Poor slecp habits. high Icvels of emolional stress, and excessive fear or anxicty Illay stern from a
limbic dysfunction. This condition negatively affects the mu:o;culoskclctal system by promoting physical and psychologk
dcconditioning. Magnetocnccplwlographic and evoked potential studies in patients with chronic low back pain ha\'~
dcmonslralcd ccntral nervous systcm hyper-responsiveness in
the primary somatosensory cortcX. n :i .1 M"lgnetoencephalogmphy has revealed a somatotopic cortic,ll nl<lp reorganization
in patients who um.lcrwent reconstruclive surgery.l.\.l TheH the
central nervous system is involved in painfulml1sculoskclcwl
disorders is no longer a question.
In response to chronic pain. ncw movement patterns arc
adopted that aHcmpt to reduce noxious stimuli: these arc often
tcmleo "pain-motor progr<lllls:' Movement patterns repeated

nc.nMOIL.llf\IIUN OF THE SPINE: A PRACTITIONER'S MANUAL

MOTOR
CORTEX

RED NUCLEUS \

r.:::J..+-r
MESENCEPHALON,

~-~--11

PONS, oml

MEDULLA
SUBSTANTIA
NIGRA ---

Spinoc.etcb~Uol

hoC I

Corticospinal
Irocl
Reliculospinol
- and Rublospinol
IIoels

Fig. 2.18. Pathways lor cerebellar control 01 volunlary movements. (From Guyton AC: Basic Neuroscience. Philadelphia. we
Saunders. 1987.)

onen enough arc learned by the cerebellum. This new central

programming is called an "engram." In regard to this pro
gramming. Pail lard says. "The existence in all animals of a
consolidated rcperloirc of motor capacities. either inherited or
secondarily acquired. is now all incomrovcrlible fact of contempof<lry ncurophysiology.";(' Treatment of chronic conditions will likely fail if only peripheral targcts (i.e., muscles.
joints. etc.) ure ~t<.ldressed. Successful care for If/{' chronic "atiem will likely im'o{l'i' treatmellts aimed at the peripheral
pain generaror.>;. central motor regularion. lind psyr;/lOsocial
facto,.s.

RETICULAR
fORMATION

Fig- 2.19. Pathways for cerebellar "error'" control of involuntary

movements. (From Guyton A: Basic Neuroscience. Philadelphia,
Saunders. 1987.)

we

Sherringtol1'S Law of Rcciproc~1I Inhibition (Fig. 2,20). Thus,

if Cl TU/'ilum{ mllscle SllC" as the iliop.WlJ.\' become.\ .'ihortemd
frorfloverusc. flot olily will it lJu!(:lumically {imit Ihe rang('
motion of it,'I {Jlltllgolli.'it 'fie 81weus max;mus. bw also iT
. wifl 'leurolO);ically illh.i11ir.j1S_GCI,h}!l as well. This combin:l
tion of biomcchanical and neurophysiologic influences is a
Clinical Features
strong stimulus to the creation and maintenance of muscular
MUSCULAR IMBALANCE
imbalances.
\Vhen muscles reacl lo protect the body from harm or lo reElectro'myographic (EMG) data (Fig. 2.21) show th;:tt a
duce pain, certain muscles become overactive while others
tight erector spinae muscle will be active during its rever:,\:
are inhibited. As a result. joinl stress is altered and greater
:lction. trunk flexion. and thus inhibits the action of the agolIluscie fatigue results. For such prolective reactions, [he poslural or anligravity muscles arc activated most easily,
Table 2.5. Postural and Phasic Muscles 13S
Conversely. muscles wilh a primarily dynamic or phasic function tend to be inhibited when physical Slress is prescnt. jandll
Postural (Tend to hyperactivity)
Phasic (Tend 10 hypoactivily)
and co-workers. who studicd thcse typical musclc rcactions in
Triceps surae
TIbialis anlerior
both neurologic and onhopcdic patients. call this common
Hamstrings
Gluteus maximus
clinical phenomena "muscle i111balancc,"I~~-I,I~
Adduc(ors
Gluteus medius
Reclus femoris
Rectus abdominus
Janda l11ul co/{eaglles (.'x"llIined that the basis for most
Tensor fascia latae (TFL)
Lower/middle trapezius
t1lflscle ;ml)(llallces comes from our predicwble respot1se to
Psoas
Longus capitus & colli
stressfttl cnvironmetltal demands (constrained pO.'iIUreS,
Delloids
Ereclor spinae
Digaslrics
Quadratus lumborum (QL)
reperiiive tasks, gravity stre,'iS, inactivity). They identified
PeCloralis
that the pO!'itural muscles tend toward overuse and eventual
Upper trapezius
shortening, whereas the ph'1Sic muscles tend toward disuse
Sternocleidomastoid (SCM)
Suboccipital
and weaknessl~-l~l (;rable 2.5). These muscles arc oftcll
Masticalories
grouped as paired antagonists and appear to be affected by

\/tlf

,,

27

CHAPTEH 2 : IN' ~l:iHAl ING REHABILITATION INTO CHIROPRACTIC PRACTICE

Sensoly ncu:uOl 1, ...,10

flelCOf muscle! spindle

\
Inhibitory

Intclnouron
E.. lcnsor
nlusdc

ttdeeps)

Fig. 2.20. Reciprocal inhibition 01 motor neurons to the opposing muscle. Impulses lrom
ttle contracted muscle .e.xcite motor .unit:!,(
the same muscle (faclhtory synaptic)nlluence designated with a plus sign) and inhibit.
through an interneuron. motor units in the
opposing muscle (inhibitory synaptic influence designated wilh a minus sign). (From
Lehmkuhl LD. Smith LK: Brunnstrom's
Clinical Kinesiology. PhilEldelphia. FA Davis.
1983.)

t)

()

htensor ~
mOloneuon
ui.lub'lCd

o
First Recordino

J\)'

-. I '.1. r--r::x::;rj

rect.obd.
lower left
er. sp.left

loop,vL
ISEC.

"'_,--

~....:

_!>

... ...... -.
...
:l

recto abd.
upper left

Second Record ing

""

41

JV

",

~
I ". ~

~,~
_:~~....L

'....-

Fig. 2.21. Electromyographic

activity before and alter stretching light muscles. (From Janda
V: Muscles. central nervous
motor regulation and back problems. In Korr 1M (ed): Neurobiologic Mechanisms in Manipulative Therapy. New York.
Plenum. 1978.)

~.

An intermediale muscle type is FR::::':J~I~!_~~y.itch fatigue

This typt: resists fatigue but illS0 has f,lst COlli raction nnd relaxation speeds. The FR type has both aerobic and
t1naerobic metabolic e<lpacilY. Like type I unilS al rest. a high
met,QJ:tolic price is paid for Illaint:.lining this fiber type.
,'- L'v1uscle types COtll he convertcd with trail1i~.lli.L1" With
'The lJO...wrai or lUlligra\'ily muscles mUitUllin ereCl SIlt/fli- ./ regular electrjc~ll stilllulatiol~ muscle hbe~:s' c:.1Il begin
illg ill gaif. The majority ofllormal gait is -'"lJell! on olle Ie}.:: ! to have altered contractile char<lClcristics within 2 weeks.!.l'l
,here/ore. special l'lI/pllll.,i", ix placed 0" the mlt.w:lex lIl\'olved }I By 6 weeks of training. histochemical ;lppeOlrance is altered.
ill olle leg ",'allC/illg. Sedentary life in modem society resulls
and within 5 months. lhe muscle behaves cntirely like a posin Overuse of postural Illuscles. thus encouraging lightness to Ltural muscle. Keeping rats under hypergravity can turn fastdevelop. Simultaneously. the ph:'ISic or dynamic muscles tend
twitch into slow-twitch libcrs.""Endurancc training CJon also
10 become weak from disllse. Postural and phasic muscles arc
alter rnt!scl.~~harilctedstics. When stimulation or lrainlll~c up of miXCirfi6Cri cs; however. "slow-twitch" fibers
irll! is withdr:'l\vn. however. the Illuscle gradually rc!!ains ilS
ro;mer prop..crties./~-- __ _n
-'
..
..(type I) .Irc predominant .in_ postural llluscles antI "fi.IS(twitch" (type II) fibers arc pr~d(;;;;i~~~~t' in -phasic muscles"
A-gro\ving body or evidence shows that Illusele imTable 2.6 dcsl:r{bcs the chilr;lc-icristlc:<>-or[rlcsE-dlff:C~~~-ttYi)esl
b;l1anccs (Illusde atrophy and hypertrophy) are prescnt in

nist. the abdominals. Alkr the crector spin'Jc muscle has been
strelched. not only docs it relax during trunk llexion. but ulso
:'1 significant. spontaneous facilitation effect is seen in the an
dorninallllllscics. Figure 2.22 shows the typic<lllowcr crossed
syndrome. which rrcquclHly develops as a result or llluscular
imQ.al:.Ulcc in the Iumbopelvic region.

~sistant:'

yp

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

Erector Spinae

,,,

Abdomlnals

.,

I
/

Glu1eus Msxlmu$

Iliopsoas

Tight

Weak

Of

Weak or Inhibited

Inhibited

Tight

Fig. 2.22. The lower crossed syndrome. (From Jull G. Janda V:

Muscles and Motor Control in Low Back Pain. In Twomey LT.
Taylor JR (eds): Physical Therapy for the Low Back. Clinics in
Physical Therapy, New York, Churchill livingstone. 1987.)

patienls with acute and chronic low back pain. Hides et af,
found lUli/metal, s('gmcmal \\-'(1.<011"8 oft},c multifidus ill llclll('
back pain patients.I>~ This dumge occurred rapidly lllld thlts
'was nor considered 10 be a di.Hl.\'C arroph,,: Stokes eI al. !owuf
generalize,! atrophy in paticlIIs with dmmic back pain. but (l
rd(ltive increase ill the CSA was noted 011 the symplOmafic
-",yide. 9J Type I Jiber hypertrophy on the symptomlJlic side and
........... tYl!!. II fiber atrophy bilarerallv have been documented in
c~roTllc back pai" patients.,}7
Muscles housing trigger points have been shown to have
dramatically different levels of EMG activity within the same
functional muscle unit. Hubbard and Berkoff showed EMG
hyperexcitability in the nidus of the trigger point in a taut
band that had a characteristic pattern of reproducible referred
pain. 79 Case studies. havc also revealcd that trigger points in
one muscle are related to inhibition of another functionally rcImed muscle. 7l19 !i In particular. Simons showed thalthe deltoid
muscle.can bc..inbibl~d _~Y!lc~1JlLcre arc infr~~p)'na1Us trigger
points.ll(t HC~ldley has .ghown that lower trapezius inhibitio~ is
related to trigger points in the upper trapezius:;:

Muscle imbalances alter the performance of related movements. Repeated performance of abnormal movements leads
incvitably to further strain, which can perpetuate muscular
imbalances andjoim dysfunction. In the work place, the combination of muscle imb<'llance and performing repetitive tasks
in constrained postures has contributed to 3n epidemic of
ovcruse syndromes.
Musch's that become overactive or tight are (~{t(!" said to
be ill "spasm. .. Loose application of the term spasm lead.\ to
inappropriate trearmelll selection. Clinical decision /flaking
would be bella sen'ed if muscle tellsioll or stiffiless is viewed
as being related to either viscoelastic, cOllnccth'e tissue.
llnd/or lIeuromuscular facrors. Trigger points. acute torticollis, appendicitis, lumbar strain with anlalgic posture. and loss
of the flexion-relaxation response in disabling lumbar pain
syndromes arc examples of incrc<'1sed neuromuscular tcnsion. 7677 Elevated EMG activity typically is present in such
situations. C.Q.nnectivc tissue changes in a muscle or its fascia.
such as adhesion or scar foonation, usuallx arise gradually
after trauma whcn the acute, inflammatol)' phase is prolongcd:'5 Improper healing allows fibroblast proliferation and
eventual scar fonnation. 45 Viscoelastic changes without increased neuromuscular tension also occur in the gradual muscle shortening seen with aging and scdentarincss.
A central source of increased neuromuscular tension is
theorized to be dysfunction of the limbic system. 1-1 This condition is thought to be related to abnormal illness behaviorslecp disorder, depression, anxiety. fear-and is <lccomp:micd
by generaliz.ed soft tissue tenderness. Sarno used the descriptive tern1 "lension myositis:' whereas others commonly refer
to this neuromuscular tension as fibromyalgia. 141 Fibromyalgia patients tested with laser evoked potentials have been
documented to have hyperalgesia. 142
According to Janda, the most typical types of functional
muscle weakness arc as follows. Tightness u(akw:s.'O develops when a muscle is chronically shortened and eventually
loses strength (i.e., IJSO<lS).I.I,1 Stretch weaklless occurs if a

.~

--- -

-----

,"

Table 2.6. Characteristics of Muscle Types"'ill20

,,

Type FF -Fast-Twitch
Characteristics

Type S "Slow-Twitch"

Fatigable"
Type II

Type I
Fatigability
Metabolism

Energy
Capillary

Resistant
""Oxidative
MitochondriaJATP
Extensive

network

Metabolic
preference
Speed 01 can

Constant muscle
length
Slow

Easy
Anaerobic
Glycogen
Minimal

(MUSCle shorteningJ
Fast

traction,
relaxation
and force
generation
Metabolism al

Low

rest
Function

Posture "antigravity"

Phasic "fight or

m9ht~

-.

-".'.

h;

~v~n~M::r:..:,.:~::n:":<--"--"::''':'''--,~:,V:'':''':"M:'''--,':..''::.U::...:....::t::'''.::'''::.::~:.:'L::'--,',-''',-'_'U:..:."_'N_' U:..:.<;:.''-H'-'H_U_P_H_A_C_T_'C:..:.P_R_A..:C'-T'-'..:C::.E=-

muscle IS p~lp.:tually plOlced in ;1 lengthened po:'\i(ion so that

rhe l1lusclc...:<;pindks become dl'SCI1",itizct! 10 strctd, ~i.c .. glu(eus l1laXilllusl.I~' .:f.;,hrogt";c W('lIkIlCS... occurs when nociceptive affcrciH barrage from a j()im or ligamcllI causes a rene" inhibilion.I~.1 Examples arc the V<lslu'" medialis "ftcr
injury of the alltcrior cruci;llc li~t or Ilh~~S or gluteus
IUAxin~~wcak~~~_~__whcn ;1 sal.:roiliac dysfulll'tioll js prc-

""

WL l-'J. Fin;'llIy. ,,.igga ,milll

!")
I"'"/

i
~

:"~

I""'
'.J

\I"("okm'.'i.\" occurs whell a muscle

C3nnot fully .1(ti\";ilC all its conlr,Klik libers hel'allse or the

presence
a trigger POil1LI~\

or

Common types of ItmSCUI;\f dysfunction. like tri~c.cr

points, arc bc:o;t understood in till' context of IlHISl'ubr imb:dancc. A short. tiglll po:O;\lIral !l\u:o;ck lllil)' house trigger points
because or its incrcn,Scd Ilh.:t;lbolic dcm'lI1ds and lcnsion.
which call produce ischelllii\ and irritilting metabolites. Also.
an inhibited phasic muscle l1lay form trigger points as a restlll
of its greater than normal f,ltig;tbility and thus susceptibility
(0 overload and mC<.:hani<:al f:lilurt:.
.

Table 2.7. Consequences of Muscular Imbalance

Allercd joint mechanicsJuneven distribution of pressure
Limited range of molion and compensatol)' hypermobility
Change in proprioceptive input
Impaired reciprocal inhibition
Alle,ed programming of movemenl patterns
(From Janda V: Lecturc. Los Angeles College of Chiroprnclic. Rehabilitation
Ccr1lhcahon COUISC. 1993.)

The gcneral crfects or llluscular imbalance ..Irc listed in

Tahle 2.7. Muscular imbalance is lypic<llly iJcmilicd by posturnl analysis (two ;lIlt! one leg st;I11CC). gait analysis. muscle
Icllg,th te~;\s. and evaluation of key movement patterns.
l'o:Hllral lIl/lIlysis (Fig. 2.23) seeks to identify structural
asymmetries (i.e.. oblique pelvis. winged sc"lpula). pelvic posilion (i.t.': .. anterior pelvic tilt. rotated pelvis), hypcrtrophit::d
muscles (i.c.. thoracolumbar erector spinae. upper trapezius),
and atrophied muscles (i.e., gluteus IH<.lximus, lumbosacral

('-""

~~jJ

...

~-

'"

~~.... ~3'

Muscle Hypotrophy

Muscle Hypertrophy

i'i

~29

Fig. 2.23. Depiction of the layer syndrome. (From Jul1 G, Janda V: Muscles
and Motor Control in Low Back Pain. In

Twomey LT. Taylor JR (eds): Physical

0' J
Cervical E'ector So"'.,

Upoer Trt'lpe,iu'
levator Scapul. .

Lower Stabiliters

01 the Scapula
Thofaco1urnblll

Elector Splnu
Lumbosacral

Erector Spinae
Gluteus

Maximus

Therapy for the Low Back, Clinics in

Physical Therapy. New York, Churchill
liVingstone. 1987.)

 '-.,,......... , ... , ''"''1 tUN UI-

erector spinae). Postural analysis in onc leg standing observes

presence of glu'teus medius weakncss, pelvic obliquity, and
other muscular compensations. Gait Clnalysis mostly addresses hip mobility (decreased hip hyperextension). increased pelvic side shift (weakness of glUlcus medius).
compensalory hyperlordosis, and lack of pelvic motion attributable to a sacroiliac lesion. Muscle leugt" tests arc specific tests to identify the amount of muscle shortening prcscili.
Six basic. stercotypic 1I1O\'('l1Iem [umems arc tesled to cvall1~
ate the muscle activation sequence or coordination during.
performance of key hip, trunk. scapulothoracic. scapulohumeral. and cervical movements.
CORRELATING MUSCULAR AND JOINT DYSFUNCTION

The most common pain generators arc likely to be those

structures housing the most nociceptors (articular surfaces,
joint capsules. ligaments). Regardless of whm is the eXilct
. pain gencrator. the entire motor system will rcact and compensate. Long after strained soft tissues havc becn injurcd.
adaptive patterns will p~rsist.
Muscles arc the medium through which ccntral motor
commands or renex spinal activity compenS31e for any dis~
lurbance. Certain muscles typically rcact when specific joints
arc injurcd or are dysfunctional. This relationship can work in
either direction in that impairment in a muscle or joint will
eventually lead to some compensatory change in its func
tional partner. Clcarly. if a Illuscle is shoncned llr ovcr~lctive.
increased pressure and strain develop in the joint capsule and
tcndopcriosteal junction, Also. a muscle that is inhibited .md
weak is associated with poorer stability for the relatcd joints,
with compensatory fhations or even hypermobility resulting.
As described previously. Johansson ct al. correlated nonnoxious joint afferent activity with inc~ased rerlex gamma
motoneuron activity.(,',I They hypothesized that long-lasting
noxious stimulation may activate the flexion \vithdrawal rt::flex.6'l Similar reflex dischargcs from the joints mediated by
effcrt::nt sympathetic fibers wcrc described by Schaible and
Grubb. lm Joint innammalion in the knee c.m lead (() reflcx
muscle inhibitioI1.t.1,.".,,~ Hides et ai. correlated segmclliai. reflcx muscle atrophy in the low back with acute low back p;.lin
in patients in whom specific lumbar joint dysfunction was
manually diagnosed.('~ Bullock-Saxton et ill. showed a corre~
lation between poor ankle joint stability and inhibition of the
gluteus maximus and medius during walkillg.';~
By wufersl(",dill~ the relationship between specific l/llISdes and joints, therapcllti<: shortcuts elllJ (~rf(m he f/llcO\crt:ll.
Finding a dUli!l reaction bellrcen IIruscrdar i1ll!JaI01l("(', WI allered flfOl'cment pattern, and specijic joint dysfunctions enables thl' clinician to find the k.ey factors in tile developfllf.~111
of functional pathology, and
c{lfaly::.es the therapeutic
program. Lewit identified spccific joint dysfunctions that arc
linkcd to individual dysfunctional lllusCles (Tablc 2,8).lH,I~~

t"W,

ALTERED MOVEMENT PATIERNS

The ,ifcscnce of pain, muscular imbahmcc, trigger points. or

joint dysfunction alters lhe :.Jbility of thL' p'lticHt to perform

rHE SPINE: A PRACTITIONER'S MANUAL

Table 2.8. Muscle and Joint Functional

Joint
CO/1
Cll2

cm
C3I6

Chains'''~

Muscle
Suboccipitals, SCM. upper Irapezius. (masticatories.
submandibular)
SCM. levator scapulae, upper trapezius
SCM, levator scapUlae. upper trapezius
Upper trapezius, cervical erector spinae, (supinatoL._@s.L
exJ=r~l-

C5.'T3 _). SCM. upper or middle trapezius. sc::aleni (subscapularis)

T3fT10
Pectoralis, thoracic erector spinae, sena-iiJsanlerior
(SUbscapularis)
.1.19AL._-,<~~~~!.qtus.lum.b:o.rJ.lm. psoas. abdominals. thoracolumbar
erector spinae
Gluteus medius
L2IL3
Rectus femoris, lumbar erector spinae, adductors
L3IL4
Piriformis. hamstrings. lumbar erector spinae, adductors
L4/L5
Iliacus, hamstrings. lumbar erector spinae. adductors
L5/S1
Gluteus maximus. piriformis, .iliacus, hamstrings, adducSI
ductors. contralateral gluteus medius
Levator ani, gluteus maximus. piriformis (iliacus)
Coccyx
Hip
Adductors
SCM. sternocleidomastoid.

certain. stcrcotypit: 1ll0vem~lH patterns. The Ilcgatin: relationship bctwct=n various individual functional p~uhologic
changes and the abnormal pcrfonllanct:: of basic m(l\t::mcllt
patterns is self-perpetuating. Ahcred or f;'llIlty movemcnt patterns thcmsch'cs place new slrains 011 the locomotor systelll
and lead to the spread or a local problcm beyond a single
rcgion.
Slid, mm'emellt paltcms ira, ji,.st n:co}.tlli;('d clinically
by Jonda. who noticed tlla! til(' do......i<: 11111.0;<:/(' testing (~r
Kendall allli Kendal{ did flO' differel11iat, !JctU'('CII normal rt!cruitmew of re!med musch,.\" and ",rick" puucms of.';IIh...ti",tirm durillK a spedjic (lc/ion. Socallcd "trick" movt::IllJ.:l1ts arc
unecollomical and place unusual strJin on the joints. The)' involvc muscles in incfficient or incoordinmcd ways_ which
thus are prone to fatigue. On thc c1~issic tcst for prone hip CX~
tension_ it is difficult to identify ovcractivity of the lumhar
erector spinae or hamstrings as substitutc!' for '1I1 inhibited
gluteus maximus. All llwt is notcd is the ovcmll slrength or
quantity of OUlput. nol how it is accomplished-its qfwli!.\:
Janda's tcsts arc far more sensitivc .md allow the clinician to
identify these clinically pertinent musclc imbahllKcs and
faulty movement patterns by seeing "bnormul substinltion
during muscle testing protocols.
Whcn a movellH::nt pattern is altered. the .tcti\~llil)ll sequcnce or firing ordcr of different muscles involved ill a specific movement is disturbed. The prime lllover lTlay be ShlW to
activate while ~yncrgists or stabilii'.t::rs subslitute .\I\d bJ.:(OI1lC
ovcraclivc. New joint stresses will then be encolllliered.
Sometimes, thc timing sequcnce is normal but the o\'e1';.1I1
range Illay be limited bccau!'c of joint sliffness or ant<lgonist
muscle shoncning.
A classic example of muscular ill1balanc.:e c.\Using an impaired movement paHern is when tight hip flexors arc L-Olllbilled with wc.tkncss in the gluteus m;\ximus. causing ;.tn incflicient or incoordinatcu hip cxtension movement pattern.
The gluteus maxilllus lllay be inhihited and activatL' poorly

--------------

)'

\,,;n/"\I'" I en G . ,,~ ..... vn/"\. II"\): H.t:Hf't:SlLlIJ\IIVN INIU

31

<;HIHOPRACTIC PRACTICE

Table 2.9. Muscular Imbalance and Altered Movement Patterns

',.

Weak A;onis:

Overactive Antagonist

Gluteus maxim uS
Gluleus medius
Abdominals
Serratus anlerior

Psoas, rectus femoris

Adductors
Erector spinae

Deep neck llexors

Lower and middle

Overactive Synergist

Movement Panero

Erector spinae. hamstrings

Hip extension
Hip abduction

Pecloralis major/minor

QL. TFL. piriformis

Psoas
Upper trapezius. levalor scapulae. rhomboids

Suboccipilals

SCM'

Upper trapezius. levator scapulae, rhomboids

Neck flexion
Shoulder abduction or lIcxion (SC.J.;::";!':::'

Scalenes. pecloralis major

Respiration

Trunk flexion
Trunk lowering from a push-up (scaptltar

fixation)

,
.j

Irapezius
Diaphragm

fixation)

OL, quadraluS lumborurn; TFL. lellsor l<lscia latac; SCM. stCfOoclcidomasloid.

during thl: 1l10\~ell\C;IH. leading to ovcrm:tivity of the st<lbiliz~

ers ill the lumhar spine. the erector spinae muscles. Although
such an ;I!tcred p;:l1tcrn nwy havc formed as a result of hip
flexor cOlllpen.\atioll to a lo\\' back :-:tr.lin. hypcrpromllion
prohlcm. kg kll~th inequ;dity, cll.: .. it cvcnlUally perpetuates
instahility h:- on.:r.slrcs:,;ing tile IIlInbOl1' joilHs on its own_ In
this C.ISC. the follO\ving functional p<lthologic ;:tbnormalitics
will he intt.:rl"lHlnCelcd: shortening of Ihe PSO;:lS. inhibitionl
weakncss/trigger points of the glutcus m<lxirnus. ovcractivjty/trigger points of the lumbar erector spinae. lumbar spinc
joint dysflJllClion, :lnd ;:lltcrcd conrdination/endurancc of hip
extensioll. particularly.' during gait,
Testing individu;:11 muscles for strength wilhout concern
for the speed of ;:lctivation or rebxation or the ;:lctivation sequence of agonist. syncrgists. and stabilizers is an elTor.
According 10 Korr. 'The tmlin thinks in tcrms of \I,:hoh:: motions. not individuallllllscles."IJf. Musclcs may h<lve anatomic
individuality. hut they function interdependently. to create
SIllOOlh. wcll-on:hcslr;:ltcd movements.
Exa1llplc~ of lypical p,tirs of overaclive and weak muscles
and the related altcred movement !)aHCrnS arc listed in T'lblc
2.9. Thc~c paucrns me used as a scrccning evaluation to cor~
I'd ate joint o\crS{rcss. lrigger poims. tight muscles. and inhibited or weak IlIllscies. Olher kcy functional dcmands such
;.IS squatting, lunging. rC<lching. <.:1<':, C;:lll also be assessed for
muscle imbalances. incoordination. and olhcr dysfunctions.
711l' plfl"lmse (~f idt,lItifyiJJg aju'r<'d IIlfwemelH !J"w:ms (11/(/
1/11.l2.c:le imbalances is to dis(:m'('/' WhOl to stretch. strem{thell,
alld adjl/st ill pati('~jl~t" di}.<;'QHl/i'iQJ.l{/.l!L~IlIdml!.t.SrlJi.'i ;11]lJl'lIlClfioll {/!l()\l'S IfS to scorch Jor /Iu: c1illical shortcut,\' aJfordf.'d f,y If/ldt~,.st{///(Ii//X the (:of/flec/ioll be/H'cell altal'll bio/I/cc!/(/Jlin (/1/(/ neurophysiology of potients with p(/{llOlogic
Jilllc/iotl (~r the malo" systelll.
Trcatment of altcrcd lIlovcment patterns is described in

Table ",I (I.

Pain motor programs. poor poslUral habils. or altered
movement paHcrns arc mcmorized jusl as is normal g;'lil. skiing. or ViflUOSO lllusici'lIlship. Inefficient or uncconomical
movemcnt p<ltlcms. once learncd. will perpetuatc the muscular imbalmu.:c and joinl dysfunclion that 111<.1)' have caused
lhem, TreatnH.:nt aimed OIL peripheral funclional p;:lthologie alICf;ltions. such as tight l11uscles. trigger points. or joint dysfUlll"tioll. often fails ifaltered movemcnt p;tlterns are not idcl1-

lified and the individual is not rc-educmcd. This ne-ed to relearn is an important reason wilY p'-lin often outlasts lhe elimination of its cause.
Janda advanced the concept that the control of mo\'ement
by the cenlral nervous system can be reeducatcd, Thi$. thcory
wns tested in a study in which propriosensory stimulation ex~
crcises were given to individuals in an llltel1lpl to improve the
speed of recruitment of the gluteus maximus and gluteus
medius muscles during gait.')!; Individuals performed balance
excrcises for 15 minutes per day for 1 week. These exercises
led to significant increases in the speed of HCli\'ation of the
gait muscles. Such propriosensory retraining improved
gluteal ;:lctivity "automatically and subconsciously. and nOI as
a voluntary muscle contmction."'ls

REHABILITATION OF THE MOTOR SYSTEM

Rehabililation includes functional capacity cvaluatil..... n. reha
bilitativc carc, patient education. and psychosoci~l! fJ.:tors, It
is ideally suited for managcd care pr<lcticcs bC(.:;Ju"e it in\'olvcs qU<llllificatioll of function;:)1 progress of (he patient.
outcomcs <lSSeSsmell(, provcn cost-containment Illethl...ds. and

sdf-c;:lrc,

Hchal)ilitation ,,"s. Consl:r\'ativc Tn.atmcnt

Rchabilitation is different from Heutc. conscrv;.uj,,(' carc.

Conservativc cme is ideal for acutc disorders. h l",uses on

stabilization of the injured part. pain control. and pr('lllotion
of soft tissue healing. Rehabilitation is concerned with restoring Illusculoskeletal function in p<Jlicnts with "ubi.lcutc.
chronic. and recurrent conditions, Rchabiliwtion ~m('mpts to
prevcnt or manage dis'lbilily through function<ll re"tOratioll.
work hanJcning. and psychosocial ill1avcntion.
In the first issue of the Journal
Ol:cUpatiollal Rl.'habilitalion. Feuerstein described thc changing. p:'lr<1digrn I..""lt musculoskeletal care: "Activc rehabilitation efforts usin~ J sports

or

Table 2.10. Trealment for Altered Movement Patterns

Relax/stretch overactiveftight muscles
Mobilize/adjust still joints
FacililaleJstrenglher: we"k ;7;:..;::;cles
Rceducate movement pallerns on reflex, subcortical basis

32

I
I

i
~

nL..",.......

medicine model directed at rapid safe return tu work l:oupkJ

with ergonomic intervention h<lve replaced much of the traditional passive. i.e., modality-driven. approaches to rchabilitation of musculoskeletal injuries."IH
The key difference between rehabilitation and tradilional
conservative care is the primury cmphasis on function rathcr
than pain relief. P.. ticnts ',ire cduc~llcd thai pain perception
will decrease as physical functioning improVt;s. This focus
transforms the patient from a pa'isivc. dependent recipient of
care to an active p.u1icipant engaged in the process of rchabilitation (Table 2.11 l, and the doctor's role becomes that of
helper rather than healer.
Rehabilitation involves lifestyle changes and behavioral
re-education (functional restoration). and thus is part of a
biopsychosocial approach. The palient's suffering and iHn~ss
arc morc important than a specific disease process.

Historically. this approach was appropriate for physically exceptiollal (athletes) ami physically impaired (lulIIdicappt:d)
individuals. To(/a...,., it is ~lCces.\'llryfo"l1lost pai" parients. The
i"dicmious for rehabilitation indude the subacute Slage oj illjU0~ chronic pain, disability, or reCllrreHT pain. Tile purpo.H:
of rehabilitation i.\ to trcat or prc\'ellt deconclitiolling syndrome (llld abnormal illness belUll'i01:

Blending Active and Passive Care in Practice

To be a rehabilitation specialise a health care provider must
identify" red /Iags. .. shift from passive to ucth'e care. lIlIder-

stmul the emerging guidelines for care. peryorm outcomes assessment and functional testing. and identify psychosocial
factors re!llling to abuon/wl illness belull'inr. It i:; impol1ant

I
I
I

,I

to rulc out morphology, infcction, carcinoma. and Visceral,

metabolic. rhcumalOlogic. or neurologic discases (red nags)
before attcmpting rehabilitation.I-lS Such patients should be
referred to the appropriatc specialists. Acute disk problcl1l~
and traumatic injuries require fonowing specialized conserv..tive care protocols. bUl these p.uients eventually will become
candidates for rehabilitation.
Current guidelines dictate Ih.u exercise .md .. ctivc care arc
crucial to the management of subacute. recurrent. and chronic
condilions. Bed res!, medication. passive methods, injections,
surgery. and manipulation all have their proper place in trcatment planning. Being able to define (Ill apprupriate re!woili*

tafion goal depends 011 knowing !low To judge fimcfiOlllll j"!a(lfS and work. dem(/luls. If ;Ill individuat has a high \vork
demand. grcatcr functional status will nced to be achieved.
Injured workers should be vic\\'cd as "occupalional athletcs"
racing high levels of stress/strain in their work placc for

'~,

...... "

... ,

.,. __ .

i.vlii>:li il,,,::) ii..::.;d ;" ~'..: propaly traincd. It is csscllli;t1 10 ;H.I.

dress deconditioning ;\1lJ leach .. worker 11m\' 10 reduce Ill!.>
chunk,1i strcss while :-;.illllllt:lllL:Ollsly training them Hl illlpnm,..
their functional stalU:,>.
Individuals wilh "hnnrm,,1 illncss bclwvior arc lIlore
likely to becomc dis;lbkd tIl' \0 th:vclop chronic p,lin syndromes. Quick shiftin;; from p:lssivc (nlllscrv;uin:l h) ;lI.:live
(rehabilitative) care ,,:an prevent llllH.:l1 disability. Rd~lTal flll"
nlllhidisciplin;I1"]' fUlll.li'lllal n~Sl\lralioll. involving psyclh1logic support and hh)bt'h~l\-ioral rt.'-;.:dueation lllay also he indicated.
Although treatlllent dccisions an.: oflcn llIade on the h;'lsis
of a di'lgnosis. palicl1\s with spinal pain n:sist ;ILTUf;lle labcling. Painful spimll syndroml:s arc considen:d mcchanical disorders mosl of the lime. bUI many ex pens vicw the psychologic or social factors to bc prcdominant Polin-sensitivc
slructures abound in th~ spinal region. :lnd pcrhaps hecausc of
the ovcrlap between ~itcs
rcferred pain from lllust:les.
joints. ligaments. fasli;l. nerves. CIt.:.. a diagnosis orten is
given on (he basis of lhe physician's pathoph)'siolo~icphilosophy rather than on any provable hYPOlhcsis (i.c.. dcgcncr<ltive disk. sacroiliac or myofascial syndromes). Unfortunately.
.J cel1ain patho;umtomic di;'lgnosis C'1Il only he det .... rmillcd approximately 20% of the til1le.111.11'.1~ll including I.:onditiolls
ranging from disk syndromcs and S\l;nosis 10 thc much rarer
spinallr3uma, rhcumalologic dison.krs.lIId infcclil1us or neoplastic discases of the spine.
The obvious limitation of thc Quebec Ti.lsk ForL'c dassilication is that it suggc~ls Ihat 80% of <.III back p<.lin cascs require no individualization of carc. Attempts to subcl;lssify the
nonspecific pain group arc under way. and progress has been
reported by Delino C( :II. l~l Thesc uuthors have shown pre5criptive validity for an approach thal identifies cxl.... nsiol1 and
sacroiliac mobilization subclassilic.uions.I.\I Di3gnostic anesthctic block tests h~I\'e also been used to identify s<lcroiliac
joint pathology as an etiologic f<lctor in 10 lo 30C;,c or chronic
low back pain paticnts. t~: Similar methods have dt.'lHlmstriltcu
that greater than 50Ci, of chronic neck pain aftcr whiplash in
jury involves the cervical zygapophysc<ll joints. I~I Unfortunately. no physical cxaminalion tests corrclat~ with the
diagnostic block tcchniques.
Passivc and activc carc arc both impol1,lI1t in casc maniJgemenl. passivc care being more impol1anl initially ;,tnd active care later on. Table 2.12 describes the stages
trealmcnt
and their goals. anu ~OlllC specific interventions uming thcsc
sHlgcs are outlined in Table 2.13. We must mcnlion. howevcr.
somc important exceptions. For inswllcc. McKenzie methods
may be used. even in acute cuscs. Whcn these methods arc

......

or

or

.1

)
)

,.'

)
Table 2.11. Primary Goals of Rehabilitation and Conservative Care
Pain Reliel

Promote Tissue Healing

Rehabilitation
Conservalive care

Functional Restoration

Passive Patient

Active Patient

+
I

(Adapted from liebonson C: Rehabilitation Ollhe chronic back pain patient Calilornia Ghiroprilctic Journal, July 1991.)

-----

-11'

33

CHAPTER 2 : IN I "GRATING REHABILITATION INTO CHIROPRACTIC PRACTICE

Table 2.12. Goals of Treatment

Remobilization

Acute Intervention

Increase painfree mobility

Reduce inflammalion
No pain at rest
Minimal pain with unstressed
daily activities
Decrease muscle ~spasm~

Minimize Clecondllioning
Promote tissue repair/regeneration

Rehabilitation and Reconditioning

Lifestyle Adaptations

Increase muscle strength/endurance

Improve coordination
Increase flexibility'
InCrease aerobic capacity
Promote tissue remodeling

Improve ergonomic factors

Education about biomechanics
Address psychosocial lactors

PAIN RELIEF <'\: !lI{OMOTION OF SOFTTI$SUE HEALING

FUNCTIONAL RESTORATION

(Adapled Irom Triano J: Standards of care: Manipulative procedures. In While AH. Anderson A (eds): Conservative Care 01 low Back Pain. Baltimore. Williams
and Wilkins. 1991. pp 159-168.)

:1,

, f'''i

-~

I
I

~"J

"(...,~

\3

...~

,
~-

-I
l

()
y

Table 2.13. Treatment Strategies

Acute Intervention
AesVice
"SupponsJbraces
,'Gentle stretching
, Physical therapy
: Antiinflammatories

Remobilization

Rehabilitation and Reconditioning

Prevention and Lifestyle Factors

Chiropractic adjustments
':"Solt tissue maniputation
~ Physical therapy .....
.4Postural correction ...
5 Functional exercise ......

Functional strengthening
Slretching
(Cardiovascular fitness ' \
'. Balance and coordinati~9-'

Stress management
Ergonomics "work stationBiomechanics ~liltingJbending
OieVnutrilion

AcnvE CARE
.'-~

i3

"j

,~ C'
,
I

PASSIVE CARE

,j
11

r'~

%2
[~

'i..#

successful. thc)' arc able 10 impart cnoml0US (~)st savings.

Similarly. a trial of manipulative therapy for a chronic suf~
rerer who has not previously had such carc is also indicalcd.
Rehabilitation of lhc motor system involves restoring norlllal joint mobility: inhibiting ovewctivc musculature (including trigger points): improving muscular flexibility. coordinatioll. strength. and endurance: stretching retracted soft tissues:
propriosensory re-education; cardiovascular training; and
poslUral rc-education, Passive and active care are both required to achieve these goals Crable 2,14), Physical training
alone would fail to address specific joint dysfunctions or
ll10vcment incoordination. Chiropractic adjuSlJllcnts alone
would fail to address muscle imbal;.mces or faulty movemcnt
patterns. A.uC"\",'iflleflf slum'd idcllfijV fIle various links ifl fIle
elwin tl./imcriollal pafllOlogic processes. Often the problem is in the patient's posture or work activities, Rcgardless of what other influences exist, rehabilitating the motor
system requircs that we scc the interrelationship betwcen
the functional pans and between thc patient and his or her
environmcnt,
This approach is cmpiric in that one identifies functional
deficits and seeks those interventions that can have the most

positive impact on improving functional integrity, RcslOring

function by rc\'crsing thc dcconditioning syndrome is Ihe prj
mary goal. as opposed to mercly treating symptoms, Highly
lcchniculmuscle function testing and training apparalll:'t's arc
not nccessary to achieve this cnd, Proctit;oners ill s11/al/, pri~
l'me practice.\ who (/.\".'iCSS a1l(/ frettf .!ffflcfiollal /)((t"ologic
problems while tmini"g alld educ(I{ing ,"e p(l{iellf ill hou' fo

Table 2.14. Integrating Passive and Active Care

in Rehabilitation
Goal: Improved posture and motor control on a reflex, semiautomatic
basis
Increase mobilitylllcxibility
Joint mobilization/adjustment
Muscle relaxation/streIch
Improve coordination, strength. endurance
Muscle lacilitation
Spinal stabjfization~ or lunclional exercise training
Propriosensory retraining
Cardiovascular training
Posturat re-education

Hl:::HAtlILI

Table 2.15. Factors that May Predict a Longer Recovery

(from the Mercy Guideline)
History of more than 4 episodes
Longer than 1 week of symptoms before seeing a doctor
Severe pain
Pre-existing structural pathology or skeletal anomaly (i.e .. spondylolisthesis) directly related to new injury or condition
(From Haldem.:.n S, Ch<\pmanSmith 0, Petersen OM: Frequency and dura;
lion of care. In Guidelines for Chiropractic Quality Assurance and Practice
Parameters. Gaithersburg, Aspen, 1993, pp. 115-130.)

preve1lt reoccurrenccs rC'present the ('osH:ll<'uin' FOllt /ille

against roda.v:\ soaring costs for caring ./f)r illdividuals with
low back pain.

Case Management and Standards of Care

PROGNOSIS

The natural history of uncomplicated spinal disorders is toward resolution within 6 weeks,I.JS.I<U More timc may be neccssary for modcrate [() severe traumatic injuries. prolapsed
disks with nerve compression. or if certain complicating factors arc prescnt (Tables 2.15 and 2.16). Intervention for uncomplicated cases is considered successful if the patient is
asymptomatic within 6 weeks. Traumatic injuries may require
more time. depending on the severity of the injury. Disk problems may also require more time bccause of the poor healing
potential of the avascular annulus fibrosis (particularly in
smokers). The goal of modern care of tile spine is to minimizc
the incidence of chronic pain and disability by focusing on
restoralion of function as soon as possible. Nordin comments.
" ... there is a very small window of time in low back pain
care; we must act quickly within 4-6 weeks to bring patients
into an activc reconditioning program if we expect to return
them to productive lives and prevent recurrence."1~4

Table 2.16. Risk Factors for Chronicity

History/Consultation
Previous history of low back pain
T9.tal work loss in past 12 months

v+i"e-avysmoKffig'

Personal problems-afCohol, marital, financial

Adversaria! medicolegalprOblems
Low education attainment
Heavy physical occupation'
Questionnaires/Pain Drawings or Scales
Radiating leg pain--":
Low job satisfaction -~
Psychologic distress and depressive symptoms-BMG
Examination
Reduced straight leg raising
Signs of nerve root involvement
Reduced trunk strength and endurance (dynametric,
nondynametric)
Poor physical fitness (aerobic capacity)
Disproportionate illness behavior (Waddell's signs)
'Only slightly incre<lses the risk of Chronicity, bul signilicantly increases Uw
dillicuHy of rehabilitation.
(Adapted from CSAG Clinical Standards Advisory Group Report on Back
Pain. London, HMSO, 1994: 1-89.)

A IIUI'l VI- I Ht: <::>1"""11'01:.: A I""" HAl,... 1lllVI'Icn 0 IVI .... I'IU .... L

Patil.'lHS ha\"l.' traditionally been categorized as having

anHe. subacute. dtn\llic. or recurrent disease. depending on
tilL' sta\.?e or soft tissuL' healill!.!. or timc course of their recov~
cry.;" l'~, The aClltc .j.!!lhlD.!!!!';~.!~,!E}~l}llase of soft tissue healing
1;1~1> het\~.~11 2-l __~!llLZLh()lIr~ The subacutc phase. in which
rl'l~ai"r and regeller;lllnil occur, !:lst.. . from 24 hours to 6.wecks.
Till' linal phasl' in\\ll\"~ . . relllodc\ing. which pro(~eds from
the third week !\l 12 l1lonths after injury. These phases or soft
ti . . slt~--llc~\iTi\g--ill:"II~~~il."e for 1~~lli~I-1IS sulTering traumatic injuries. hut for illlli\"iduab expl'rietH:lng. pain syndromes related to cumulati\'e l1liewtrallllla. such a framcwork is not appropriate. Ikca/fsc of rht' pl"csC/lce of a!JJ/ormal illncss
hdw\'io/, dis/ll"Ollol'ti(lJlatl' to illlpail"lllel1~ or strtlctura! parI/()logic .lindillgs. Ihl' chl"OlIic slap,e is (~tieil eJ/te!'l'd as S(J()/UIS]
\1"('eKS ({tier paill ollse(. 1511 ~ccording to \VaddClI. cases in~
\'ol\"ing back pain should he regarded as aellte. recurrent. or

chr()nic.!~S

The individual suffering an episode or pain an~r injury or

trauma should be better in 7 to I() WCCks.'~J The <lCllt~ phase
ma\" last I week (J~llltil the patient has no pain at rest and he
. can perlorm
,
I " Y acl1vttles.
,.. I~')AU
or she
unstressetI (,II
' \..:: P to.3 to 7
da\"s of "relative rest' and illllllohilization mav be neceSSar\0
.
-.~Prolonged imlllobili/.atlon lllust be -a\"oided, however, becalise or its deleterious crrects (sec "Negative E~rfects or
Immobilization"). The subacute phase should -.t,tst ,6"J0_J)
weeks if it is iI minor to moderate injury,'<" This phase may
last H-'It) f6-wceks if the injury is moderate to severe.I~" For
soft tissue injuries. any patient still experiencing symptoms at
the 16-wcck mark should be cOllSidered in the chronic
phase.l(~) Soft tissuc healing is completc at this point. except
for the most sevcre injuries.
The popular mcdical practice of assigning the label "nOI1sped tic or idiopathic back pain" is likely to lead to decreased
patient satisfaction. II.! Some pf<lctical patient l~lassincatiolls
should be sought that can be used to direct thc choice or therapeutic intervcntion,l.<l f\llost patients have a gradual or nontraumatic onsct with nonradlcular symptoms. Repetitive
strain is the most likely etiology for the first time or recurrent
symptoms. If there is no nerve root involvement. such pain
episodes should be expected to resolve within the same time
frame as allowed for mild to moderate injuries (6 to 8
weeks).I.lIu~u The prescnce of complicating factors as listed in
Table 2.15 may legitimize additional care. JI/.\t~I.'illg (l lOll}.:!'/"
recovery time because ortlze S((Iges (~r\'(~fi lis,\'lu' healing is WI
in{{ppropriate application (~r{{l1 ae/lll! injury model to patie/lts
suJ)'rill}.: from clI/Ilularil'l! (/"(//111/(/ or. n'[J(,tith'e straill. 1~II,1.~')
The patient with radicular symptoms (symptoms distal to
the knec or elbO\v) and cvidence of nerve root compression
(i.e.. nerve tension signs) is a specific example or a complicated case. the natural history of which involves greater than
6 \I,.'ceks before resolution can be expected. This prognosis is
due to a strong correlittion between clinical symptoms and
structural pathologic lindings. Nonctheless. even patients
with large disk prolapses can he expected to recover without
surgery.III.I.IU~lI,!/,~,lt,\ Treatment in such cases might follow
a similar time frame as for moderate to scvere injuries.
-

- - - - - - - - ~-

-_.,-

Simple Backache or
Nerve Root Complaint
Yes

Yes

Timeline: 1-3 Days

LI_R_e_,_e..,rr_a_'-J
Reassurance:
- No serious pathology
/C- P~ive prognosis. but possibifity 01 recurrence (
Symptom Control:
Analgesics. NSAIOs

- Heat or lee

Activity Modillcatlon:
\. Bed resl 13 days (<. 7 days lor nerve roOI pain)
i .. Avoid aggravation

Is pain settling within

Ihe first 13 days
(2 weeks if nerve root pain),
even if still present?

Yes

--1

Increase Activity

No

Time/ine: First 46 weeks

Pain Relief:
Goal -to facilitate active rehabilitation
Adjust analgesics

Yes - - - + -

Manipulation (avoid if severe or progressive neurological deficit)"

- Active exercise, "hurt does not equal harm" (gradually increasing)

No

Physical agents (gradually decreasing)

.
- Increase activity
- Early 10 o! distress or depression

"Red Flags" (See Table 18.1)

~

Non-mechanical pain (constant,

progressive, no relief wiJh ...

bed.r~

- PH: carcinoma. steroids,

HIV. drug abuse
Weighlloss i ' V

yes......

Malaise"":""\.oo-'
- Unremitting flexion restriction
Fever _.
Violent trauma

Return to Normal Activity

No

Widespread neurology

Timeline: 6 weeks
Reassessment:
Review diagnostic triage
- Consider imaging & lab work
- Psychosocial & vocational assessment (see table 18.4)

No

Leg pain> back pai

- Radiales to lower leg
- Dermatomal numbness .
& paraslhesia

posilive SLR
- Localised motor, sensory, reflex
changes

Timeline: 6-12 weeks

Continued Primary Management:
- Active Rehabilitation (active care> passive care)
- Id of factors which may predict a longer recovery
(table 2.15) or risk factors of chronicity (table 2.16)
- Alternative symptomatic measures (muscle relaxants .
antidepressant, injections. supports)
- Objective outcomes utilized'

No

Low back. buttocks. Ihigh

pain
Mechanicar pain (varies with
posture & movement)

PH past medical history

SLR straighlleg raise tesl
Lap low back pain

Yes-+-I Simple Backache

f--

Is function improving within

12 weeks. even if still
with some pain?

Yes

+-I

Return to Normal Activity

No

Continued next column.

Time1ine: 3-6 months

Consider Second Opinion:
- Active Rehabilitation Specialist
(reconditioning, functional outcomes, behavioral principles)

Ves

+-I

Return to Normal Activity

No

Time/ine: by the 6th monlh

Secondary Referral to MUltidisciplinary Rehabilitation Center
- lnc[emental exercise
- Behavioral medicine principles with functional objectives
Close liaison with the work place

Fig. 2.24. (A) Diagnostic triage algorithm. (8) Treatment guidelines algorithm.

Type of manipulation should change if no progress after 2 weeks (t84).

Treatment beyond 6 weeks must be tracked by acceptable, outcome assessment

measurements. Failure to show significant progress by the 8th week of an uncomplicated
case or the 16th week of a complica1ed case or nerve root complaint should resuft in

......... .'\.

ncnMoll.. IIJ"\IIVI'l ur- I nt: ",..11'1.1::: A .... HAl,;

Table 2.J7 ~ulnmarizcs the pnlglHl~i~ for tll~ \'ari(lll~ g~n~ral

typ~s of cases, Th~ algorithm in Fi.surc 2.24 is llsd'ul for UIldcrst;:lIldin!.! the indicati()n~ for bed rest, m<lnipu!;lIion, ill;livc
care. <lnd ';'llitidisciplinary fUIKtiollal restoration,
Certain patients can be idclIIilkd e;lrI)' as being "di~ahil
it)' prone,"!f,.l A certain profile of the chronic pain or disability-prone patient has emerged that can be lIsed 10 pn.:di<.:( .:1
poor respOllsc to <.:al"l.::,,I.IM ('J'ahle ~,J:-\). These raLIUl'S arc nol
Slnlctural or function;1I (organic). hut om: psychnsoci;1I
(nonorganic).I.~-:.II. Such psychologic fattors as poor pain coping stratcgies. cXl;{~ssive anxiety. depressioll. and ~ymptolll
m;onific:'17ion arc si!.!nilicant.'l~. 1M Soci;11 or economic f"l;tors
lik;job dissatisfaction. pcnding litigation, low income level.
and low educ;ltion levcl ;Ire 'llso ill\portant.If..t.lh.~.I'''' \Vaddell
and colleagues studied the relationship between pain, impair-

ment. and ~disability in patients with inappropri3h~ signs

or

symptoms of illness behavior. nil An individual who is ullwilling (0 move from being a pain avoider to becoming a pain
m;n.llgcr is such a patienl. Exccssi\"l";: dependenc)' on medk:ltion or passive forms or thempy. along with an unwillingness
to develop internal control ovcr symptoms hy Ic'lming ~clf
treatment skills. ;lrc clear signs of a potcmial chronic pain
patient.
The treatment plan for spinal disorders focuses on aggressive. conservative care for promotion of soft tissue hcaling
after an injury, When p.llin is a result of a repetitive strain.
conservative care may be approprialc for p:lin relief. but treatment goals must quickly change to rehabilit:Jlion or rcstor;,,
tion of function. Intervention involving manipulative therapy
has demonstrated a clear advantage over other methods (reduced disability) in the initial care of the patients with pain. 17J
Early. active intervention: preventative education: and rehabilitation approaches have all shown their positive imp'lct on

Table 2,17.

prog~o(Musculoskeletal

Syndromes'5!J

Pain

'/

Syndromes

Mild-moderate
injury
Moderate,
severe injury
Repetitive
strain
Nerve root
compression

Acute

Subacute

2-3 days

6-8 weeks

<1 week

8-16 weeks

2-3 days

6-8 weeks

<1 week

8-16 weeks

Chronic

4-12 months

Table 2,19. Guidelines for Management of Uncomplicated

Soft Tissue Musculoskeletal Pain Syndromes
\. Bed rest should nOI exceed 2 days and passive methods 6 to 8
weeks.
2. Treatment frequency IS. 210 5XJweek for the first 2 weeks (pas
sive care with manlpulalive therapy appropriate).
3 From week 3 to weeks 6 to 8, treatment frequency should be
decreasing,
4. Functional capacIty evaluation is recommended when patient is
subacute (week 2 10 4) and mandatory.'3t 6 to 8 weeks.
5. Progressive exerCIse prescription and sell-care advice recom
mended within 1 10 2 weeks and mandatory at 6 to 8 weeks,
6. Evaluation by a rehabilitation specialist may be appropriale at 6 to
.--. 8 weeks,
( i Advancgq ima9!,:l.9.~r,tqu_~_2rc appropriate only when n~ur_o
V .{og;c.function is deteriora1ing or progressive exerCise therapy has
r:"- failed.
',8. Evaluation by a palo behavioral specialist may be appropriate at 6

months.
r~dllcing futur~ recurrcnces and prcVl'nting the emcrgence of
duonic pain SYOl.lrolll~S,~'I.r,(un.r:.' Bush showed that <lggre:-sivc conscf\'ativc care is highly successful for the managt:'ment of severe di:-k protrusions with nerve rool compr~s.
SiOll,l"1 Muhidi:-.dplinary. function;,.l restoration programs.
ha\"e rCpc~ltetl:y demonstrated their success in returning (he
chronically disabled back pain sufferer to work,lf-oll,174-111, Otha
studics havc shown that failurc of passive therapy approaches docs not imply tll,:lt active rehabilitation efforts will
fail. m.17!I
Pain relid anti prc\"clllion of recurrenccs ;:m:: thc primary
aims or C<lrc. Restoring function is the means by which thc:;.('
ends are <.lchievcd. III 11I0.\t u/lC:omplicated cases illVoll'illg
SlI/mcll1e or rt'('//rretlt pail/, treatmellt aime(/ at pain relic/wuJ
Jill/eriol/al restoratiol/ takes betH'cel/ 2 a"d 6 weeks, Illirial
In.'alll/cJl! /requency 'thrce tillle.\J!!r week f(Jr 2 weeks) is

often .mfJiciCl/t to idelltif.), !!!l!. keY/I,mc.r.~'.!.!!~lJp.~~t!I(!{~!~~ problef,-i7i-lizatwlf[ cmlble{7;~-il(.'lliik(:llrc_pmvid{.',. to indi\'iduali:'t'

a .'ielf-trc~,;,~;~,~~,-~-';~-teJi.\~-Collii;Ule(J ~~;;e-;~:i;/~ (/~~~e(i.~~lg frt'qllency for approximately another 4 Il'eeh is I;sually llppn l !,riate. Additional care is often required in ca~cs or Jnodcrm('
to .,,>c"cre trauma, di'do-; prolapse with nerve root compression.
or chronic pain, or when significant complic.iting factors or
abnormal illness behavior arc present. The disability-prone
patient often requires intcrdisciplinJry rcferr"l. Table 2.19
provides an ovcr\"iew of these guidelines. which arc also discussed in Chapter 21,
REPORT OF FINDINGS

4-12 months

Although it is sometimes considered speculative to assert that

a specific tissue is the primary pain generator, it is not nccc::-s;jry 10 burden the patient wilh the diagnosis of nonspecilk
back pain,lf.1 Kirkaldy-Willis discussed the cardinal signs of
difrerent sources of nonspecilic pain. such as facct. sacroiliaL~.
and myori.lsciul.l!'~ Cherkin and MacCornack noted that offering <In explanation to patients and clearly outlining goal:,
for care leads to 2featcr patient satisfaction. I -N ,lIm Bogduk
and Simons summarized the kcy clemcnts for di'lgnosing
myofascial sources of pain from articular sources (sec Ch.,p-

Table 2.16. Profile of the Disability Prone Patient

Symplom magnification
Pain avoidance behavior
Psychologic distress
Job dissatisfaction
Anxiety
Treatment dependenc'r
Catastrophizing as a coping strategy
Pending liligation

- - - - - --

IIIIUNI::H'S MANUAL

ter 18),'~'

----

,
I

After the patient has been given the working diagnosis. ii

is important to explain that although most {Xoplc gel bcltcr
within 6 weeks. recurrences nrc the rule rather than the cxceptionY' For this reason, it is prud.:nl to spend some time

tcaching paticnrs how to reduce further strain on their back

and how to increase their intrinsic capacity to handle extemal

demands. If a patient is "disability prone:' psychosocial as

well as biomcchunical issues will need to be <Iddrcs~cd.
Referral LO a psychologist SPCchllizing in biobchavioral cdu
calion may be necessary.
Simple chans can be used (refer to Fig. :!.4) to educal!.: the
patient about the importance of reducing external demand
and/or increasing functional capacity to prcvent re-injury. The
more external stress, the greater (he chance of injury. Such extrinsic sources could include prolonged sitting. improper lift-

ing technique. or repetitive manual handling activities. The

simplest way to avoid fwure problems is to reduce the external stress. III as Ilmdr as this change is IIot a!l\fllYs possible,
intrinsic fiU/ctiol/al capacity call be iI/creased. Various intrin-

J_:,.
1~ ,'~

".J

37

vnM.rlt:r14!; 11\1 I tUN1\1 INu Ht::HAl::.iIUIAIIUN INTO CHIROPRACTIC PRACTICE

sic factors such as muscular imbalances of strength or f1e~d

bility. postural faults (i.e.. slumpcd posture). structural asymmctry (i.e.. shon leg). impaired coordination or balance. or
poor cardiovascular fitncss also predisposc to recurrent pain
episodes. TIle dangers of even low level repetitive strains
should be made clear (refer to Fig. 2.7). InstnIction should
stress taking frcquent "microbrcaks" from either prolonged
slatic loading (i.e.. desk \\"ork) or repctitl\'c activities (i.e..
1Il<1IIW,!i m;,ucri;,li handling).
Whalcver the pain complainl, proper managcmelH hinges
on reducing strain so .IS to promote healing and to prevent recurrences. In the acule stage, especially with disk syndromes
or trauma, reducing load on the injured structures is called
"relative rcst:' This measure, along with chiropractic, physic.11 therapy. and exercise. may be used to reduce tissue
swelling or irritability and to prOlllote a good environment for
healing of soft lissue injuries.
PatielHs C;1n be cdUC;'ltcd about the dangers of recurrences
as pain subsides and [he need to increase intrinsic back fItncss
and decrease exposurc to harmfUl. extrinsic sources of back
struin. Comparing the patient's treatment w that of an alhlete
will help to motivate Ihe patient tow;.1rd seeking m,ore than
just symptom<ltic rdief. Tables 2.12 and 1.13, along with
Figure 2.9. can be used to show the palient how the spons
medicine paradigm of rchabilitation is the best method for
achieving optimal results. For example. an injured p'!liellt
learns that he'lling starts with innummation. The goal of treat
ment is lO decrease swelling and p;:lin. The stratcgies used include rest. icc. SUppOl1S, t;lc. A pOitient with subacute injury
learns thal their tissue:; arc going through repair .lIld various
passive methods along with exercise arc necessary (0 relax
and mobiliz.e lheir healing tissucs und simultaneously prevent
scar tissue <'lIld dcconditioning. Next. this patient learns lhal
they must strell.luh('JI lind stabilize their "weak link" or injured tissues to pre\'ellt recurrenccs.
A p;:lliClll wlto suffers pain withoultrauma IC,lrns thal oncc
serious medical causes <:Ire ruled out. trcatment will focus on

fUllctiuilai restoration .......ays to rl.:ducc eXIHlsure to h;:lfmful

extcrnal stress :lOd how to increase functi()n~ll Glp;'lCity arc thc
focus of carc. Rmhcr than adhcring to the philosophy or "no
pain-no gain," thc patient is taught how to "handlc" pain, The
difference between "hun and harm" is cxpl>lincd. Strelching
exercises may hun slightly because stiff ..;tnlclures arc heing
stretched. but strcngthcning cxercises should he painkss in
lheir symptomalic arcas. They may feel ;\ "hum" in thl.: lllLlScle being trained. bLH thcy should not cxpaicnce pain ill tlh:ir
symptomatic area.
Manipulatioll alld OIher thcrapie,\ may be used to acldrcss
key trig.~cr poillts or)oillr dyJjillictiolls \\'itll the' goal (~frl'iax
ing and IIwIJili;:';lrg t(-'lI.'it or sriff tis,\"fIc'\" (.H't! Chal'tt'l' II'.

Then. IUlJiems Icum abOlll strellgt!tL'lling and sIahlli:i".!: III('

"wea~

link" b)' training Ihe "l1ig:'.,l,IJUsr!t..'s (,!I/adri~{'l"'i.

(lb~~.~) to do 1~IOSl oj the \\"ork and to m'uid
o~!!I~!8..Jhe "s/1~~ll1e!~__ p.!!.:g!~rt.tI II1IlJdl'S alld clapa
,~P..!.I!!!UJrJ((t!tres.This training may lead to sOllle postexercise
soreness, but this discomfor:L~hQ~].I~UrlY,o(yc_a[ea.'i_quiil:distinf.!Jrom their primary area of complaint (sec Chapter 14).
\Vhile training these "big". muscles. the patient is taug.ht to
pers...~~~.-!.~~~af~~~~~T.p~~_~~lrc.With repetition. lhey
ICi.lrn to cOlllral their posture bClIer. by dcvcloping improved
kine~_tic.l\..~a~~ness.and to lise the "big"' muscles to pCI'
formJJ1Q.S!9f.the work, \~:.~ic.~Jakcs strain off all the structur~s
oLl.hc_l)p.inc.._W.isk~..ligaIJ1ent,j oint. etc.). Uhil11alcly. their improved motOr conlrol should become automatic, r~qlliring no
conscious effort.
(S() long ns the patient's case is uncomplicated. recovery
c:.H~e expected within 6
If r~lclors are pre:.;cnt that
complicate the cast.:. these should be explained to lhe pmient.
Such a paticnr should be apprised of lheir poorer prognosis. It
call bc mentioned lhat approximmely 15Cj( of p~Hielll!' with
low back pain develop chronic pain syndromes. and at least
33% of illl paliellls suffer recurrence5 at :,;ollle time.
Complicated cases require pro-active management to dCftlsc
tllese "ticking time bombs." It is bCHcr (0 inform such p.ltients
of their risk for chronicity lhan ((l allow them to build up
anger and rcsentment when they arc fnJstratcd by lheir unsutisf'lctory progress. A brief course of manipulati\e therapy,
rollowcd by aggressive rehabilitation efforts with an active
care focus, arc cssential for thcse patients. If thi~ :.;cqucncc is
unsuccessful. a biobehavioml approach incorporating multidisciplinary SUppOrl is necessary.

gluteal.

wcc0

REPORT TO THIRD PARTY PAYOR

It is imponanr to be able to communicate lhc rationale for rehabilitation to the group responsible for financial reimbursement. With musculoskeletal injury or pain. changes will occur
in_.t1!c ;,trcas of strength, mobility/Ilexibility. balance. coordination. and c;.Ifdiovascular litncss.~" These functional losses
arc a result o(immobilil.ation <Ind'adaptation and arc termed
"deconditionj!lg."I.~s To prowct YO/lr riMht to reimbursemellt
for ,\'er\'ice.~ I'l'I"I('l"{'d IIwt ad"en' to stwuJards of Ctll"(-'. follow
t!lese .'iteps: (f) Documellt tIll' pr('.H'lICe of OilY complicating

g b.
i,-.::::---~--------------_.
__._._-.. _.

nc.n..... OIL.I.I'\IIUN Ut- I He tiPINE: A PRACTITIONER'S MANUAL

faCIal's ill the 1)(Ilicm:, hi.\"/Ory and c'xami"atiolf: (2) Use outcOllies a......cJslJleJl( /(wlx /0 doC/mlc'lIl (Illy fimcliOlwl changes
Of

subjeclive illlpml'(.'l1wllf:

(3) IJUr"1'(Jllfi(lf('

'0

ch'od.\' betwl'eJl

passin: a/ld aClin! can: tre(ll/lll'1/T lIPIJI'oac!/{'.\': lind (4) Quote

I-J/lblislted gtfidclil/cJ (Quebec. Mclty. AHCI'U and CSAG) /0
(/('IJ/OIlJlrare the op/,mpriate!lCJS (/1/(1 pIcK{' of llulIlipu/mioll
alld eXl'rc:ise (oClil:l' ('til''). US.l'1.11.l~:

It might he hdpflll lO explain the phases of care <lnd ap~

propdate trC<ltmctll ~dct.:tilln for each phase. After a ",;id ttl
1II0c/C'f(llt.' iujury. lhe ~o;lls or iniliallrcalillelll arc to reduce innnmmation/swdling. cOlllrol rain. anti resl lhe injured soft
tissues. This acult.; :'\!agc of l;i.Irc lypkally ILists only 2 10 3
days. Trc;ltmcnt is indusi':C of resllice. supportslbraces. gen~
tic stretching. physical Iherapy technillues. chiropractic joinl
manipulation. illHJ nutriti<.Hlal supplemellts. Progress is measured by using spccilic. quantilii.lblc olltcomes assessment
lools. OUlcomcs assessed include mobility and pain intensity
(Visunl Analog S<:'lle).
Once inlli.lIl1111;'lIion has subsided. the paticnt cnters the rc~
pair or regeneration phase of soft [issue healing. This phase
usually lasls from 72 hours to 6 weeks. In this subacute stage,
the goal of treatment is 10 promote ~he repair/regcneration
proccss and remobilize the patient. This goal is accomplished
by mobilizing the soft tissues. Treatmclll is inclusive of chi~
ropractic joinl manipulation. soft tissue manipulation. physical therapy techniques poslllral exercises. and individualizcd
exercises for muscular imbal.mccs. Progress is measured by
improvcd mobility. dccreased pain. ;lnd increased ability to
perform normal activities of daily living (Le.. Oswcstry
Survey).

In C;'lses iJl\'olt'ill.~ moderme 10 Jc\'er(' i"jury. Ihe acute

stage may last up to I \veck and the subacute stage up to 16
weeks. A chronic phase follows in which the goal of Ireallnent
is to promote reillodeling of the s;)n tissues and rehabilitate
any lostl11usculoskclctal function. Rel110deling after a moderate to severe injury can 1:.1St up to 12 months. Treatment is inclusive of muscle siretching. strengthening. cardiovascular
filness, coordination exercises. and decreasing applicmion of
physical ther;'lp), techniques and chiropraclic joint manipulation. The goal is rehabilitation of the patient to their preinjury
level of functioning. Measuremcnt of specific outcomes becomes essenlial to prevent patients from developing chronic
pain syndromes. Outcomes evaluotcd include mobility. activities of daily living. and muscle strcngth.
For patients who suffer pain without any acute trauma. a
repetiti\'e stra;n is the likely cxphmalion. Repelitive "l1\icro~

Date

trauma" from prolonged overuse and/or constrained postures

I~ads
gradual dcconditioning o( the strained soft tissues.
This deconditioning weakens the various musculoskelct3.1
stnJcturc..~ to the extent that painful injury can result without
any trauma. Such pain ean occur without the innaml1l<ltion or
sw~lling :lssociatcd with <In acule injury. The treitUnent is similar 10 that for mild to moderate acute injuries.
Another type of case is that involving the putiefl! I\';rh
dmmic pain. This patient Ims completed all soft lissue heal~
ing. and often has abnormal illne~;s bchavior disproportionate
10 impairmenl or p;,nhologic evidence. The goal of treatment
i~ rehabilitalion with an emphasis on functional restoration
rather than on pain relief alone. Psychologic intervention to
incre<lse coping skills and to reduce fe'lf is neccss.uy in combination with a physical rCHctivation program.
Patients with uncomplicated cases and not suffering unstab~~J!1juries or chroE2~!)l syndromes should be fully rehabilitated wlthm 6 to 8 weeks. A severe whiplash. grade; II or III
knee ligmncnt injury. or disk herniation with ri:ldiculitis me examples of unstable conditions that usually require lreatment
well beyond 6 to 8 weeks. Complicated cases may require
more (reatment limc because of the presencc of chronic pain
with its associmed physical and psychologic deconditioning.
By demonstrating to the third party payor what type of P;,llient is being lreated: the standard of care of treatment for that
patient typc~ and progress being achieved through objccti\c.
quantifiable outcome measures. the c1inici;m should be able [Q
justify reasonable ex lens ions of care for a complicated ca~c
(fable 2.20). When functional outcomes do not improve with
care. then continued care is not justil1ed and referral becomc~
appropriate.

INCREASING PATiENT ADHERENCE, COMPLIANCE.

AND MOTIVATION

".'

Converting a pain patient from f.l passive recipient of c;,m: to

an active panner in their own rehabilit::llioll involves beha\'ioral psychology::'(l,lll.l specifically. making. the shift fwm
being a pain avoider to a pain manager (Fig. 2.25). A key 10
Ihis process is convincing lhe patient that their pain is not a
stop light warning them away from all activily. Reassuring an
individual that we do not advocate a no pain - no gain approach, and instead teaching them how to differcnti,\tc !:'I,,>
tween hurt and harm. helps Ihem become re;,\ctiv<.lled. Chronil
pain requires a different coping strategy than is used for aCllt~
pain.III.lls~ Increased activity is Ihe goal. because gre;'I(Cr stiff-

")

Trunk Flexion and

---;: SLR (degree) ---:7' VAS (low back) (%)-:7 Extension ROM ----7 Oswestry (/0)

219/94
2/16/94
3/1194
3/16/94

30

85

60

50
26
1.3

75
85

20/60
40/60
50/60
60/60

and
and
and
and

5125
15/25
20125
22/25

78
54

30
04

'SLR, str;lighllcg r;lise; VAS, visual analog scale; ROM, rango 01 motion,

,
i

l'HAI-' I t:H ~ : IN I t:t:iHAIING REHABILITATION INTO CHIROPRACTIC PRACTICE

Injury

Nociceptor activity

Fear of pain

Acute pain

Psycho3ocial
context:
Stresslullife-events
Personality
Familial influence
Medical influence
Personal pain history
Pain-coping strategies

39

plained that this tightness or weakness is what leads to irrilUtion and pain with activity. They must learn that rchabilitation
Of restor,ilion of function will prevent pain from arising in the
first place. and although such rehabilitation Illay be more
painful in the shon term, improving function is the key to
long-tenn pain relief. Always seeking tcmpormy pain relief
will do nothing to prevent the problem from sHIrting again.
\Patients can be re<lssured tlmt most of their exerciscs \\'ill
be relaljycly pain frce. Everything that can be done to rclax and-mobi1f:t.e-thcir-tiss..ue~ill.De done before attclllpti'!-JQ...~n.gthcn--lhCJll)The ultin~~te--g~~il is increased
kinesthetic awareness and improvcd stability. Exercise will
focus oo.strengthening the "big muse 's" that arc neighbors to
tlH~.p'ain.~L~p'~~~~.~"p.~~~.~cas. he D~;ri~~Fl_:~?'_gain- phl-

">

.!2~jJ.hY. __<JQ~s. _nm~W_t..9-c.h~on i~ . .~j!L.~~.h!l~.i.!.Hat i(l~l})

Exercises afe performed untBthe point of muscle fatigue only

'so long as proper coordination is maintained. The only pain
should be in the muscle being worked (~l 'burn"). If :.1 symptom.alic area (spinal muscles) is activated during the exercise_
the movement is stopped. When we can achicve an illlcnsity
of training that leads to postexercise soreness in dccondiPain-confrontalion
Pain-avoidance
tioned tissues without exacerbating the original symptoms.
we arc well on our way to a successful outcome.
Fear of pain
Motivation
Objectification of function is a key tool in mOli\'ating
increased
Calibration of
patients. Helping patients focus on function rather th,m on
Exaggerated
pain-stimulus with
painperceptic
pain experienced
pain is an important first step. Then. baseline levels of funcSecondary gain
Rehabilitalion
tional impairment. pain distribution and intensity. and levcl
Chronic
Full recovery
of disability should be qU<:lmified. These quantifiable base
invalidism
lines can be used to track the patient's progress objcctively.
Fig, 2.25. Fear of pain and the generation of exaggerated pain
Treatmcnt should be guided by the results of thc objecperception. (From JOG Troup: The perception of musculoskeletal
tive. functional capacity cvalu;nion. Progress can be monipain and incapacity for work; prevention and early treatment
(Qred at regular intervals (every 2 to 4 weeks) to give the
Physiotherapy 74:435. 1968.)
patient :'lccurate feedback on how thcy arc improving. Se~
ing an increase in their walking and sitting tolerance as wdl
as in the number of trunk curls serves as positive reinforceness :.md wcakness will othcrw'ise dcvelop. which will only
ment. Pre- and posHre<ltment checks of painful mancu\'t:r:, or
complete a vicious cycle causing more pain. not less. Once <I
mcasumblc functional deficits (i.e.. strength. llcxibility) is an
pain <1voidcr is identified. additional timc spent with patient
excellent way to motiv<lte patients.
cducation is csscntial.
Rchabilitiltion seeks to reduce function:'11 impairmcnl. It
The prinwry goal of patient carc is to rcduce ;IllY disabildocs not focus on the symptoms. Quamilic:.ltion of fUIl<:ti(lllal
ity. Often. patients havc sacrificed different features of thcir
capacity and paticm education nbout well behaviors are the
lifeslylc as a result of pain. An Oswe5ry survt:y can quantify
keys. ManipUlation to restore function to key muscles ;mel
thi!' level of adjustlllent. Such things ;IS decreased siuing tol
joints is cssentiallo initiate patient reactivation. Fin..lly. phys
cnmcc can be identified in the history. The paticnt may say_ "I
ical tr<lining that focuscs on stabilizing the lurnbopclvic recan'l go to the movies anymorc:' Indi\'iduals m:'IY have givcn
gion and trunk is the !inal step in rchabilitation of the mowr
up or compromised certain activities such as tennis or golf. If
a patit:1l1 says they alw:'lys feel pain after 9 holes of golf. :'1
system.
goal may be to be nble to playa full round. Sexual ,Ictivity
may also be a problem. Whatc\'cr lifestyle changes they h:.wc
I(EFERENCES
made as a result of their pain should be uncovered in the his
I. D~Y\l RA: MeastJrill); fum:liullOlI (}WCUI1\~'S ill Ih~r;lpcul1l: lri:ll~ t"\lr
tory, Then. the festoration of these activities becomes:'1 mutll
chnllli' disC;L'ie. C(ll\lwlled elin Trials S:::!D. 19R-l.
2. Binkley J. Peal M: "h~ effect nf inllllobili1.:ltion Oil the ullr.l~tnt..tur~
ally agreeable goal of rchabilitalioll. Establishing functional
and m~ch:lllical prOI'ICrtics (If the fitt mcdi:-ll ,u!lalcr.ll Iig:llll~lll. elin
restoration as a goal. along with pain relief. is csscnti<:ll to
Onhnp 203:30 I. 1%6.
achieving a positive outcomc.
3. Noy~.~ F: Funclional pror~nie" of knc~ ligalllclll:O :1Ilt! :111~ralilll1~ ill_
To achicve lasting pain relief. the patient is educated
d\l(~'d hy illllll(}hili/:llinn. Clill On!l(1!' 1::!.l::! 10. 1977.
tholt their musculoskelewl function c:.1ll and should be illl
-1. Vi~klll;lll T: Ellpcrinl"'nt;11 lllutlcl" HI' lI~lcllarthrilis: 'Ille mk ~If i1HlIlt 1bili,a!iull. eli" lli,lnh'dl 2:22:\. II)H7.
proved. if their muscles arc too tight or weak. then it is ex

REHAtilLllAllUN UI"" I HI:: :::it"INt:: A I""tiAl;IIIIUNl::H-:::; MANUAL

4U

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41

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163:182.llJl J:!.
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nt:.nl"\u ..... ' ,n."VI"" v r

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101.
t02.
103.
IQ.I.

105.
106.
107.

108.

109.

110.
III.
112.

Pain .55:5, 1993.

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I n t >;)"'1I~r::.: 1\ t"HAl.,; IllIUNl::.HS MANUAL

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.~

.'
,

..

,$
.J

....nMr-' I t t i ~

REHABILITATION INTO CHIROPRACTIC PRACTICE

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Ii'll t\,jHAIING

,,

43

170. W:uJddl G, Bin:her }'1. FilllaY~llll 1>

.:1 :11: SYIlI(lhllIlS :.lIld si~m::

PhYl\ieal disease or illn.:ss bchavin(~ Br }.kJ 1 ~HI):7W. 11)1\4.
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1i

1(~
~

11 {)

i
~I

t,_..::~;::
~:...tlb

I fJ

Ig

,.....

3 Training and Exercises Science

".'

JEAN P. BOUCHER

Human behaviors ;Ire dictated by many laws. constr.lims, and

dcgrees of freedom. In other words, (hI: human s)'stcm has
limilalions. Many IimjtJlions in rcgartllo mOlar bcha\iors. or
movcments. are wcll dOCUl11cnL~d in the field of excrcise science or kinesiology. defined as the science of movement in biologic syslcms. Such limilations liS the muscle dynamics lind
the fundamental facLors of performance arc discusscd in this

including the feet. legs: and thighs. l Any measurable discrcp;lucie,., in the measuremcnt.s from olle side to the other ~,re
wken ~,~ an asymmetry. Tr'lditionally. an<llomi'c asytlll11ctric$
'Ire derived from differences in lhe It:ngths of the bones detcmlined radiogr<lphically or on the basis of external tapc'
measurements. The latter technique presents. however. serious limitations.

elI,j!)(cr.

THE LOCOMOTOR SYSTEM

The locomotor system. which is responsible for all motor behaviors involved in locomotion. is composed of fundamcntal
\lnits that must be controlled to achieve complex movcments.
such as walking or runni~g. Understanding the locomotor
systcm rcquires then a knowledge of the fundamcntal units
composing il (e.g.. boncs. joints. and musc.:les); of the qualities characterizing these units: and of the operations im'olving
them. Concentr<lting on function. these fund<lment:ll units can
be labeled as anatomic. mechanical. and functional. It is important initi:llly to consider these units <lnd their molar control
that underlies smooth execution of movcments before discussing training and exercise topics.
Fundamental Units
\Vork by Desmarais ;]nd Boucher l and Boucher and Hodgdon~
focuses on the need for systematic invcstig<ltion of the fundamenial units activated during any movement. Funclionally.
these units have bt.:en defined in three scts: the anawrnic. mechanicaL and funelional componenls. Thc subsequent definition ~lIld description of thesc components of lhe locomotor
systcm reflect that Illost of the work concentrating on the fundamental units has centered on the lower limbs and their
aSYIl\111ctries.
ANATOMIC (STRUCTURAL) COMPONENTS

The "n.Homic components represent lhe Slnlctufal units of the

system. They dictale the status of lhe internal environment
that must be controlled. These units, the bOlles or rigid segments, represent thc baseline informalion requircd by the control system to producc fluid. well-coordinated movements,
FOf the lower limb asymmetry model. the ~matomic factor
is defined by the lengths of the scgmenls in the lower limbs.

MECHANICAL (STATIC COMPONENT OF POSTURE)

COMPONENTS

The mech'lllkal factor represcllls the static mechanics Of positioning or the joints. The mechanical components arc described as the st~ltic postural units of the system. lllcse units.
the joilll~ and soft tissue holding lhe bones together. dictate
thc passi\'c mcchanical alignJ1ll:nt of the l11ultiscgl11clllal
links. such as thc 10\\'l:f limbs. the trunk, and the upper limbs.
These unit~ ~lrc then responsible for the passive basclinc meeh'lIlies that thc system must t.lke ..s a starting point when executing and cOlltrolling 1ll0\'cmCllts.
The mechanical factor is measurcd through thc honc-bone
rel:ltionship. or joint ~mglcs. A lllcchanic<J1 asymmetry can
then be operationally defined as a difference from one side to
the other in the lower limb joint ilngles, or as <111 above-nor~
mal amplitude in a specific joint ;:lIlgle. It is important to rnC:lw
sure lhe<;_~ ;:ll1glcs in a normal wcight-bearing situation to apprcciaLc fully the implications of the mechallic~11 factor. With
this in mind, the lower limb lengths ilnd pelvic till mcasured
in a weight-bcaring position art:: ;lIso considered mechanical
variables.
FUNCTIONAL COMPONENTS

The fUl1Clional components, llluscleS and motor units. are rc~

spol1siblc for moving the bones around the joints. In other
words. lhe functional units make it possible fOf movement of
the structural units to occur. st'1l1ing from the posture dictated
by the mechanical or posturalullits.
The functional f<lctor characterizes the execution of any
functiori. This factOf is by far the more complex to assess. The
asymmetries in functional patterns ean be brought to light
only through kinenmtic," kinetic.~l or clectrophysiologic'~.I'
analyses conduclcd during ,I given normalized function.
Hence, functional <lsymmetries can be operationally defined

45

MCMI-\OILIIf\1 tUIIi

I
,

to mutually exclusive sets of struct\m::s. Anatomic factor!"

reveal the staWS of the hones. the mechanical factors

CENTRAL CONTROL IFEEDFORI'IARD)

J1

and joints. Using this three-component approach. Desmarais

and Boucher~ and Zarow ct all> demonstrated that functional
components and not anatomic or mechanical components
arc the major contributor to sacroiliuc joint dysfunction

::i

I
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Ii

I
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'f:
:~

and chronic low back pain. Systematic evaluation of the

human system according to its fundamental components
will allow a better undcr!'i1anding of specific factors underlying any dysfunctions. and a wcater chance of efficient
treatment,

Motor Control
Following the siudy of the units composing the human system, a greater challenge is to understand how this system can
produce and comrol voluntal')' movements, In general. movement comrol C;;1Il be divided into two mechanisms: (I) fecdforward conlrvl and (2) feedback control. These modes of

TRACTS

Ihe different I1ll'l'hanis1H:", hm abu how Ihe:-=c l11edl;ll1i:"I1IS

interact 10 ;Khicn: hKOIlHlli\\n or any oth..,!" i.:oordillal~d
movemenlS.

The fccdforwarJ conlrol ml"l'h:llli'Ill, also n:fCITl'd ((1 ;1-. Cl'lltral or supras~gmenlal control. i... d~:"nihcd ,I:" Ihe dir~l'l L'()lltrol {)f effector" by the cel\tral na\'Olls sy:"h:m withOlIl ill{craClion with thl.': information fwm Ihe I..':llvironlHclH. i.~ .. Ihl..':
moving limb or segmel\t. UnJ~r this type of control. movemel1ls arc carried oul by the excnl\ion of 11lotor COmll1alKls or
programs whik the :-;ystem is nol concerned by the feed hack
coming from the afferencc:-; ;lCli";'llcd during the mOWIHCtlb.
The motor commands arc sent d\)WJ1 dilTerell! ~lru(llIr~" ;md
through pathways or tracls rl."prescl1lcd :"Chclll;lticall~ in
Figure 3.1. Such a I11cdwnislll j, useful for underslanding Ih~
execution and control of fasl. hallistic movements that arl' :"0
rapid thaI fcedbck contraction, cannot modify the llHl\'C~
ment. Learning or modification or (hi:" type of 1Il0VCllh:1H {':Hl
occur only by modifying the motor commallds after thl" fact.
by using the knowlcdge of response inform;,nion. InfoflU:llion

about the error committed can be incorpor~ted through ~Xle

roceptors or proprioceptors and the ccntral (ol1l1nand elll be
modified as to reduce lhe alTIOUIl1 of error detccted. Thi:-; lype
of learning or plasticity is then (arricd out in ;,ttl 01Jt:n loop

STRUCTURES

Fig. 3.1. Neuromuscular slruc-

tures and pathways or tracts implicated in motor control.

- - - - Cerebral Cortex
Conicospinal-------'.\

1------ Thalamus

II
lI

f\.iANUAL

..:onifO! ;.11\: .Il"~' ii.,J;t;~,il;d:~, .~fI.':IT~Ll to a:" {lpJ:H hhlp ;llId

dosed loop cClntn,ll. Till..' (halkllg~ is to umkr:-;t:IlHI not only

I
~

I Ml: -=:.t'll'H:: 1-\ t"HAL; 1llIUNI:H ~

as any discrepancies revealed between the paltcms of the uut~

put parameters (c.g., forces. muscle aCii\'ity) from onc side to
the other. Such discrep.mcics arc quantilicd by determining
the difference between the pilucrns. or by establishing sidc-[{)side ratios on specific discrete variablc~.
According to these definitions. all three f;Jctors penain

reveal the status of the Iig.aments hulding the bones together, and the functioll<.ll factors revcal lhe status of the
muscles producing Ihe funclion or .mo\'cmcm of the bones

ur

Cerebellum
RubrospiJlal-------~==='1Ioi

Reticulospinal-------_.I'
Vestiblllospinal--------Itt-

'-----,'---- Red Nucleus

-+----- Reticular Fonllation

01

.f4------ Spinal Cord

Muscle Fibers

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IIIi'1lmi.lIi~
.-

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system in

\\'hidl ;llllkip:llillll

anti knowk't!gl' of response ;11'("

modify fnlUrt' 1ll00'L'llll'nIS. The cxc.:c.:t1litlll-l!c!l.'C
lioll-inILgr;lt;on-n.'('\l'l.'l!lillll loop is S:I;(\ ttl hL' Ilpl.'ll hl't'au:>:!.'
the <.it.'tC(titlll anti intcgration arc lUll I'l.::lii/cd IHlline whill:
the Illovement is \)Ilgoing. hut rather :1t'1I.:!" thl' I\hl\'L'llh,'nl is
Icrmi n:ltctl.
FUl1hcrl11orc. it j, illlll\ll"t,IlH to 1l01l' that the motor (""Illl1I:lIld rl"ponsihk rill' I Itt' cxcnJlion {If :1 1Il0\"l,'mCllI under
I'ccdltl\\;lrd COlllnll i, rc"pol\sihk IhH (lilly for the ,lew;!1
1ll0\TIllClit. but :t1su for the pllslllr:1I :IJjusllllCllts needed to
maintain Ihe equilihrium. H~l1t.:L. Ihe pO~lural ;ldjustlllellt j~
not only a rdlcx fl'aClion to ,I pCl1urh~lIiol1 c;luscd hy thl.'
lllO\Tllll.'llt: it is pn1l!r'111111l1.;d within the movClll~'llt C0111manus .md pre<.:cdc~ the aeW,,1 1ll00cm~nt. Pr;,\ctIGilly. this
fact is imp0l1<tnt hceau"c postural mllscles. often invoh'cd in
dysfunctions. arc highly intlucnced by tl;c execution of 1ll0VClllciHs under volulltarv control. Undcrswnding the underlvin!!.
causes of;l dysl;ullt.:ti<f)lj involving p()s1lJralm~lsdes must ihe~
include thc evaluation of 1ll0\'CI11CI1IS involving l\\(lrC than the
control of postun:.
Fin;llIy. C\'CII thnll~h U~dllito cxplain some level of con11'01. man)' tnovelllcnh ;Ift; l"crlainly l"olllrolled and learned
differently: i.e.. sl(1\\...: r mon;lllcllts ,m; correctcd as they arc
pcrformcd. Thc next "l.'clioll is ..I disclission of the fecdb~lt.:k
Illec.:hanisms involvcd in this other lype of (ontrol.
llCClkd \I)

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PERIPHERAL CONTROL (FEEDBACK)

i\'1an)' movemcnts :lJ\: corrcl:led as tht::y arc produ('cd. If lhe

object wc arc picking up i~ displaced immediately before wc
\\,;,lIlt to grab it. mo;;t of the timc we will be able 10 change the
trajectory or (lur hand in order to m<ltch the new position of
the object and thCll pid it up. The efficient corrcction of ongoing movcments is lll;Jde l)()ssihlc lhrough feedhack control.
The inronn<ltion from the cxternal and internal environments
is const;,mtly monitorcd and compared with the internal goal
(e.g.. picking lip the objccl) in ~uch ..I \\'ay that the illlcndcd
movement is executed. The execution-dctcction.integr'llion
rccxeculion (or -correction) loop is then closed. The sy:w::m is
;,ble 10 keep track of th~ Oow of inform;'ltion and nuid movelllCllls arc organii'.cd. i..'.xccutcd. and corrected if ncceS~:lry.
The sensory information needed for this control is transmitted
through sensory p:uhw<lys and sent toward the different structures shown in Figure 3.1. Three levels of correction arc recognized. First. tht.: short loop or myolactic rdlex O<:Cllrs
within thc lirst 25 milliset.:onds (mscc) and .is mediated
through the spinal cord. Sc<.:ond. the long loop reflex. which
occurs in 85 to 12) mscc. is cOlltrolled by subt.:onical stnJc
lures such as the ct.:rcbcl Illlll. Third. when the relkx contrac
tlOIlS tin: not sunk-ient 10 correct the movcment. tlit.: voluntary
cOl11l11and must be triggered from cortical Slructures.
The role of n::<.:cptors is fUlH.lal1lcl11al lO (his type of control. For cx;,ullplcs. the eyes provide information on the accuracy. while proprioccptors {c.g.. muscle spindles. joilH recep
tl)l'S. etc.) prr)vidc information relative to the status of {he
iIHcrnal cllviml1lllent: joint position, speed of displacemcnt.

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47

I HAININlj AND EXERCISES SCIENCE

n.::huivc positions. etc. R~ceptors play an important role in the

COIuwlof movement ;,IS well as in lhe learning ~r modification
of motor behavior. The status of the locomotor system, and of
the IllllSdcs. al any given time is influcnced greatly by the dist.:hargL of reL:eptors. Their role must then be well understood.
especially for functional rclmbilitmion. which is often based
011 heha\ ioml approaches.
Relwrioral Systems and lipproaeh. Ajoinl adjustment or
lIlllhilizalions basica;iy it funclional stimulus applied to the
bouy. Th~ body. in lurn. can be seen as ;,1 behavioral system
in lhat it hehavcs ill a stimulus-response mode. In other
won.b. all heh:lviors of lhe human system are Ihe result of
a stimulus that is perceivcd ..md integrated. and then a response i~ org;'lnized ;'lnd carried out through lhe effeclors (e.g.
musclesi. Therefore. for a practitioner to be successful. he or
she must understand well the stimulus-response relationship
associated with any given functional or behaviorallcchniquc.
A successful practitioner will be able to prescrihe and administer the proper treatment because he or she is able to predict.
with acceptable accuracy. the outcome of the treatment in the
specillc case. Naturally. lhe receptors represent lhe first line of
COIll:tct between the environment and Ihe human system. In
fact. a qimulus-responsc reaction will be obtained only if the
rce(;ptor~ mc simulated and'l response is triggered. Therefore.
the efficiency of any behavioral approach depends immensely
on the ability of slimulating specific receptors. The mechanism triggered th~lt will ultimately produce the desired re~
sponsc is no longer under the control of the slimulus. il is oc~
curring Iwwrally. This explains why several researchers are
now intcreSlcd in the role of different receptors in (he rnodu
I~llion of neuromuscular information.
From our study of joint receptors especially. some data
stlgge~t IhiJt sacroiliac joint adjustments and direct sacroiliuc
pressure arc responsible for a significant modulation of reOex
respon"c ... ::"~ Such results conflnned that sr:inal infonnation or
commands call be modulated as a result of a joint :ldjustmcl1t.
ami th;'lt the pressure component especially could be the triggering mechanism. Such a reaclion could be medialed
through joint receptors. Further. joillt receptors. more so than
muscle or tendon receptors. are interesting becausc some me
slowly adaptive and nonad<tptive receptors. Thus. Iheir effects
;'Irt.: longl<tsting and can thcn be rcsponsible for long-term dysflillCliolls or treatmcfll effects.
TRAI:"I:"G OR EXERCISE SCIENCE
undcr\l;:md lhe behaviors ;and modific~lIioll in lhose behaviors of the locomotor system. one musl study not only the fUlld:unental units. but also the operations of the system and the
lJualities of these operations and unils.

T()

Fundamental Physiologic Qualities of Pcrrornwncc

The physiologic qualities of the human or locomotor system
arc divided into thret.: categories: organic. muscular. and perceptivomotor.

I
;

H~HA~llIIAlION

ORGANIC QUALITIES

The organic qualities can be presented on a cUlHinuulll based

on the type of metabolic processes underlying lhe production
of energy needed. These qualities ;Irc: C/UlltrtlIlCC, rcsiSf(l/lcc.
and POWCI: The aerobic processes. underlying the cnduf,ancc
quality, are those realized in the presence of (l,Xygl:ll. On till.:
otlter hand, resistance and power arc based on the (///(/('fof,ic
Q

processes available when the oxygen is not presenl.

MUSCULAR QUALITIES

Ii
I

TIle muscular qualities of force. <.'Iu/ural/Ce, resi.'lUlJlcc. and

fJowerarc best understood using the concept of the strength continuum. This continuum ranks the strength production capabilities from the production of a movement requiring vel)' little
force (e.g., moving a limb without an cxtCnl31 loading). to the
production of tile maximal force output. On <l relative scale. this
continuum ranges from a contraction demanding almost 0% of
the maximal force output [Q a contr..lction producing I(XlCk of
that possible output. A contmction requiring pure force is one
that demands 100% of the maximal force output. At the othcr
end of the continuum. contractions dcm'll1ding below 50% of
the maximum can be sustained almost indefinitely and arc siJid
to require endurance. Ifa contraction reaches a level between 70
and 90% of maximum, the blood flow to the muscle will be altered and the amount of oxygen available to fuel the contraction
will be drastically reduced or Slopped. These conditions represent the resistance quality under which contractions can be
maintained for a limited amount of time. Power is a combinmion
of force and speed, A powerful contraction is one thm is iJS
strong and as fast ali possible. Finally.flexibility is <.11so considered a muscular quality. his in fact a quality that is dictated by
the ability of the muscle to relax and let itself stretch passively
and by the elasticity of Ihe soft tissue surrounding the joint. Accordingly, flexibility is more accurately called articu/omu.H:u/ar
amplitude. because it is a function of articular <IS well ns musclIlar structures.
TIle qualities arc import.lI1( to consider for exercise Of
training prescription. In fact. training is highly qualily specific. Force training produces a stronger muscle without improving the endurance. i.e.. Ihe ability to produce a lillie contri:lction for a long time. The reverse is also true. Endurance
training increases the efficiency of the muscle tlt producing
small cOlHractions for a long period of time but will not incrc<.1SC p,ure force. Therefore. knowing that different muscle
groups arc used differently. one should then rCi1lizc that they
should be trained differently,
For example, postunll nmscles (e.g.. abdominal and dorsal muscles) arc used for long periods of time at a low level
of force (50% and below). Accordingly, exercise aimed at de~
vel oping those muscles should involve endurance training
(Le.. low intcnsily and high volume). On the other hand, for
muscle groups involved in high intensity contractions (e.g..
typically upper and lower limb muscles). or occupations rcquiring high force Ic\'els, exercises should target the forcc. resistance. andlor power qualities (i.c.. high inlellsily and IO\\-

OF THE SPINE: A PRACTITIONER'S MANUAL

v()llIm~). Thercr\lr~. w!ll'n p:"escrihillg rc!wbilil,ltion excr~

cis..:s. on~ should k~l'p in mind the l~lrl!...t quality. th~ nature of
the Ill11SCIt.: cOlHr;It.:(ioll r... quircd in a real-life sitU'lIioll. and thc
spct.:ilic nature 01" ll111SI,:k training. The prescript1tlll of exerl';:-;e is disl"lISSed rurth~r in sllb."~qlllnl se('liol1.
Trainiu/.: COl/sid{'rtlt;tH/s. Til... !HO\( important cOllsideration for the prcscriplillll of Ir:lillill~ cx......ciscs ;tntl pmgr:uns is
the: Iraining InaiJ Ill' O\"l'r!O<ld, Till' load is dC\I:rlllined with 1"1.:speet to the quality 10 train ami the "pt.:cilk dfccl desired.
Endurant.:e training. for C.x.lI11Pll'. requircs a low 10:11..1 (e.g.. 50
to 60("1(- of Ihe maximum force). At thc other end of the COI\tinuum. j"orl.:e tr,tining requires loads neighboring. IOOr;{ or
maximum force output.
When considering the. eoillrol of the training loau. it is '1lItomalic and simple to think abollt illcrcasing or JC(Teasing the
:unounl of weight lIsed as a Iraining stimulus. as just presented. Two CQlH':CptS IllUSt be atldrcssed, htm\?\'er: (1) lhe
lraining threshold. and (2) the ddinitiol1 of fOfCe: (i.e.. F =
m x a). The concept of training threshold is r('\<.lti\"t.:Iy simple.
The trilining. stimulus. i.e.. the load. 11l1l"t reach it ....atain value
relative to the subject"s Glp<lcily in ortl('r 10 ha\"c a training. effeel. The magnitude of this threshold Illust lonsidcr two "key
pm..lInetcrs: iHll'lIsity (i.e .. lhc 10'lJ expressed ;IS a percelll of
maximum force outpUlJ and \"(J!W/1(-' (i,c.. the Illllllbr.:r of series
and repetitions). The specific training stimuli ho.\\"e been described. The second concept conccrning Ihe ddinition oj"
force is imponant for controlling the tr'lining. ('omJitions and
respecting the tr:lining "pccilicity rcquircmcIHs. i\10n.:: specifically. the t1clinition of F = III X ..I makes liS r('ali/e th;'lt the
load (i.e. F fm force) can be l1l<lnipulated by ... hanging lhc
miJSS (i.e.. Ill) and/or by manipulating the aCll'!cratioll (i,e..1).
The mass e<1Il be modified in thc usual fashioll. by increasing
or decre<lsing the amount of weights" Most peoplc, however.
forgclthat the effective training load can a1:-;\l he manipulated
by changing the lever ann used for lifting th(' IllaJ. PI;.Icing
the 10o.ld closer or fanhcr :.J\\-<l)' from the joint will decrease or
incre<Jsc the tr.lining !Himulus, rc~pccti\!dy. Till' te:dmique C.1l1
be useful when prescribing rehahilitation cXI..rli:,e:s with surgical tubing or Thcr;:lbands (Hygcnic Corporation. Akron,
OH). The last way to control the training load is to manipulatc lhe gravily. which is (he aceeler.llion applie:<..I on the mass"
Bec<Juse gravity is a vector alw:.lYs oriented in {hc S'lme direction (i.e., pointing!O the ct;:nter of the earth\. Illl)difying the
position of the body makes gr'lvity a<.:( lll(lrl.. or less on the
mass. modifying the effectivc training slil1lulll~. Trunk nexions. or sitllpS. me morc demanding when pcrrl1rm~d on an inclined surface because raising the pelvis relative: to the hcad
allows gravity to .Iet more cfticicnlly ;.lgain~t th..:- trunk along
" greater range of movement. thus producing" more impurtant training slimulus,

I
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PERCEPTUAL OR PERCEPTIVOMOTOR QUALITIES

As the name suggests. the pl:rccptivomotor qualitit:s represcllt

the interaction between perception skills ;lI1U l1lotor output.
qualities specific 10 the ncurollluscul.lr SystClll. The differellt

.,

49

CHAPTER 3 : TRAINING AND EXERCISES SCIENCE

pcr.;:cptjQ 1t11l1!Of qll<lli(i~s ar~ reclClim/ rilll'. SP('('(/ of /11O\'C11/('111. /1/(1(01" (1('j'lInIey. ;lIlU hody ill/{/,t!,('. \Vhilc Ilwintaining
amJ fO(lI:-in~ 011 the phy~iology of motor hehavior. it is as imporlilill to be PI\,:oCl.:upicu by the diffcn.:nt way~ in which the
fundamcntal unil:-: can be activated and controlled. The pcr~
ccptivlllllotor qualities address hmv the motor actions afC CO~

-,i

unJinah::u ;lI1d how perception is imponanl in the control .1Ild

I.:Xl.:l'Ulillll

of any

1110101'

(ask.

.)
Musdc Dynmnics
Muscle dynamics focus on the mechanisms underlying muscle fU1Iction. First. the smalkst functional unit of the neuro-

I
j

llluscular sY;";'Clll lllust be addressed: the motor unit. Then. the

basic mechanisms arc di~l:u.sscd in light of the strength continuum. which facilit:IICS the prescnt;,uion of lhe contraction

(,-"::;

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typc~.

MOTOR UN!TS

The motor unit i~ defined as the alpha motor neuron. its axon.
and the Illusclc libel'S it innervates. 10 The motor unit and IllU5ck libt:r types call be catcgorized in lllany different ways. The
Illost objcl:livc ways arc',IC(;ording to electrophysiology. fatiguc resistance. ~izc. and histologic classifications. In all of
thesc quantitativc motor unit classifications are three types of
units: [<.1st fatigable. f<.lst fatigue resistant (imemlediate motor
unit). and slow motor units. Edington and Edgerton ll prcsented one of the 1110re comprehensive descriptions of the mo101' unit types (Fig. 3.1).
To fully apprcdalc thc mcchanisms underlying the muscle
dynamics. the cnc;rgy sources that fuclthe contraction must be
discussed (Fig. 3.3). The first source of energy available to the

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muscle is the immediate source stored in the muscle <lt the

contraction site. Thi~ source of energy is short lived and is
<lvailable for only a few seconds (30 seconds maximum). The
oxidat;\'(' metabolism is the result of rC<lctions taking place in
the presence of oxygen. This energy production system is responsible for cndurance excrcises during which smaller contractions arc produced. Stronger contmctions obstruct the
blood now to the muscle. thus Slopping the flow of oxygen
and preventing the oxidative processes. Endurance contractions in which blood fiow is not obstructed C.1O be carried out
almosl indefinitcly. Finally. the lwlloxit!ative metabolism undcrlies forceful and powerful contractions. During this type of
contraction. blood vessels in the muscles arc crushed and
blood flow is stopped for the duration of the contraction. The
oxygen is no longer available and the reactions that can occur
to produce energy use glycogen for fuel. These reactions produce byproducts. such as lactic acid. however. that reduce the
contractile possibilities of the muscle. especially when they
accumulate. Therefore. this type of energy source is available
for a few minutcs only.
The objectivc of training is then specific to the type of
exercises executed. Endurance exercises increase the efficiency of the muscle in using the oxidative processes. On the
other hand. resistance training forces the muscle to work
without oxygen <lnd it must increase its capacity to contract
with a greater oxygen deficit. Finally. force training is almost independent of the metabolic processes because pure
force and power w,c immediUlc encrgy sources almost exclusively. It should then be obvious that parameters such as
speed of movement, resistance to movement. and duration
influence greatly the depiction of the energy sources nnd

Fig. 3.2. Summary of the

motor unit types and char~

FF

acterlstics.

~i

Motoneuron

la EPSP

'0

'0
'0

,~

'0

~I

Muscle lInds

SO

e; D()fk

10
~

!.

J! ,'-"
! ~ ...

T --::c,j

~.f'

(From

Ed~

ington
OW,
EdgerIon VR: The Biology of
Physical Activity. Boston.
HoughlonMifflin. 1976.)

------,---------------------------------------.

....... ", ........ ',",' 'VIII

Fig. 3.3. Energy sources

available for muscle con-

vr

I Me

~I-'INt::

A PRACTITIONER'S MANUAL

Oxidati ve i\l eta boliSIll

\ ..

tractions.

Glycogen - - . I

Nonoxidativc
1---.1 ATP
Metabolism

Contraction

ADP + Pi + Heat

---',

, 1

AT? Stores

AD? +- Creatine Phosphate

ADP+ ATP

"

should be considen:J can::flllly when cXl:n:iscs or training :Irc

prescribed.
Finally, <IllY discussion of the motor units ;'ll1d their COI1lrol would nOI be complete without a prcscntmion of the
concepts of series clastic and of reflex or spillal control.
Sludied together. these concepls rcveal that the muscle C;'1ll
be perceivcd as an intelligent clastic lh;'lt is <luachcd 10 ;1
simple level. This simple but imponall( definition helps 10
appreciate the impommcc of the contraction types ,lIld their
control.

CONTRACTION TYPES

Simply stated, muscle contractions C<1I1 occur under only

three functional conditions: (I) the external force (F) is
equal to the contraction or muscular forcc (F,) or F,. = F",:
(2) the external force is smaller lhan the muscular force or
F.: < F",: and 0) the external force is greater than the
muscular force or F > F . The lirst condition. vielding
contractions while no "rnov;;ncnt occurs. produces i,~olllelri;'
contractions. The second condition. usu;,tlly the desired ('on
dition. makes it possible for the expected movement to
occur because of shortening of the lIlusck producing a displacement in the expected direction .It a given ~pccd. This
type is known as cOllcell/ric contraction. The third condition is the exact opposite of the second. Eccentric: con
tractions afe produced while the muscle is aClUaliy being
stretched and movement is going in Ihe dircclion opposite
to the one the muscle would normally produce. For that reason. cccentric contraclions <lrc oftcn said 10 be involved in
so-callcd "neg<ltivc work." These definitions <Irc <It the core
of the understanding of muscle dyn.unics. They arc fundamcmal to an important aspcci of musck contraction known
as the!orce-\'(:!ocil): relationship or curvc.

- -- --_.----------

FORCE-VELOCITY RELATIONSHIP

A schematic representation of a typical force ...elocity curvc is

shown in figure 3A. This curve shows clearly that the grt:atcst amount of force is produced in the eccentric condition.
Thb faCl could he explained by t\\to distim.:t mechanisms activc simultancou .. ly during muscle lcngthening ecccntric contractions. One mechanism is lht: \tretching of the clastic COI11poncl\ls in the muscle. In fact. the muscle acts panly OIS an
clastic: it is able to si(lre energy while being stretched. This
storage of energy automaticillly increases the force output
monitored. The \ccono mcclw.ni\1l1 is based 011 the ncuromllscul;'lr control jJvail~lblc to Ihe muscle, Receptors. the muscle
spindle specilically. arc sensitivc to stretch. When the mu:.dc
is being stretched. the spindle is excited. the Ia afferent libel'S
thai connect directly on lhe alpha motoneuron respollsiblt.: for
the ongoing contraction ,Ife soliciled. and thc nerve output to
the muscle is increased. producing gre;'ltcr force. These (wo
mechanisms arc speed dependent. Accordingly. the forccvelocily curve Ic\cb off at greater levels of negative velocity.
As soon as movement starts in the desircd direction (Le..
concentric contraction). the capacily of the muscle to produce
force is drastic<.llly reduced. At greal speeds. force production
goes down to 30 to 40% of the isometric force levcl. This rt:'1liwtioll is disconcerting. because usually the object of muscle contraction is to produce a given 1ll00'Cl11cnt and in that
vcry condition the muscle is less efliciem
Onc can ask: so what? Wlwi is the relevance of the forc~
velocity curve? Outside of acknowledging our limitations in
producing force during voluntary movements. it is important to consider the force-velocity curve for two rc'lson:'.:
(I) training spccificity and (2) recognizing naturally occurring eccentric contr<u;tiolls <.Juring which the risk of injury
is greater. These aspects of Illuscle dyn'\Inics arc discussed
subsequently.

---!

-k.

vHAt" I t:H

;j:

51

I HAININ\j ANU EXERCI::iES SCIENCE

, ~";

Torque (Nm)

100%

Fig. 3.4. The force-veiocify

relationship.

(nux L'iOI1H.1riC)

i,:

I,
I

~<:>.

<j

,.,..,-,\
~-}

~.

II

(}

'~
0. _ '1'

Eccentric

I
B

I
I

FORCEANGLE RELATIONSHIP

Figure 3.5 presents an idcaliz.ed force-angle curve. The importance of this relationship is the dcmonstration that .1I1Y
muscle. or muscle <'IffillP and jQint system hilS an~()ptjlllai
\".q!ki_~..p..Qs.it.ion. Joint position or angle, related to the Icngth
of the n~1s._~nfluenc~~Jh<:...f9J:ce p~oduc~i.9~ E.~P~~.!.!J' of the
m~le.~ the knee extensor muscle group. for example. the
maximum forcc output is measured at between 80 and 90 of
Jn~c flexion, Again. this relationship is important to consider
because of its implication in training effects specificity.

:......,~

-::. 3

"

f\\

'-\/

TRAINING SPECIFICITY

As suggested previously. training effects are known to be ve

locitt~'l and position (i.e., joint angle) spccilk.I~.I~ Training
with neg.llive work. for example. increases force output of eccentric contractions without affecting. thc muscle capacit)'
during concentric contractions. !':urther, training at a specific
joint angle (full joint flexion. for example) will not or may not
influence the force omput of the muscle group when the joint
is nenr full extension. This fact suggests {hat a rehabilitation
program ~hould be specifically adapted to the muscle. the
joint. and the task t<.Irgclcd. Accordingly, a person expected to
do static work requiring isometric comractions in a specilic
joint angle should not be traincd or rehabilitated in the san~c
way as <l pcrson working in a dynamic situation.
A training ovcrnow, or :m-called window of nonspecilicity associatcd wilh isomctric cxercise~. was mcasurcd. I(' Wc
demonstrntcd th.1t training the knee isometrically at 90Q innucnced significantly the concentric and eccentric forcc over a
r<.lIlgc of up to 46(' (i.e.. from 54 to I O()~) of knee flexion). Su'.::h
findings suggcst that a joint can be If<lincd st;,ltically at a spc-

[)

{/J

tffi

I, ..
I

~:"""

-tJi

i
I, (-.$
~ ~
~

",
~

I1

-- ....
-';..;$

Cc;:;

Velocity

Concentric

cilk painfrce <1I1glc to achieve a functional treatment effect

within the painful or dysfunctional r<lnge of movement.
Further. it has been recognized th.1t the risk of injury as:-.ocialcd with eccentric or negative \\!ork is greater because of
the higher levels of force output achieved in this condition.
Do we produce eccentric conmlctions in rcal-Iite situations'!
in fact. any contruction needed 10 decelerate ::l movement reM
quires cccclllric work. and lhe muscle accumul.ltes energy
while it is Mretchcd. Thc bcst example of that situation is in
locomotion. w.llkillg or nllluing. when eccentric contr.lctiol1s
<Ire executcd many times c\'cry day. Two muscles especially.
lhe tibialis anterior controlling the fore foot contact during:
gait, and the hamstrings decclerating knee extension .1lso during gait.Irc constantly used eccentrically. Afrcr an injury or
immobilization. those muscles should be remlincd using eccentric exercises to ensure that they regain the necded level of
strength for their specific diJily activity.
Some muscles arc used eccenlrically because of their biarticular nature. The gastrocncmius .mel hamstrings arc good
examples. Such muscles often arc stretched at one joint while
lhey arc required to contract to move the other jqint. When
lifting a Imld. for instancc. the hamstrings arc required to extend the hip (shortening contr.1ction) while the knec is being
extended (hamstrings being str~tched). On th~ one hand. this
synchrony is lIseful because the energy can be transfcrr~d
from Ihc knee 10 the hip by only keeping the hamstrings.tt Ihe
same length. When the knee extends. the hamstrings i.1utomatically pull on lhe ischial tuberosity to produce hip extension if they <irc able to keep the same length. Bjarticular muscles arc indeed good for transferring energy from OIlC joint to
lhe other. On the other hand. this type of sustained and repeatcd activity Gill explain why these lllllsclc:- arc often tight

mrary I.P.H.
Ace. No.~.l.j.?c

Isometric

Nt:n .... OlL.. ll .... 1 IVI'I vr I nt: "r-1I'1t:; 1-\

t"HA~

t IIIUNt:H':::; MANUAL

Fig. 3.5. The forceangle relationship.

Torque

100%.

(I'm)

(pc:lk 1\'f'IUC UlIll'lIt)

,,,

'.

!
l

1i

'.",

,
! '",
I
J

..

! i

Full Extension

5:

I
J
!~
~

.~

Joint Angle

and prone.: ttl l:onlraCllIr..:. Hem:..::. hi ...Ulilular lllllscks. such as

the hamstrings and Glif mu~des. should be trained (0 pronl(lle
elaslicity. through cIH.lur.lIlCe and stretching exercises. and not
force only.
finally. the neural <ld<:lJHation underlying exercise or train ..
ing cffects is oflen taken lightly. In raet. l-trcnglh increase can
be obtained through modifications at the neural level alone. n
\Vhcn morphologic changes do occur. they comc into play after the neurophysiologic modificmionsl~,I'J Illeasured. for example. through motor unit recruitment frequency or synchro..
nization of molor units. Funhcr. the highcst Icvel of twining
specificity may be in the neural adapt'llion underlying the motor programming or Icarning associillCd \vith exercise. The
motor comral levels achieved with a specific exercisc can bc
totally inappropriate for il given functional task. even if the
same muscle groups arc used. A slrong recommendation is to
selecl training or rehabilitation exercises according to specifIC
motor tasks taken from the patient's daily activities.

;j

I,
~

i
)
~

:]
$I

i~

EXERCISE AND/OR TRAINING PRESCRIPTION

Professionab dealing to ~ grc:1l extent with functional problems (e.g.. pathologic or traumatic) or dysfunctions are often
calkd on to evaluate. treat. and rehabilitate Illuscular functions. Exercise and/or tr;'lining prc~l:ripti()n is then a common
demand. The basic training in exercise science or kinesiology
is often limitcd. however. In that respect. lhe information rel ..
ative (0 the force-velocity and force-angle relationships and
training specificity arc fundalllcntal to the practice of exercise
prescriplion.
More specifically., when confronted with exercise or train ..
ing prcscription. I always consider lhe following: (I) the objectives or goals pursued by the exercise program and the
concerned individual (c.g.. rehabililation, well-being. compe..
tition); (2) lraining specificity (e.g.. velocity and position): (3)

Full Flexion

popul;lIion segment to which the concerned individu<ll he..

longs (c.g.. age. sex); and (4) the targeted quality (i.c.. where
011 the continuum will the persOIl exercise in function of the
specific lask to be executed?).

USE. OVERUSE. MISUSE. AND IMMOBILIZATION

Dysfunctions are often associated with usc. overuse. misus('.

or immobilization. It appears that too much or too little move..
ment brings aboul a functional problem.
Movement in men and women is neither accidental nor in..
cidental. Movement is cenainly csselltialto heahhy life. if not
its essence. Realizing that both use and immobilization. two
opposites. can or will cause functional problems leading to
discomfon. dysfunction. or dys..e'lse. highlights the need to
define what can be called a u'ilU/ou' of ol'lima/ a<"li1'il.\: On .1
!1(.',!ormlllKe COIII;IIuum (Fig. 3.6). this window should bt:'
placed in a functional zone between rcactivation and activa ..
tion. This concept of performance continuum. including tilt:'
levels of intervention (i.e.. rehabilitation. reactiv:.Hion. and ac ..
tivation). the types of intervention increasing performance.
and the eve illS leading to decreasing perfornlance (see Fig.
3.6). should help to organize the research needed to under
stand the complexity of functional health or pathologic
change to organize the inlervention needed to mainwin an in
dividual in an optimal position along thal continuulll. ,lI1d to
reveal the imponancc of overuse and immobilization.
Such a conceptual framework is the bal;js for the re ..
search. in chiropractic, kinesiology. and SpOrts medicine.
produced in our laboralory. Our focus is on imbalances.
knee dysfunctions, ,lOd lhe relationship existing between
the mechanical and neuromuscular cOl1lponellls of function.
This research program should help 10 understand this win ..
dow of optimnl activity and the consequences of being oul ..
side of it.

j) - - - - _ . _ - _ . _ . _ - _ . _ - - - - - - - - - - - - - - - - - - - - - - - - - -

-,

.;

53

CHAPTER 3 : TRAINING AND EXERCISES SCIENCE

LEVELS of
h'lTERVENTION

REACTIVATiON

REUADIUTATION

ACfIVATION

TYPES of II\TERVENTION
Incrensing Pcrformun(:c

..
"NORMAL"
Performanu

DECREASED
Pcrfornlance

EVENTS

LEADL'~G

to

LEVELS of
PERFORMANCE

..
PlIlhology
TnlUnlll

Decreasing Performance

INCREASED

.,

Ule
ImmoblllLatloD

..

Fig. 3.6. Performance continuum including the relalive position of the levels of intervention (rehabilitation. reactivation, and activation)
and the different phenomena responsible for increasing and decreasing performance.

CONCLUSION

",

(~

! ,J

I
~

0
,

;;)

<i

i ()
i, 'J
f,
~i

-;

"

":,:
t)
l~

I 'd
t'

;;

,"~ 0
~

'8

All exercise science appro;'lch outlined in this chapter should

be useful in guiding functional cvalu<Jtions. All three fundamental components of !he systclTl-anawmic. mechanical.
<Inu function..l1-should be investigated systclll<lticaJly to dc~
termine objectively the course of events after the evaluation.
This course of eVCnls, 1c'.Iding to the rcstoralion of the dy:-function, most probably includes reactivation and aClivation
of the functional units. The cxercises or techniqucs lIsed to
:'Ichieve the rC<lctivation goals should be guided by:
The type of muscle involved {Le., firer type (.-()lnpositionl
The type of delll'Hld or work normally imposed (111 the muscle (Le ..
concentric, i~llrnctrjc, or eccentric conlractions for p()~tllr,,1 or \"0-

disciplin<try approach to enlist .lIld bencfit from the assistance

of an exercise sciemist or kincsiologisl.

REFERENCES
I. OcSI1l,lr:tis F, Boucher lP: t\ Illwer limh a'YlIlIll..:lry modd: /\nal<llllil:al,
mceh:lIlilal. and functillll;d faelnr,. In Pmc..:..:~ling' (If Ih..: 1991
tntcmation:11 Cnllf..:r..:n..:..: (Ill Spinal \l:mipul:uitlll. FeER, r\rling.t<1l1.
VA. 1991. pp 129-133.
2. Bouch..:r JI', Hodgdon JA: AnalOllIk:ll. m..:chanil'al. :llld l"1I11cli(IIWI l":ICtors in l':lIdlo-fclllor...1 p:till sytldrome;,. Chiwpract Srorls M..:d 7: I.
199::!.
3. DCSI\l:U'alS F. Boucher JI': . \l1;l{(lmk':11. mech;lIIic;,1 ;mtl f!llIctioll;\1 dt:lr;IClcri/.:llioll of ~:tcroili:1l" .i~linl lixali'Hl. In Prol'ccdings of lhc 199.\
hlletllaliol1:tl Confercncc Ill} Spinal ~talliplIl:lti(lll. FeEH. Arlin~l(lll.

litional work)
The normal work r;lllge of motiull (i.e., angle specificity)
The luad required for the specific development targeted (i.e.. Spt>
ci(ic muscular qLl,ilit}', endurance. rcsist:lllce, force, power, or articu!ol1lUscular <Ullplitudc)

Only when all these "spects arc considered carefully <m~

the reactivation and activation goals reached systematically.
Therapists lacking background in the exercise scicnces which
is needed to appreciate aHlhe important details underlying the
reactivation and activation techniques, should seck a lIluhi-

VA. It}tn. I'l' 52-53.

..1. Hcrwg. W, NiJJg OM. Read JL: Quallljl"~'illt,: 111..: df..:t:b of ~pill:11 Illanipll!:tt;olls (Ill JJ:lil, llsil1g p;It;cnb with low h;lCk pain. J ~hniJ1l1"'li\'e

PhpiolThcl' 11:151.

(I.

chronic lC'w b<lek p<lin. Spine 14:992. l<J~9.

brow FM, Boucher JP, Hsieh J: Anatomical. mech:lIIical :lIIl1 (unclional cha;';IclCrizalit)ll or dlronil.: low b:Jl.:J.; pain. In Procecdings of lhc
1993 l111crl1;llion;L1 COI1t'crClJl.:C Oil Spin:l! i'bnipul:llion. FeER.
Arlin~ltll1. VA, 1993, flP 5"'-55.

7. Ch,Hh(lnn{':1U M. Boucher JP: Scgrncnl<.J1 nw<!u!:lti(11I Ill' T <lnd H rc-

--------------_.._-_._1: :~

Ins.

5. Roy SH. Dc Luc;1 CJ, C'Isa\,:llll DA: Ltllll!>;lf mu!>dc f:lIiguc :lml

llcxcs and ,....1 \'I:I\'C lollnwill,!C

;1

chiropr;lcllc :ldjuslIllCIlI: A pilot sllldy.

b4

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

III I'ml..'l;cdin!:s of the 1990 Intcrn:ll;on:,t CmlfcrCIICC on Spinal f\h

Ilipublioll. FeER. Arlingl<lll. VA. 1990. pp .19.1-:198.

S Ldchwc S, Ch:lrlwnlll:all M. Ihllldlcr JP: :...1odllbtioll of scgmcllIal

~pin:ll c ....cilahilily hy mC'l.:hanicll :-Ifl'"'' l'l)tl11 Ihe s;\cf(l-ili;tc joint:
Prdimin;ll)' rcpt'rI. In l'rt>l'ccdill~S IIC tll..- 191).1 llllcm:llional Conferc:nc..: on Spin;\l l\1;1I1iplll;tliulI. feEK :\r1in~lOn. VA. 1993. pp %-57.
9. ..\slr'lIld PO. Rodah! K: Texthook (I( \\'prk Physiology. New York.
!'-IcGraw HilL 197i,
10. Ba:'lI1ajbn JV. n.,.. I..U~.1 CJ: ~l11"l;k Ali, ..... 5lh co. Baltimore. WilIi:nns
& Wi\kills. IlJS:\.
II. Edington D\\'. Ed~~'rion VI{; Th~' Bit'],l';:~ of I'hysical ACli,ily. Bo:-lull.
IhlUghwlI ;"lifllin. 1',17(1.
12. !\lotTried MT. Whipple lUI: Sp.. . lilkiry of spL:ed e:'tercise. Phys Ther

i!

I
~
I,

50:1693. \970.
13. C:liz...o VJ. I'erille. JJ. Edgerlt1u VR: Tr;tinin~induccdalteralions of Ihe
in "jvo fllrce-vcllx-:ilY rdalinnship of human muscle. J Aprl Physiul
51:75n.1981.

14. Bcnder JA. K:lplan HM: 111e llluhipic anglc test ill. rnelhod for
lhe evalualion of muscle stren~th. J Bone Joint Surf: lAm) 45,\: I 35.

1963.
I~. ~k)'C;rs

C: Effects of 2 isometric roulincs on sln=nglh. size and endur:llIce uf excr~'i~ed :md lion-exercised anns. Res Q JSA30. 1967.
16. Boucher JI'. Cyr A. King MA. el "I. )ltOUlClnc t(:linin/; ll\"er!ltlw: Dc
lerlllin;l\ioll of :1 ll(lIl':"I~ciliciIY winuow. ML:d Sci SPllriS EXL:n.:. 2:':
SD4.19<)J.
17. EllOk:t R~'1: ;-':curumech:lIlic;11 Ibsis til' Kiuc..il,lugy. Ch;ullllaij!ll. 1L.
Human Killclin BI1lOlks. 1985.
JR. S::tle D. ~hcD(lugall (); Spccili..:it)' III ltlrellglh lraining: A re,ie\\ f{lr
Ihe coach ;L1111 :Ilhlele. C:m J Sport Sci 6:87. 19S l.
\9. RUIIII.:rford O~'l: Muscular comdin:lliml and strength lr;lining. implications for injury rehabilitation. Spuns Med 5:196. )9SS.

II
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C)

II
ASSESSMENT OF
MUSCULOSKELETAL FUNCTION

'I

:1,

4 Pain and Disability Questionnaires in

Chiropractic Rehabilitation
HOWARD VERNON

"An old joke: \Vhich is better to have. a watch that's

slOpped. or a watch that's always five minutes fast? Answer:
T.!!c wmch that's slOpped-because m Icast it's dght twice a
day!"
[[valuation is the cornerstone of clinical mcdicin,flNo diagnosis can be reached and no effective treatment can be rendered without conducting a clinical evaluation. which allows
for the identification. of salient signs and symptoms 9f lhe presenting disorder. This fOfm of clinical assessment is conducled by using a time-honored system comprising a patient
intervic\\' or history. obscrv~Hion. and clinical examination

procedures. These procedures often include established and

traditional "tests" 10. for eX<lmplc. provoke p::tin. feci for tissue changes. visualize the struclUrcs.lOd otherwise diagnose
the condilion. In the biomedical disease model. I some physical disorder must account for the disease. and the process of
clinical evaluation permits the most precise nnd trustworthy
d~tcrmillation of the nature and underly::lg cause of the disorder.
New clinical models challenge the limits of the tradition 1
disease model":.1 and of its classical fonus of clinical c\'aluatien. One important new way of viewing disorders of health
is GlUed the "functional modcl..,\-s In this model. it is recognized lhm .llthouglt'two patients may havc.J!! same diag-

~~~cd_condition. each may have diffcrc:~t_a!.t~!.:l.~~~~.~~~unc

11011. CSPCC1<ll1y In rclev<lnt areas ofl1JTiy--hVlng-antl wmk y
"~,e altcr~ltions arci)'pic<llly dCfl11C'd as lc\;cls of disability.
.tnd they arc not always fully measured in the classical clinical evaluation.
Also of imponance is the "illness behavior modcl.''Lll in
\vhich the distinction is made between "disease:' defined in a
mechanistic sense as disordered physiology, .md 'illness. delined as the manner in which thc 'person with the disordered
physiology adapts to his or her own cnvironment These two
1110dels arc p.mkularly appropriate when applied (0 rehabilitalion of p.linful disorders of the musculoskeletal system.

dcfinitions ,Ife helpful. a com:eptual model .Iids greatly in

clarifying the c.:omplcxities in\'olved. Locser's modd depicts
pain as a multidimensional hicrarc.:hy. hc~inl1illg ill its lowest level with nocic.:eption. which leads to p.lin. which h,.'ads to
pain beha\'ior and ultimately to suffering,I,I'Each of thcst.: dimensions lends itsclf to particular kinds of ;lsseSSlllcnts. On
the other hane!. the further \.... c asccnd in the multidimcnsional
hiermchy. the more it is that uny p:.lrticular phcnomcnon is a
product of e~cll of thc dimensions subscrving it. For examplc.
tcndcrnes!' levels measured in the somatic tissucs may reveal
something abollt nociceptive activity and its interprctation <IS
pain. espcci~lIy in tcrms of the threshold to perception by the
patient. This particul'lr measuremcnt. howevcr. ma:' have little to do with other pain outcomcs, such ~IS retunt to work.
Return to work is a function of the social dimcnsion or pain
and is thcrefore inlluenccd by a host of factors beyond that or
the current quanlum or nociccplion experience by thc paticnl.
Also warranting considering is the currently ,ll'L'Cpted
model of p<lrallcl and interactivc proccssing of scnsory as
compared to affcctivc l1lotiv.ltional dimensions of pain. l~ It is
generally accepted that tests and measures that cvalualc olle
of these crucial dimcnsions may nOl be applicolble to the other.
Whcn considering p:.lin .Illd loss of function. especi<.llly ill
regard to low back pain. a cfucial distinction musl be orawn
betwecn disease and illncs'\. \.11 The illness beha\'ior 1110dcl
provides it framc\vork within \l,Ihich the subjct:tivc expericnce
of discase becomcs legitimizcd conccplually as illncss. which
is then viewed operationally as disability./the physical cornponcnts of diseasc .rcqu.irc treatment. whcrc;;'ilic illness COrtl
ponent of disability requires care.,Trcatmcllt and earc become
two distinct opcr<1lional domains with differclH objectives.
different measurcments of assessmcnt and diagnosis. dilTcrent
strategics of managemcnt and. most important for this discus
sion. different outcomcs. Gaining separatc but ilHcgr.ncd perspectivcs on thc outcomes of treatment as opposcd to thusc of
c.lre will substantially improvc the delivery of rdlabilitation
services.
M

CONCEI'TUAL BACKGROUND
It is useful for this discussion to st.lrl with a definition of pain.
as originally ..dopted by the International Association for the
SWdy of Pain: ':,Pain is Ih.'1l associ<t(ion of stimuli with responses whic!l.ffiSll.1tl~anunplca.~am cx~rience which hurts
a I~ and from which they \\':!~tto-tx;-rrccd:li.A:fihou-gh
~~-'

.~.-_._-

',"-'

....

.~-------_

_~

Properties

or Measurements

As a preface to a discussion of lests for pain and dis'lbiiily. the

HAlder should .'pprcciate ~cvcral axes alUund which tests such
as these arc configured (subjectivc \'s. objeclive. qualil;.ltivc
vs. quantitativc). l..,lcasurcments arc idcally designed to mini

57

,,,

t,
!

('it

!u

H~HA~ILIIAIION

Table 4.1. Attributes of Tests in Clinical Rehabilitation

Reliability
Validity
Sensilivily

Specilicity
Responsivity

mize error and 10 reduce variability. In the clinical selling.

the involvemcnl of the patient in the process of measuremcnt
of pain creates a great dC<l1 more variability than O1:lny scientists arc willing to toler<ltc.1.~-17 Nonetheless. hy its vcry deflnitton as an experience and not ,10 objeclitlable state, pain
eludes such rigorous O1l1alysis. Often. the best we can do is to
n)anagc systematically thc high degree of variability in paHem groups. Whcn discussing the issue of outcomes measures
in chiropractic rehabilitation. numerous attributes of such
measures must be undcrslOod.lI'u" Table 4.1 lists some of
these attributes,

i"leasurcment Scales

All instrulllents usc a scak to measure a specific para mcter.!(I,:1 Typically. the scale is only representative of the phenomenon itsdr. For example. the increase of temperature is
really measured in lineaf)lnits of increase in a column of mercury-a thermometcr,@milarly. the visual analog scale
(VAS) uses a 100-mm line [0 represent pain intensit . In this
ins-iilllcC:-the anchors or ell poll1ts of the scale arc both absolute and arbilrary. They are absolute because they are intended to measure the phenomenon from its lowest to its
highest level. On the other hand, they are arbitrary because
the numbers assigned to these and any intennediate states arc
purely a miHter of the choice of the designer of the scale. In
fact. many pain sC<llcs usc the numbers 0-5. 0-10. or even
0.:101. wl.lcn. all thc while. there is no more p<lin with one
scale than with the nex.t!
The manner in which numbers or units are used in a scalc
is organized according to the degree to which the scale :lctually represents the quality or quantity being me~lsured. The
lirst scale uses a numeric code to represent the response
category. If only two answers-yes or no-arc possible on
a cenain scale. and numbers such as_lor 2 are assigned to
rcprc.sent these answers. then these data are said to bc
"omit/al (lata. In this respect. the numbers actually represent
- a code for other data. Nominal data :lre said to' be the lowest order of data in !hat liule of the actual parameter measurcd is revealed by the dat~1. All the qualities of the P~l
ramcter thm are measurable are reduced to one of two
statcs-presen[ or absellt. yes or no. male or female, etc. As
such. this type of data is also referred to as "dichotomous
dala" (Table 4,2).
On the onlinal scale. numbers arc still used as codes for
other characteristics. but the numbers arc used to rank the
level of llle characteristic and. therefore. bear some (if only
indirect) relationship to the measured value. On an ordinal
scale, the number 2 represents a greater value than I; however. the true intervals of such a scale arc really unknown. In

OF THE SPINE: A PRACTITIONER'S MANUAL

other words, whether 2 really represents twice as much of the

value as one. or, on a scale from I to 5. whether each interval
really represents 25% of the tOlal value is. at best. uncertain.
Nonetheless, this relationship of ::In ordinal scale to the value
measured is often assumed by users, prompting some inappropriate conciusions.
In the ;ll1en'al scllic. numbers do not merely n:prcsellt
units of value. they constitute the units of \'aIUl~, Thi.;. ,;,c;lk j..;
synonymous with a type of data known as "continuous daw.
On the interval scale. data points arc true numeric rcprcsenla~
tions of the value of tht.: parameter in questiollUI,ese data
(X?i nts c::ar~..~~~~l~~~51.{~t J<:.<}~t ~1).t?~!e~i~al!y.l1IJ1Qinfinitely
smaller uni~s. each of which would still repreSCIlL3 true unit
.of~ea-~u!~!l,lc-l1tof~h~,p'.ax~_mS:,~r.'Forcxamp-I~.tempcratureis
measured on a continuous scale, whereby a measurement of
10Q is hotter than 9::1. and colder (han 11 0 , and the diffcr~nc~
between 10 and 10.5 0 is real. On an interval scale. however.
there may not be a true zero point: there arc three different
temperature scales. each with their own zero poinl. As such ..
at least on the Fahrenheit and Celsius scales. there may not ~
..In absolute representation of the measured vnluc by the scale.
in thm 20 may not be twice as hot as 10.
The laner aspect is the feature of scales known as ralio scales. When measuring the angle of the straight \('g
raising test, the angular scale from 0 to (typically) 90 to I (Xl~
is used. Data are continuous. and ratios can be formed such
that 20 of angle is. indeed. twice as I~,uch as 100. This
scale allows the observer to make true comparisons l:letween measured results of a test under a variety of conditions.
As an example of appropriately ratio scale comparisons.
consider a patient with low b~ck pain who scores 30 oul of 50
on an ordinally scaled disability questionnaire...Hld whosc
straight leg raising signs. bilatenilly. arc limited to 45<:. If.
after a course of treatment and rehabilitation. the dis<lbiliry
score drops to 15 Oul of 50 and the straight kg raising signs
increase to 90, it is reasonable to say that an increase of
100% h.<ls occurred. Because the disability scale uses ordinal
data. however. we are advised to conclude that a subst'lIltial
decrease in score has occurred. but not Olle that really rcprcSCnlS 50% less disability.

Table 4.2. Scaling in Pain and Disability

Questionnaires
Nominal Scale:
~Do you have painT

Yes/No

Ordinal Scale:
wHow severe is your painT

o2

4 6 8 10

none
Testing

awful

Interval Scale:
Determine Ihe thermal pain threshold in a pain patient (Range:
40 to 55)
Ratio Scale:
Determine the pressure pain threshold in a pain patient

(Range: 0 to 10 kg,'cm l )

'-.

CHAPTER 4 : PAIN AND DISABILITY QUESTIONNAIRES IN CHIROPRACTIC REHABILITATION

Sources of Bias

SP~llbl'

One funuallleiHal premise tllltkrlying dinil.::d lllC;lSllrl.'l11t.:nl is

Ihe notion Ihall'lTOr and bias Ill.,)' l..'.\i,q at :lll len::ls and from
.111 sources throughoUl Ihe measun::mcnt pnH;ess.: I :: Thcsc
sources include lhe subject. the instrullh.'IIt. ;Iud till..' l..'.\alllincr.
THE SUBJECT

:"\

_-~

59

Emotional. f'."ycIJ%gic. ami pl'rsollalily jt'C!o"x illl..',ilahly

pl;t)' a p;U1 in lhl' :-uhjel:I's n,:spOllSl' hI lllcaSlirCIllCIll.:; bc it
sclf-r.tting qucslionnaires or physi":<.ll paforlll.ult.:e lcsls. Such
fal.:lors as p'lin IOkram::c, sdf-image. beliefs ;ll1d ;l\titudes
<loom health and health practitioners. mood. and underlying
Illotiv.ltion Ill.ty .tll innuencc Ihe participation uf'lI1 individual
in functional measurement.
Physiu(o!-:ic factors certainly pia)' a rule in physical perfonnill1t.:e testing. For example. fatigue. nellrulogk sti.ltll:>, and
pain Ie\'c!s may all influence testing.
Cogllitil'cj(ICIOf!i playa crucial role. especially in the .lrea
of instructions for test activities. Language and cullural and
cdUl.:.uional lal:turs all impact the subject's comprehcnsion of
the ovcmll purpose of .IIlY tesl. as ,\:ell as the manner in whit.:h
it is to be conducted.
Fin.lily, In.tditioll:.ll sources of IH.n.:/wl/Il!lric bias oist.:!
such as in the tendency of subjects to choose responses in the
mid-range or at the extremes of a scale; the crfccls of the
order of different responses, itcllls. and, indeed. of different
tests when using a battery of tests: and Ihe tendency of subjects to ovcr- or underestimate depending 011 their pcn:cplion of the responses expected in the lest.
THE INSTRUMENT

The coll1elll domaill of sclf-reponing instrul11ents Jll~IY be insurllcicllt to capture all necessary chLlrac((;rislit.:s of the parameter to be mC.lsurcd. The [On/1ll1 of qllc.'ifiOIlS eilll ilHroduce
errors or response bi.L<.;cs. by providing too Illuch or tOo little
prompting information. If <Iucstiolls arc alw.lys rilll"ed in :1
similar order, thell order bias may creep inw a p.tticnt's re
sponses. Finally, the ill.Hruc:ticms, either on the form or by the
ex.uniner. m.1Y be insufficicnt. misleading. or poorly under~
sLood by thc patienl.
THE EXAMINER

The cmlf'.W (lthe cli"ical .'lellillg is an important aspect of the

mcasurcment. Questionnaires may be filled Ollt differently before relative to after seeing a health practitioncr. The quality
of the ovcrall health care experience of Ihe patient may influencc their responses.
The IJI"('scm:e or ab.\"(!/l(:e ofall examiner while the piiticl1t
is completing various lests may influence their responses.
Response expectations 1ll.IY be operative. such as the
Hawthorne ctTect,:1.2S in which the patient's responses may be
inl1ucnccd by the knowledge that the)' arc being tested, or the
Pygmalion crfect.: 1.2S in which thc patient Ill:"y erroneously
assume th.u the practitioner or examiner has .1 ccrtnin rc-

----,.,'..... ,..... ,." ..... ".

expectation that the patient merely fulhlls. The dellh::.IIHll of lhe examiner and the cucs and instructions they
gi,l' af(' all iIl\POI1~1I\t in minimizing lhis sort of error.
Rdiahilily
Rdi"hilily m.ty he ddlned most technically as the degree to
which random I..'rmr in a tc~t is reduced. More colloquially, re~
liability is charaClaii'.ed by the degree of l:onsistcl~cy in the
rl..'sulb oht;lined wilh repeated lesting. The d'lI01 obtained rron~
only nne 'Ipplicalion of a lest can reOcct results from any~
wht::r(' ill the typical range of the tt::st. With repeated 'Ipplication~ of the test. the.: results tend to Ilarrow ill their variation.
In fact. in c1assiL:-mcasliremcllltheory. the reliability of a statistic increases ill proportion to the squ.tre root of the number
of additional data (or test applit.:atiol1s). The mean of 16 data
points is four times morc rcliable lhan that of a single data
patll!.
In rcgard to pain and disability questionnaires, the mos(
important fonn of reliability is test-retest reliabilit)~ which
mcasurcs stability ovcr time in repeated applications of th~
Icst. Some assumptions must be made when considering lhis
form of reliability. In delCfmining if thc tcst itself is i.1 source
of error, all other factors th:lt c:.tIl contribute to variability in
the I('st result must remain constant. In c1inic.ll settings, the
natur;.1! histQry of the condition under invcMigation is .1 variable. Changes in the course of the condition will n.llurally introduce variability \\lith repcated applications of the test. making it dinicuit to determine the reliability of the test itself.
Typit.:ally, two applicmions of the test are made in an intenal of time that is suitable for the n.ltllral history of the condition itself (typit.:ally within hours to I or 2 days). The results
01" these tests arc t.:ompareu using some form of reliability
statistic, such as Pearson's R or the Intraclass Coefficient. Acceptable levels of n::liability range from 0.70 to 0.90
and up.
Olher mcalls of determining lhe reliability of questionnaires for pain and disability include the "split-half' method.
in which the responses of one h.t1f of the test ar(' comp<trcd to
thosc of the other half. and other tests for wh~ll is known :I:'
"jOlcrnal consistency:' or the degree to which ~lIlS\""ers to individual items rcncct the towl score of the questionnaire. :(,
Another important lypl:: of reliabilily is the.: consistency of
findings between dirferellt raters (inter-examiner rclinbility)
or in mcasurements made by the same rater (iIHri.I-cbservcr reliabilily). Depending on the type of data lIsed in the instrument, reliability stiltistics. such as Pearson's R. ll1tracli.\~s
Coefficienl, or the Kappa Com.:ordant.:e slatistic, can bt:
used.: 7
Validity
The concept of validity pertains to the accuracy of any test. or
Ihe degree to which it truly measures the attribute under investigation. McDowell and Newell proposc a somewhat
broader definition of validity (() include the (,.'ontext in which
the lllC.lsurCl11cnl occurs, "(he r..mge of inlerpretations Ihat

may be placed upon the test; what do the results mean !"21 This
definition also L<ts the advantage of connecting results (data)
of the tcst to the theoretic constructs underlying the use of thc
test. In this way, data plus mcaning becomes something use~
ful; i.e., information.
FACE VALIDITY

Face validity, or content validity. refers to the dcgrcc to \vhich

the questions or procedures incorporated within a tcst make
scnse to its users. Typically, a group of experts is asked to review a test and come to a consensus on the overall sensibility
of its components.
CONSTRUCT VALIDITY

This term refers to the degree to which a test and its result
fit with accepted theory. As an cxample, lift strength testing has a high degree of construct validity when used in
assessing an injured worker with low back pain whose job
involves significant manual handling and carrying. Assessing small differences in the length of the legs in such a worker
has poor construct validity given that no evidence suggests that a small leg length difference equates with work
impairment.
CONCURRENT VALIDITY

One way of determinir..; th;.::: .. ~lidity of one test is to correlate

it with another test done at the same time. In some cases. dif~
ferent tests have been designed to measure similar attributes.
For example, a VAS for pain intensity can be validated by
comparison to a verbal rating scale for pain severity. In this
context, relatively higher correlations are expected between
tests of similar attributes. On the other hand, a test of one attribute can be correlated with tests of another attribute that is
related. at least theoretically if not empirically; for example.
reduction in levels of activities of daily living with levels of
pain severity. In such a circumstance. the levels of expected
correlation are usually lower.
CRITERION VALIDITY

One form of concurrent validity that is particularly robust is

to compare the results of one test with the best test available
at the time-known as the gold standard. If the new tcst performs in a relatively similar fashion. then it can be said to
have good criterion validity.
DISCRIMINANT VALlDtTY

This attribute of a tcst refers to its ability to discriminate

between major categories of test findings, often referring
to categories such as "normal or abnormal," positive or neg~
ative, symptomatic or asymptomatic. S'ellsirivilY is the at~
tribute of a test whereby a positive test result is highly correlated with the true diseased or abnormal state; i.e .. high
true-f.'(\~!tive rmellow false-negative rate. S[Jecijicily is the

opposite. wherein test r:cgativc:~ C\.ji.i'HC :lig:,l::; .,';;::; :ruc

negatives (with low false positives).
Respolls;l';ty. One form of discriminant validity involves
the perfonnance of a test ovcr time. It is reasonable to determinc if the test accurately measures the amount of change
in a condition or attributc when such change truly occurs.
In the development or the Neck Disability Index (NDI)..'s
we studied 10 subjects with neck pain who had undergone chiropractic treatment for 3 to 4 \vceks. All 10 individuals reported improvement. They were asked to complete
two instruments-the NOI and a visual analog pain scale
(VAS)-at the beginning of treatment and again at the cnd
of the treatment period. We correlated the change in VAS
scores (as a percentage) with the change in the NDI scores.
The average change in VAS scores was approximately 757c,
whereas the change in NOI scores avcraged only ,\bOUl
50%. These data correlated at 0.62, which is a relativcly
good level of correlation. \Vhich test result reflectcd the true
level of impro\'ement'? \Vhieh was the more responsive? Only
fUl:ther research using statistical techniqucs dcsigned specifically to study responsivity~(J-:lI will provide answers to these
questions.
MEASUREMENTS FOR PAIN AND DISABILITY
Each instrument discussed subsequently is representative of a
greater number in each category. This section provides a SUlllmary of the content and description of each instrument and
then a discussion of its reliability and validity.

Location
Pain may be localized by using the pain diagram.1>t 7 (Fig.
4.1). a standardized self-report measurement of the location.
extent, and, to some degree, the quality of pain. As well as
these descriptive features, the manner in which a patient de~
piets his or her pain has been shown to reveal a grei.1t deal
about interpretations of the pain experience, mood, and psychologic state and behavior while in pain. In this respect. tilling out the pain diagram becomes a pain behavior, and it can
demonstrate an appropriate as opposed to an inappropriate
manner on the pan of the patient..1~
Outcomes are derived from the pain diagram in a number
of ways. First. subjective ratings by trained observers Gill be
made from the appearance of the diagrams. These ratings. in
facL can be system~tized, using rankings from more 01'g:'ll1ic/more realistic to less organiclless realistic and, perhaps.
psychogenic or inorganic."'" Second, scores from a checklist
of penalty points, which rate the anatomic fidelity, the prescncc of cxtraneous markings within and outside the body. etc.,
arc compiled. The higher the score, the more likely it is to reflect inappropriate pain behavior:''<'l(, Third. body area charts
can be used to quantify the size of the painful area so a single
mcasure can be derived from the pain diagram:l1
High reliability of the pain diagram has been reported.
Murgolis et aI" reported test/retest correlations for body area
to range between 0.83 and 0.93; for pain locatio:. they found

V.,.... ,.. I r:n .. : r-'f\Il'l AI\lU UI::>At::HLlTY QUESTIONNAIRES IN CHIROPRACTIC REHABILITATION

PAIN DIAGRAM

PAIN DIAGRAM

INSTRUCTIONS

INSTRUCTIONS

On the following diagrams. indicates all areas of :

pain
stiffness
numbness
other
(specify)

-xxxx
- /I /I

-0000

,.,

.":"',"

'-,

. !

.: i

l:ll:

61

On the following diagrams. indicates all areas of :

pain
stiffness
numbness
other
(specify)

-xxxx
- /I /I

-0000

,.\.
t;
.. ,

8
Fig. 4.1. Pain diagram. A, Example of a well-delinealed, analomically correcl depiction. B, Example of a poorly delineated. anatomically incorrect. exaggerated depiction.

lest/retest .lgreeJ11elll to be 7(IVr. These authors rCluno no .lge

or gender differences in the degree of reliability.
With regard to validity, high pain orawing scores h;'lve
been correlated Wilh elevated hysleria .lno hypochnndri;'lsis
scores 011 the l\;1inncsota l\1ultiph;'lsic Personality Index
(MMPI): greater chronit:ilY of low back pain iJnd higher 110spiWliz<ltion rates: and high McGill P;'lin Qul'stionnaire (!V1PQ)
scores. l <
finally. with reg;'lrd to its usefulness. the strengths of the
pain diagram are case of administration. relative ~a:-c of interpretation. and implicit facc validily as a tool with "'hich pOI
lients can effectively COmltltlllicatc their compbilH [0 health
care pr<lctitioners.
Intensity
Several simple ~calcs e'xist that arc designed for lhe sell'rating of pain intt.:nsity. The visual <lnalog scale (VAS), dcvised by Huskisson in 1974:'1'\ (Fig. 4.2). is illlumerically continuous scale th;,1t requires that pain level be identified by
Ill~king a nwrk on a IOO-mlll line. The uniformity and density
of this type of pain scale creates a high level of sensitivity to
Vmii.Hions in pain ratings.
Verbal descriptive scales (VDS) also cxistN ....;.: IFig. 4.3);
some are ordinally scaled. like the Present Pain Index of the
MPQ.'-l and others arc r,nio scaled. like the Borg pain scale:":
The numeric rating scale ;'lIld the Borg pain scale arc IO-poim
scales. In lhe newer Numerical Rating Scale (t\RS) 101.
which is a version of the VAS. u patient chooses a number between I and 100 to rate lhe severity of their pain.-l
\Vith regard (() reliability. these pain sc::lcs arc lhe mainstay of most pain studies <lnd clinical tri;,i1s. The original n.:ports of reliability included correlations betwcen the vertical
.Illd the horizontal forms of the VAS. which arc reported .IS
high as 0.99. with simil;'lrly high test/retest reliability, 'li.-l~--l"

'0
;;;

(',~

Concurrent validity among these scales and with mher

measures of p.tin ;md loss of function is reponedly high. SCOlt
and Huskisson~7 reponed comparisons of the VAS and the
VDS-t)'pl' sc.alcs that correlated at 0.75, where:'ls a coefficient
or 0.63 was reponed betwecn the VAS scores and MPQ
scores.~7 The VAS tli.lS been shown time and again to be sen
sitivl' 10 treatment cffccts.~s although Scott ;,md Huskisson
t::.Iutioned that providing lhe original scorc or using a VAS for
relief or improvement may be more appropriate.~oj Other authors disagree with this stf<llcgy. however. and n:quirc ;,111 absolute mcasuremcnt. ~rl.~1
The scales just described arc casy to administer and to
SCNe. although the ordinal scales of the VDS-typc scales
should be uppro;'lched with caution. especially in regard to intergroup comparisons. There is a high degree of sensitivity to
change, especially on the linear st:ales.
Quality

In 1975. Melzack introduced the McGill Pain Questionnaire

it has since been llsed in numerous studies
musculoskeletal and other pain syndromes. It has undergone
a great de;'ll of rcplicmion ,,1I1d is acknowledged :ls onl' of the
gold standards in the field of pain assessment. Tht: MPQ consists of 20 category scales of vcrbal descriptors of pain.,'I.l5~
ranked in order of severity and clustered into four ~ubscales:
st::nsory. affective. evaluative. and misccllaneol1:-i scales. us
well as a five-poinl "present p;'Iin rating index." Scores can be
obtained on the rank scores added for the total instrument or
for each of the subscales. or grealest inlerest to researchers
has been the ability to distinguish the scn~ory and the affeclive domains of the pain experience.
Test/retest reliability had been confirmed as high from the
outset. with Melzack's lirst report indicating .1 70% consistency of responses of three trials over a 3-day period.~1 Aikll

(MPQ).~1 "lIId

or

Ht:.NAt'ILIIAIIUN UI" IHt:. ~I""INt:.: A

Make a mark (I) along the line which you think rGprese;,~:; y~.;; CUi;en~ :l;:ve; vi IJdill in youl
major area of injury, somewhere between ~No Pain At AII~ and ~Pain As Bad As It Could Be",

Fig. 4.2. Visual analog

scales for rating pain (A) and
visual analog scale for rating
improvement (B).

:1

PRACTITIONER'S MANUAL

No Pain

Pain As Bad

A AtAIi

As It Could Be

ABF YOU RETTER SI~CE YOUR EIRST

IREATMENIl

1t

Date

Nam~

Please try to remember back to the first day when you started these
treatments and tell us how much you have improved since that first day.
Please do this page before today's treat~ent begins.

1
i

1.

P~IN

RELIEF.

..',>

No relief of
pain since
treatments
began

I
I
I
,~,

I
~

I
I

slight

moderate

relief

relief

10

lots of .
WORSE
relief
DOESN'T APPLY
TO ME

2.

ACTIVITY INCREASE (walking, standing, working, exercising, etc)

No increase
in activity
since
treatments
began

slight

moderate

increase. increase

I
I

Complete relief
- of pain since
treatments
began

10

Complete
recovery of
- all activity
since
treatments
began

lots of
increase.

WORSE
..

DOESN'T APPLY

..J

TO ME

)
and Weinmann~~ reportcd similar results over four tri.tls
within I week. Phillips and HUlllcr~(o studied tcst/retest rcli'lbilily of the MPQ in patients with headache and reponed correlation coefficicilts as follows: for the Presclll Pain Index.
which is the total scorc. an R of 0,94; for tbe sensory scale.
0.83; and for the affective scale, 0.95. These findings indicate
thut people can, wilhin a rel.ltively short period of timc. remember their pain state from one measuremcnt intcrval to

anothcr.
Thc greatest imcrest with the MPQ has bcen in the area of
validity, Numerous factorial analysc~ have confirmed the fac~

torial structure, especially of the sensory and the affective

scales.:>1'{,(J The concurrent validity has been confirmed be(ween the MPQ and the MMPI and many other instrumcnts
that measure pain intensity. mood state in pain. and psychosocial disturbance. Phillips and Hunter reported an interesting and significant correlation between MPQ scores and
the pain diary in headache subjects.~
With regard to discriminant validity. Dubuisson and
Melzack!>-l found that 77% of 95 pain p;.nients could be correctly classil1cd into diagnostic groups on Ihe basis of their
MPQ score alone. Reading~7 studied patients with acute ilild

.J

..J

.J

,
,
; ..

'vM/"\t"j t:H 4 : t"AIN ANU

UI~At:HLlI'Y UW:.::>

IIUNNAIRES IN l,;HIHUI-'HAL; IlL; Ht:.HABILlTATIQN

63

Fig. 4.3. Borg verbal rating pain scale (A) and verbal pain rating scale (6) (from the Roland-Morris
scale).

()
Patient Directions:
On 8 scale of 1 10 place 8Jl X In your current pain level
NORMAL

( )0

LOW PAIN

MODERATE PAIN

INTENSE PAIN

( )1

( )4

( )7

( )2

()S

( )8

( )3

( )6

( )9

EMERGENCY

( ) 10

t:

;.,:
!! t)

The pain is almost unbearable

Very bad pain

()

1
j

,)

I {)

Quite bad pain

')
'.-

Moderate pain

")
"<,

Uttle pain

I,
I
~~

No pain at all

?
i;

"2

I,.

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IJ
I, \)

chronic disorders and found that the fomler 'used morc sensory words whereas the laner. as predicted by the theory. used
more affe<.:tive and c"i.llu;nivc words.
Finally. the MPQ has been used in a many treatment trials
(lnd h.ls been found to be sensitive to treatment effects.f'l Its
usefulness lies ill its relative case of administration. Also, it
is casy to score and rich in data, particularly with regard to
the sllbsc;llcs and how their scores may apply to the thc(Hetie <.:Ollcerns mentioned previously. Because of its
strengths. it has taken on the status of a gold standard in pain

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aSSCSSlllCllt.

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Course

t)

<X.,.

The course of the complaint can be monitored by using the

p;'lin diary (Fig. 4.4). The diary is im often-used tool ror ongoing. patient sclf-rcpol1. It <lllows for continuous recording of
a wide nlllgc of pain-rcl;,ncd outcomes, such as the frequency
of painful episodes: the time course of constant pain complOlints. which can be recorded o\'er daily and hourly intcr

i \J

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i0
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p
;,

{)

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$;

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....

vals; the sevcrity and actual dUr<ltion of these episodes: medication usage: and effect on activitit:s of daily living. All of
these parmnctcrs can be combincd into;1 compact instrumcnt.
Thesc various c"llcgorics me typically l:ombined into ordinal
or continuous scales with frequency COllnLs and cominuous
dma on the time. course. and duration.
Bl<mchurd reviewed the stabilily of pain diary data. especially for headache (an episodic complaint). and determined
that an avcruge of 2 weeks is sufficient to obtain stable
baseline values from the diary.('~ For COllst<!nt pain syndromes.
such .as those involving the low bi.lck or neck. stable values ought to be obtained within days of i.ldministr.atiml. The.
drawbacks of the pain diary arc the bi;'ls and Hawlhorne
effects that arc likely to creep into the data recording process. as well as th~ rarc instance of <:omplctcly rabe and
misleading recordings. which arc more likely from a complete malingerer. As slich. pain diary dal<! should. if at ..iii possible, be cross-chccked with somt.: comparabk obscrverbased datil ;'IS to the pain behavior Of clinical sWtllS of the
patient.

K\::HAt:SILIIAIION OF THE SPINE: A PRACTITIONER'S MANUAL

PAIN DIARY

PAIN MAP

Day 3

Htl:::l+t-:::::: - i,; :

Day 4

""

Day 1
Day 2

Day 5

'-'- -'- -!-'<

_L

[~F::: --

-;-

",

,'

"

,Day 18 - - - - - - - -

,+.

'--',

__L.

''l;,,,{

-:

, ?;i

Day 20 -

Day 21

,," L
Day 22 - - - - - - H+t-+'T-,,
H+l-+-f-fLif Day 23

Day 7
Day 8

:::..il Day 24 - - - - - - -

Day 9
Day 10

-- -- --.- . Day 19 - - - - - - -

" ' k . . -'

Day 6

Day 16

"H-!-;,;"
_.I..! , ' . Day 17
I ! i

. ,
i-+::::I-H'-H1' ,

Day 25

.-~'\

+-Ht+-H-+-: .~: Day 26 - - - - - - - L , Da 27

1-
._L. y
-------

Day 11
Day 12

I ,

r-r-i Day 28

;j--!-+-+-+,r-=-8

Day 13

Day 29

Day 14

;-i'~ Day 30

Day 15

Day 31

---------

Fig. 4.4. Pain diary.

PAIN BEHAVIOR
This section addresses five instruments. the purposes of
which .Ire less to describe the p'lin complaint itself than to as-

sess the behavior of the individual in pain <lnd come

10

an un-

derstanding of the motivational components Oflha! pain state.

Le.. to assess the illness/disability component of the disorder.
The foclis of this discussion is on systematic behavioral observation. and then four scales that m~asurc activities of daily
living: Oswcstry.;'-' Roland-ivlorris. fol Neck Disabilily.:Ji and
Pain Disability.('S

I,

I
I
~

I
,~

I
~
~

I
i

S)'slcmic Behavioral Obscnalion

Keefe ct all,( devised a method of observing a patient's pain
behavior in order to provide qUilnlifi~lble data regarding lhe
patient's dis~lbility that would be directly relcvant to functioning. Thcy identified a group of overt behaviors thut appeared to be unique for the pain cxperience: grimacing. bracing. guarded movcments, rubbing.md sighing.
Thc protocol of Keefe et al consists of a IOminutc video
of the patient undergoing a standardized series of movements.
They walk. sit. recline. and stand lip :.tgain, and lhe frequency
of various pain behaviors is recorded by trained obscrvers.
With regard 10 reliability, Keefe ct al reported interexamincr
agreement levels as high ~lS 88%.(,(> Findings from a study of
patients with chlonic low back pain by Jensen el al1>7 COtl-

firmed the high dcgn:e of reliability of th(; prolOeo!. They reported inter-rater agreement Kappa c(xflicicl1ts betwecn O.SO
and 0.93. Test/retest correlations over I ~ days were al O.7};.
\\lilh regard 10 validity. Kecl"c c! al'''' n.:portcd scnsili\'ily 1.0
treatment changes <is wdl as high cOITc!miolls with pain intensity ratings. physical findings. and functional disability
scores. They also demonstrated high correlation bClwc(;n
scores of tr'lined versus naive observers. Sf) these pain behav~
iors arc consislent aems:, ev.dualOrs.
The pain behavior :,cores discriminate betwecn pain pa
tients and control subjects. Author:, (,f a recent sHidy found
that the obsen'alional melhod can i.lCtlIally discrilllin~\tc !"(lUr
subgroups of back pain with different pal1cms of pain behavior: in other words. people who 11<I\c a hOl11ogelle(lu:-: pl\1hlem. like back pain. appear to behavc differently. and. in r"ct.
consistently in those differences. In this study. guarding and
rubbing were lhe behaviors ohserved mo:-t often.!'?
In n report by Jensen el .11.',7 the tolal pain behavior SL'(,rt.:s
correlated significantly with the VAS ~lnd the Bor~ pain
scales. as well as with measures of reduccd spinal mohility
(i.e., where flexion and extension w~r(" reduced) and increased medication usage. In tllei! sHldy. correlation with
depression '!nd two sC~lles of thc Sickness Impact Profile
(SIP) were also investigated. The only pain hdlavior III l"lmc(<ltc consistently with these psychosocial pan11l1ctcrs was
"sighing:' which was actually the (c~lSI observed o('havior.

,,

.~

J,----..,.----------------------------i$ ...

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I

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---_._.~---._--

'.. ~

,~n

'1'

rM."" M.liV UI;::.1\t:SILII Y

UUESTfONNAIRES IN CHIROPRACTIC REHABILITATION

Nonctheless. lhe link between pain behaviors and pain sevcrily i~ not lirlllly estahlished. evcn at the thcorctil:al levcl.
Observers haw noted a grcal dcal of pain behavior in (he absence of high lc\'cl~ of pain severity ilsclf. ns well as diminished pOlin beh~l\'i()r <lnd even recovery of relatively normal
function in the presence of severe pain. So. theoretically and
empirically. beh~l\'ior and scvcrity may not be absolutely
linked.
Oswcstry Low B<lck Pain Index (Fig. 4.5)
index W:IS reported by Fairbank ct ill in :980.t..' It is a
IO-i\cl1l scale in which each item has six ranked detractors,

Thi~

scored from 0 to 5, so a total score of 50 can be compiled. The

lirst section is a pain-rating s~ale. Thc other sections deal with
various daily activities deemed relevant to low back disability by the consensus tcam,
in lheir original report. Fairbank el al included a test/retest
reliability coefficient of 0.99 and a spli!:!l~Jf...~f.fici~.OLr~
poric(f~~rgood: Regarding validity, Fairbank et al rcported
only th,lt O~wcstry scores lowered after ~l 3-wcek rest pcriod.
which is presumed to indicatc sensitivity to trcalment effcels.
Triano ct al f " provided a much necded study of concurrent
validity. They compared Oswestry scorcs to measures of mus~
cle dysfunction and reponed a good correlation between
higher O~\\vcstry scores and the prcsence of signs of abnormal
muscle function. with the conversc correlation existing as
well. This finding speaks, if only implicitly. to the sensilivity
and specilicily of this instrument

Roland Morris Scale" (Fig. 4.6)

This scale consists of a sct of 24 questions pert<lining to work.
lime at home, \v.llking, personal care, sitting, etc.-a widc
range of activities rclevunt to patients with low back pain. The
tcstJrctc~t coefficient (halfday interval) was origin:.ll1y n,::.
ported as 0.91. The internal consistency of the itcms. Il\ca~
smed using an "agreement percent cocflicienl," was ca1cuI'lted as 0.83.
To Icst the validity of the inslrumCI1l. the original authors
compared test resuhs to a verbal pain raling instrument and
reponed lhese to be in "good ngreement." Some test questions
were compared to doctors' physical findings. with generally
goootocquivocal agreement. Scores \\!erc not related to age.
gender, or social class. indicolting th<lt wide lise in gencml
practice was probably well supportcd.
One criticism of this instrument is that it uses the nominOlI
scale. and therefore may miss important inform<ltion about
clinical SlaWs. Patients arc forced to agree or disagree completely wilh each of the tcst items. when, in fact. the stutus of
most patients is usu<llly a maHer of degree of some limitation.
not whelher it .is present or absent. Nonetheless, this attribute
of the instrument may lend itself to an improved level of responsivity. Hsieh et OIl found the Roland-Morris scalc superior
in its rcsponsivity cOl11pnred to Ihe Oswestry Index (which
uses an ordinal scalc) in dClcnnining levels of improvement
in patients wilh low back pain."1

65

Neck Disability Index (NOI)'" (Fig. 4.7)

This index. a re\'ision of the Oswestry Index. W.1S developed
at thc Canadian Memorial Chiropractic College by Vernon
and Mior to address the nced for an instrument specific'llly
designed to measure reduced activities of daily-..Jiving in
l?~lents \rilh....n~1in.Q.he lcst/retest reliability was found.
in a suitable sample of subjccts. to be 0.89. The total Crol1~
b:1Ch's alpha. which is :.\ measure o~lal reproducibililY. was 0.80. and all of lhe itcms acilic\'cd aip1lalc-\~els
above 0.75.
Regarding lhe construct validity. scores were nonnally
distributed and clustered al the moderate severity level. which
was approprialc for an ambulatory clinical population. \Vith
regard to concurrent validity. wc compared NOI to MPQ
scores at an R value of 0.73. and sensitivity to change was
measured by comparing changcs on the NOI to visual analog
scale rating changes. This correlation wns 0.60.

Pain

Disabilit~ Index

(POI)

The PDI was first reponed by Pollard in 1984. 65 It is a ~cven

item scale using VAS to rate illlensity of disturbances to a variety of psychosocial variables and activities of daily life. Tait
Cl apo reported a Cronbach's alpha value of 0.87. As for \'alidity. POI scores for inpatient groups were higher lh,lIt those
for outp.ltient groups. and more recently. Tait et ai' I found tllat
high PDI scores correlated well with higher psychologic distress Slates. higher dis:.lbilil)' 1C\cls. high pain dcscriplion
scorcs (from the MPQ). <Jlld higher pain behavior scores frum
the protocol of Kcefe and colleagucs.f~' The adv'Ultage of the
PDI as opposed to the other indices is tll.1t it is nOl specific for
one type of pain and Ihe seven categories can be applied 10
virtll<llly .Iny pain syndromc.
ILLNESS IIEH.-\VIOR
The psychosocial indices of illness behavior warrant discllssion.
B:.\ck P:'lin Classificalio(l Scollc

Leavitt and Garron !ina published this scale in 1979.': It is a

subscalc of a larger check list of symptoms .Ipplicablc 10 back
pain. Of the 1,Irge list. 13 words werc found to discrimin<ltc
pain of organic origin reli:lbly .md accurately. These words includc the negatively scored items: nagging, dull, throbbing.
inlcrmiuent. shooling. and punishing. These lerms as a group
pose some interesting par'ldoxcs. COllvcrsely, the words
squeczing. exhausting. si<:kening, troublesomc, tendcr. numb.
.lI1d tiring indicate a high likelihood of ~I psychogenic origin
for the pain complaints.
Tcstlretcst reli~lbi1ity after I day achieved a corrclalion co
efficient of 0.86, where'ls the split-half rcli;lbility score wa...
reported at 0.89. Cross-validation with the MMPI sl'a1cs is
high. Improvement ratings correlate highly with the Back
Pain Classification Scale: that is, "organics" respond better
th~11l "psychogenics.'1:.7'

HtHAt::lILIIA1IUN Of THE

uu

~PINI:::

A PRACTITIONER'S MANUAL

r:aase late (he st:vt:1iiy 0: yvv,' :ow back pain by circling a number below:

No pain

Unbearablo
pain

Date

Name

_ _-"-_ _1-_ _ '

File #

lnstruclions: Please mark lho ONE BOX in each section which most closely describes your problem.

I
1
I~
~,

"

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Section 1 Pain Intensity

$eclion 6 Standing

0
0
0
0
0
0

2. Th p",in is mild and doos not vary much.

o
o

2. I h;)vo somo pain on Sl.1.nding bUI It doos nol incroa!iC with timo.

3. The p<)in comos ill'ld 900S and is moder:lIO.

3. I caMol SI3nd lor longor l!\Jn ono hovrw1thout il"lCfoasing pain.

'.

o
o
o

1. Tho pain comos and g005 and is vory mild.

The pain is moder<lt6 <Inc! doos not v;uy much.

S. The p.,in comes and goos and is SOVetG.

Tha pain is sovors and doos not vary mIlCh.

I would not havo to chango my way of washing or dressing

in ardor to avoid polin.

2. I do not normally dlntlgo my way of washing or dressing (lvon

though it causes some pain.
3. Washing and dressing increase the pain but I manage not to

change my way 01 doing il.

Washing and dressing increase the pain and llind it nacossOiry

to ch<lnge my way of doing it.

S Because of tho pain I am unable 10 do some washing and drossing

without help.
6. ~cause 01 tho POlin I am unable to do any washing

Section 3 - Lifting

I can lilt hoavy weights without extra pain.

02
03.

I can lif! heavy weighls but it givos ex'lra pain.

Pain prevents me biting heavy weights off the lloor.

II
I

1~
,fi
~

or dressing

Without help.

Section 4 Walking

6. I avoid SI<1ndlng

o
o
o
o
o
o

.~
;j

5. I cannot stand lor longer than 10 minutos wilhout inaoasing pain.

Section 7 Sleeping

I
I

4. I cannol stand tOf longor than 112 hour without incro<lsing pain.

Section 2 - Personal Care (Washing, Dressing, etc.)

1. I can stand ~ long as I want without pain.

4, Pain provents me filling heavy weights otllhe Roor, but t Cin

manage if they are conveniently positioned. o.g . on a table.

:] S. Pilin prevents me from ~Iting hoavy weights but I can manage

lighl to modium weights ;t thoy are conveniently positioned.

6 I can only lift very lights wflights at the most.

3. I CMnot walk more than ono milo without incr<l<lsing pain.

4, I C<lnnOI walk more than tJ2 mile with increasing ptlin.

5. I cannol walk mote than "4 milo without inC/easing pain.

6

I cannot walk al all without increasing pain.

1. I can sit in any chair

2 1 c.Jn

2 I got patn in bod but it does not prevenl me Irom sleeping well.
3. Becauso 01 pain my normnl nights stoep is reduced by less than 114

4. Becnvso oJ pain my normOll nighlS skwp is reduced by leSs than tft

G. P.:r.in prevonts me from slooping :1t all.

"':>1

Section 8 - Social Life

):

01
02.
03.

My soaal hie IS normal ;lnd gives me no pain.

0,.

Pain has rC5lricled my social hie .ilnd I do nolgo out very olten.

05.
06.

PaIn has toslllcted my SOCI.il1 hie 10 my homo.

My soci<'lllife is norm<ll bU\lncreasos tho dog roo of pain.

Pain has no signiflcanl effoct on my social lifo opart Irom
limiting my morQ energelic inlerosts. e,g.. cklncing. olc

I have hard1-, any socinillfe because of the polin.

Section 9 - Traveling

01.
02.

no p.ilin when 1r::Jvehn\J

gel SO'TlC pnin when It;lvehng bUI none at my usuallorms

of travel m.,kc II any worse

3_ I gCl cl(tra pain while lr.ilvcl<ng but it (foes not compel me to

sook nlternativo forms 01 travel

04
0

I get

gOI Olllra pain while travu!lng which compels me 10 seek

altern;)tive forms aflrnvol

5 . Pain tCSfticlS

mq

10 shorl flUCP.ssary journeys under

30 minutes

06.

P.ilin ICSttictS alllollTls 01 It.ilvel

01.

Pain prevent!;. all fOlms of lr,wel

~I(Cepllh.il1 dono

lying down

as long ilS llike.

~il only in my fOlVorl!O chair as long as I like

3. Pain prevonts me sitting.mom than 1 hour.

P"in prevents me lrom sil!lng mora than 1/2 hour.

5 P.1in pmvents mo Irom ::oitting lor moro than 10 minutes

6 I avoid silting because it incr03ses pain immodlately.

t. Myp;un is rapIdly 901l<n9 bettet

02.

My pnin fluclualos

o
o

My rmin is nr:ilhN gr:llin!)

2 My p,lin SCorllS 10 be gell<ng "',ner but improvement is slow

3

01

bUl overall is definitely gening hetter.

h(!ll<:!f

nor worse

My pilln I;' gr;ldually 'watsonlng

5_ My pain is rapidly Vlorsemng

Fig. 4.5. Oswestry Low Back Pain Scale.

<

I
11

i-f;

,!_----~----------------------------------
N -

Section 10 Changing Degree of Pnin

Seclion 5 Sitting

0
0
0
0
0
0

1 I got no pain in bed

:] S. Bocavso of pain my oarmi1l nlghLS stoep IS reduced by less than 3/4

1. I havo no pain on walking.

:] 2 I hi1VO some pain on w<llking but it docs not increaso with d'is\.1nco

o
o
o
o

o
o

boc,luse 1\ lI'IOO<lSOS lho pain immediately.

... _._ . . .

o
o
o
()

........ ,u~ ..... n~.;:J

11" ..,. "nurn/'\"" I I"" t1t:.NAI:HLlTATION

1. I stlly home most of the time because of my back.

2. I change position frequently to try and get my back comfortable.
3. I walk more slowly than usual because of my back.

I:}

4. Because of my back, I am not doing any of the jobs that I usually do around the house.

o
o

5. Because of my back, I use a handrail to get upstairs.

7. Because of my back, I have to hold on to something to get out

of an easy chair.

8. Because of my back, I try to get other people to do things

for me.

o
o
o
o
o

9. I get dressed more slowly because of my back.

6. Because of my back, I lie down to rest more.

10. I only stand up for short periods of time because of my back.

11. Because of my back, I try not to bend or kneel.
12. I find it difficult to get out of a chair because of my back.
13. My back is painful almost all of the time.

14. I find it difficult to turn over in bed because of my back.

o
o

15. My appetite is not very good because of my back.

17. I only walk short distances because of my back pain.

18. I sleep less well because of my back pain.

19. Because of my back pain, I get dressed with help from someone
else.

20. I sit down for most of the day because of my back.

21. I avoid heavy jobs around the house because of my back..

22. Because of my back pain, I am more irritable and bad tempered

with people than usual.

23. Because of my back, I go upstairs more slowly than usual.

24. I stay in bed most of the time because of my back.

16. I have trouble putting on my socks {stockings} because of my

back.

Fig. 4.6. RolandMorris Back Pain Scale.

67

. . . . _

'

"

, I ,

"

' .. '

vr .

NECK DISABILITY INDEX

, ,

Section 1 - Pain Intensity

[=::J I have no pain at the moment.
c:J The pain is very mild.at the moment.
c=:J The pain is mode:rateat the moment.
c::J The pain is fairly $CVere at the moment.
[=::J The pain is very severe at the moment.
c:::::J The pain is the .....orst imaginable at the moment.
Stion 2 - Personal Care (W.ashing.. DK'5SinS dc.)
(=:J I can look after myscl nonnally without causing
~ra pain.
I can look after myself normally but it caUSl'S
extra pain.
It is painful to look after myself and I am slow
and careful.
J need some help but manage most of my personal care
J need help every day in most aspects of sclf cat"C..
J do not get dressed, I wash with difficulty and
stay in bcd,

=
=
=
=
=

Section 3 - Lifting
(=:J 1can lift hC:lVy weights without extra pain.
c=:J I can lUt heavy wcighls but it gives extra pain.
c:::J pajn prevents me from lifting heavy weights off the
floor, but I can manage if they a.rc conveniently posi
tioned, forcxample on a table..
Pain prevents me from lifting heavy weights,but I can
manage light to medium weights if they arc convcn
icntly positioned.
( can lift very light weights.
J cannot lift arcany anything at illi.

=
=
=

S1ion 4 - Re.ading
[::=J J can read as much as I want to with no pain in my

I
I
II
}I

1\
11

I
~

=
=
=
=
=

neck.

I am read as much as I ""'ant to with slight pain in my

ncd<.

r can read as much as I want with moderate pain

in my neck.
1can't read as much as 1want lxxausc of moderate
pain in my neck.
( can hardly read at aU because of severe pain in
myncck.
I cannot read at all.

S1ion 5 - Headach~s
~ I have no hC<1dachc:s at all.
[=:J J have slight hcadachc:s which come in.frequently.
c=:J I have moderate: headaches which come in-frequently.
~ I have moderate headaches which comc frequently.
[=:J I have $Cvere headaches which come frequently.
~ r have headaches <llmost aU the time.

Section 6 Conccntr3Lion
I can concentrate fully when J want to with no
difficulty.
I can concentrate fully when I want to with slight
difliculty.
I Mve a fair dcgroc of difficult,y in concentrating
when I want to.
J have a lot of difficulty in concentrating when 1
W,1ntto.
I have a great dC3.l of dimculty in concentrating
when I w;mt to.
1cannot concentratc at all.

=
=
=
=
=
=

Section 1 Work
c::::J I can do as much work as I want to.
C=:J I can only do my wual work,. but no mot"C..
c::J I can do most of my ust.J.a.l work,. but no more.
c::::J I cannot do my usual work.
c:::J I can hardly do any 'work at all.
c::J J can't do any work at all.
Section 8 - Driving
c::J I can drive my car without any neck pain.
c:::J I can drive my car as long as I want with slight
pain in my neck.
I can drive my car as long as I want with moderate
pain in my neck.
I can't drive my car as tong as I -want because of
moderate pain in my nock.
I can hardly drive at all bcc:auscaf severe pain in
my neck.
J can't drive my car at aU.

=
=
=
=

Stion 9 Siuping
c::J I have no troublesJccping.
c::::J My sleep is slightlydisturbOO (less than 1 hr. sleepless).
c::J My Sleep is mildly disturbed (\-2 hrs. sl~less).
My sleep is mooCr.ttcly disturbed (2-3 hI'S. slc:cplcss).
c:::::l My sleep is greatly disturbed (3-5 hrs. sleepless),
c::J My sleep is completely disturbed (5-7 hrs. sleepless).

Section 10 ~ R~.1;tion
c::J I am able to engage in all my f'CCl'C4ltion activities ....;th
no neck pain at all.
J am able to engage in all my I"CO'C.1tion ;]ctivitic:s, ....; lh
some pain in my f\CCk..
I am able to engage in most, but not all of my usual
recreation activities bocausc of pain in my neck.
I am able to engage in a few of my usual recreation
activities because of pain in my neck.
I ca.n hardly do any recreation activities because
of pain in l-:ly neck.
I can'l do any rccreJtion activities <It .111.

)
)

-J

=
=
=
=

Fig. 4,7. Neck Disability Index.

11

"~--------:-----------------------------------------------------------~i

_f

"

.J

69

<;HAPTER 4 : PAIN AND DISABILITY QUESTIONNAIRES IN CHIROPRACTIC REHABILITATION

ILLNESS UEHAVIOR QUESTIO,,"-:AIRE (IBQI

First reported by Pilow~ky ilnd SPCl1(~ ill 1<J76.;~'- the IBQ
\Va!\. dcsignctllO aSSlOSS fundamclu;11 altitudes (Owanl "i... kncss.
the role of doctors. ~lIld a VariL:ly of ~Hha psychnst\\..'ial v<tri

., .

abies considered imponal1\ in explaining abnormal illlll;SS

bchJ.\'ior. It consists of 62 items ;\n:'i\\'crcd in ;\ yc"/no 1';\"
shion and comprises sevell factor seaks. The no'liability of

;\"")

ano

"

thc:-.c scales

o
()
tl

I~)
I ")

I
~

~"'!-t

'1

I,)
.J

test/retest correlations has been

hel\\ l"L"n

0.(17

The following !"oK!S h;\\,c hccn rcpl~rlcd ;lhllUI the IBQ. II

has good correlation belween patient .IItU spulIs,,1 ~\'aIUaliuns.
so it seems to be consistent. Factor ;'\Ilalyses have L'01111nnc<.l
the seven scuk structure and. in fact. other scales ha\'c been
found by Main and W"lddell. 1h Compar;.ltivc and L'olltrol stlld~
ics demonstrated dirfcr~lIces bc(wCCIl symplOIHatiL' and
control subjects, be(wc~n various clinical groups, and be
twecn responders and nonrcspondcrs. Concurrcnt v.llidity has
heen established bctwcen the IBQ and the ZUllg depression
scalc;7 as well as other IllCi.lsurcs of anxiety. Waddell.
Pilowsky, and BOlld;~ correlated the IBQ to previollsly deter
mined <'lbnorll1i.l1 illncss behavior. which incluth:d thc non
organic signs of WaddcIL 1 ') One of the strongest findings in
tlwt study is the impon<1llcc of the disease conviction scale of
the IBQ in distinguishing p.uienls with low buck pain who
demonstrate abnormal illncss behavior. In other words. they
belicvc strongly that Ihey havc il serious problem. even
though they may not.

Sickness Imp"cl Profile (SIP)

011

(1.~7.

The SIP~o",~~ consists of 136 statements clustered into 12 catc

gorics thm involve issues ranging from those from the simpler
ADL scales as \\.'cll as Ihose from the abnormal illness be
havior rc.lIm. To address the n:liubility of the SIP. Pollilrd
cl <.II'" rcp0l1cd (estlretest coefficients between 0.88 and
0.92. with an intcrvicwcr~ldministcrcd <Ipproach achieving
a higher reliability than the self-"ldministcrcd approach.
The shorter version of the SIP has bCi..:11 rcportc.;d as equally
rcliilblc.~l

".--~

I:
1
. "}

1'.

10
I

',1,
,~1

I~

Nonorganic Signs
The 1l00IfJI".!.lllllic siglls of Waddell and colle"lgllcsl'J arc lISCful in dislill~lIishing those Ixuicll1s who manifest abnorm'll
dines" bdl<l\'ioL These signs arc the palient responses to
sevell di(ferellt tests performcd by the practitioner and in
elude (I) tenderness thtlt is superficial or llonanatornic in
locillion; (2) pain with axi;i1 loading or (3) full trunk rot,,
tion in the :'I;mding position: (4) lack of p;'lin on sit'-li.Q!! straight kg raising (when supinc. lest W'S POSItIVC):
(5) uncxplaill~d weakncs~ and/or (6) sensory dislUrbancc:
and finally. (7) a pilllcrn of exaggeration 10 all pnwoc<ltive
testing.
The highc.:r thc number or positive signs. the higher thc
likelihood of l'~sponse bias to the pnill phenomenon and .111
cxaggcnllcd response representing critical f~IC((lrS in the p'lticlH's conditil)IL

LSES OF PAIN AND IJISAIIII.ITY

QlESTIONNAIRES IN C\SE
YL\\A(;E\IENT ITahl,' ~..\l
Timin~

/;0.\,'1"11", TtH:d s\..ores I'm each lest help to darify and qualltif~ Ih\..' \..'\Ielll of

p;lill :l1ld disability. Tlll~sc scores l:all be eOIllparl'd lt1l'XPCl:tcd \';lIuc... in thl..' literature or within Illles uwn
dillll"al p\lplIl;uit\ll.
Indi\'idu;lI ilellh I..:in [ll"\lyide IllL':1I1ingful inrtlrlll:lli\lli (,n
\\t)r'I-~':h~' i~~lle~. rtlr cxalllpk. Illl thc Chwestry llr NDI
~c;lk,. any itl..'lll sl"orillg -l or :' rcprcscllts a key issue in
Illl.' paticnt"s lire. Id\..'llIifying tllal ilCIll (i.e., driving or lifting. ctl.',) as imponant and 11101'\..' highly i1\lj'h.lircd allows
for indiddualizcd ~oal sClting ill Ihl' l'l'hahilit;lliOIl pl;lll of
managcmcnt.
St'qt/('It/;al re,\rin,::. SL'rial tt:,,,aing. at appropriate illlt:rv.lb
(i.e .. weekly for acutc lOIHlitioIlS. biweekly for chronil' cases)
allo\\"~ for ongoing evaluation or progress. Puwiding feedhack to the patient C<l1l be an imponalll source of I\lotiv<ltioll
10 "ustaill their compliance with the program requirelllc1lts.
A./rer m:(l//I1('lItldischargc. The hnal CV<ilLwtion Gill be
compared to b<lseline levels for a dctennin;llioll of towl in-
progrill1l bcnclit.

Mode of Applic'Jtioll
Douor-ollly. Patients Illay lill out a \";lriet)' of forms. the r~
sulh of which may neva he disdo...cd to thelll. This pnlL'licl".
is suiwble Ii-x l'ohort rcsl'..m.:h. ill which some level of palicill
blinding is useful to reduce bias ill sclf-n:p~,rling.
DoC/or plus PllI;CI/{ .I(>clllwd.:. Ongoing n.:suhs_ especially
in the form of simple !\crial C()lllP~ll"isons (i.e .. "Your pain
level is 50% reduce,!"'. arc provided 10 the patil'llt for,lllotivation <Ind c:ncou.r.;lgcl1lc}1t;'ll1d as I?a~ or _the learning process
th<.lt underlies the 'lpplic.ttion of;l rch"bilitati(,m program (i.c~.
learning 1(\ cmiii,'ly-wilh iilstrllc!;(JliClC~irrl"ing tile mcaning of
various disahility issues relevant to their own condition), This
dis ..u ... "iofl is especially mcrul for the h:y itcms identified al
ba... c1inl.: (i.c" '" sec your kvc1 of comfort while dri\'ing is in
crc"... ing. That's good:".
{)(J('(rJr ,,111,\ patiell( pIli.\" .\"((~a: In programm;Hic care. all
Ien:l ... of the clinical rehabilitation te<ll11 share in the scri'll
data (."ollcction Clnd feedback process_ This approach maximize (lpportunitics for positive reinforcement fnr identifying.
area of poorer response, ..llld for risk-nlUnaging "redllag
areas. Pl'ogr;,un staff should usc the ongoing. data for modifying the plan of llli.lnagclllcl1t as necess<lry and for kt:'cping the
program on targct for the p;.uicnt's individualized goals.
Table 4.3, Uses of Pain and Disability Questionnaires in

Patient Care
Timing

Application

MeasufCs of post-treatment

Doctor-only
Doctor plus patient feedback
Doctor plus palienl plus staff

outcome
Measures 01 ongoing

improvement

m----....- --,---------------------------------------'ri

Iv
~
I,'

.P

"

I ' , ...... ~- 1I'lIt::.

CONCLUSION
As r~habilitalion pro~rams develop and expand within chirojlmctk. a corresponding need ~lriscs 10 document both the

progress of the pmit.:JH and the outcome of the care pro\'idcd,t'~S6

regardless of its spccilic components. The instruments discussed in this c1mptcr will hdp lhe modem chiropraclor meet the chalk'ngcs of outcome ;lSSCSSl11cnt.
REFEHEi'I'CE.."i
I.

Valli.~ "DiC

I\kHugh

s: Jllrl~'''''s

hehavior: C'h:dkllgin,!; Ihl.: lIlcdiC;lllllOOCI.

HUlllan.: ~h:d . \::~. !Y:\'7

2.

En~d

GL: The need f(l(;l new medic;,1 nltl(kl: r\ Ch;lllclll;C for biomedi-

cine. Sdcllcl'

l
~

-iJ

~~

i
,
~

I,
!

i~

iI

I,
I
~

196:1~'J.

!y77.

3. Wadddl G: A neW dini\:JI llltldd for the tr,;-;lIl1lcn\ of low hack p;lin.
Spine 12:632. 19X7.
4. Frc)' WD: FUnCli(ln;l! :t~"'e~~l1lenl in lhc 'SOs: A conccplU:l1 cnigm'l, 01
technic:11 chalkll!;c. In lhlflCm liS, Fuhrer ~'1J (cd!'): FUI1I:tion:t1 As
SC~SmC111 in Rl'h:ltJililalit'll. lbhimorc. !';lUl Brooks, 1984.
.'i. Forer SK: Flln~li{lnal :t~~C"'Sl1lCIll inslnullclII" in nH:dical rch<Jhilil<Jlioll.
J Or~ani1.Olti()Il:l1 Rchahil [vOlluOltOrs 2:29, 1982.
(l. Willi:llll.~ RCA. JOhll~101l ~1. Willi." l.A, CI al: Disahility: A model :md
lIlCa~UrClllclll h:chniqul:. Br J lin.;" S(lC ~'kd JO:71, 1916.
7. Gallin RS. GiwlI C\\': The COllCo:jll :lIld dassilicatiOIl of disability in
hC'lllh inlcrvJcw sun'cy", Inquiry D:J95, 1976.
S. Harfl\:r A<;. H;u1lCr [),\. L:1l11l1cn U. ct al: Symptolllsof illlpainllcm. dis
ability and llilndic:lp in low h:Jck p;lin: A taxonomy. Pain 50:189.1992.
9. r..1 cchanic D. Volkhan EH: Illness behavior and medic:!1 di:lgllO.~i~. J
Health HUlll Beh:!\' 1:86. 1960.
10. Pilowsky I: Anllorma! iIlne,." bchavior. Br J ~lcd PsychoI42:3J7. 1969.
II. Vcmon H: Chiropr.lctic: .-\ model of incorporaling the iIIncss heh;wior
mooel in thc management of l\lW back pain p:lllenl.... J Manipulativc
Physiol Thcr 1..1:.'19. 1991.
12. Vcrnon HT: Applying re~carchb'l~d ;)"SC~!iments Qr pain :md lo.. ~ of
function 10 tht.' i!'~tJe of developing s1:Indards of COlrc in chiropractic. J
ChiroTt.'<"h 2:1~1. 1990.
I .1. Loeser J(): COIKCptS of pOlin. In Stanton HM. Bo.. . !' RA (cds): Chronic
Low (hick POlin. New York. Raven Press, 198~.
I.... Mclzack R: The I'uzzk of Pain. New York. Basic Books. 197:\.
15. Koran LM: Reliahility of clinical mcthods, data. and judglllcnt~. N Engl
J Meil 293:(,.;2. 1975.
16. Waddell G. ~hin CJ. Morris E.w, ct al: Nonnality and rcliabilil)' in clinical asse...sTllcn! of backache. Br r-.led J 284: 1519. 1982.
17. Nelson MA. Alkn P. C1:HllP SE, el al: Rdiabilil)' ami reprtxIudbililY of
clinical finuinp ill low back pain. Spine 4:(J7. 1971).
IS. H.lIlsol1 DT. Ayres JR: Chiropr.lclit t1utcomc mea.~ures. J Chiro Tech
3:53, 1991.
J 9. [kyo RA: i\k:lsuring l!le funCli(lnal stalu~ of p:llieuts with low back
pain. Arch Ph)'s Mcd Rchabil 69: IO.J4. 198~.
20. Torgerson WS: Theo(\- and Methods of Scalill2. Ncw York.
~kGra\\'-Hill. 19;'iS.
.
~
21. McDowcll!. Ncwell C: ~kasuring Health: a Guide In ROllin!;. Scale... and
Qllcstionnairl's. New Y(lrk: O.dord Press. 1987.
~2. Bennell AE. Rilchie K: Qucslionll;lin,:.~ in i\lcdkillC: A Guidc 10 Their
Dcsign .lIld Usc. London. Oxford Univcrsit)' Press. 1975.
2.1. Fordycc WE: Beha\'ioral ~lclhods in Chronic Pain and Illness. 51. Louis,
CV Mosby. 1976.
24. Bradhurn NM. Sudman S. Blair E. Cl .11: Que~li(lll lhrt=at and rt=sp<m"c
hias. Public Opiniun Q .J2:221. 1978.
25. Philips RB: 111e challenge of proving lhe cfficacy of chiropraclie:
Plat:coo. Hawlhorlle and Pygmalioll effccts in rcscarch. ACA J Chiro
20:30, 19S~.
26. Cronbaeh U: E!iOSCllli'lls of Ps)'cho!Ufic,11 lCsling. 3rd Ed, New Yt)rk.
Harper, 1970.
27. Keating J. Ikrg:llI:lIln T. Jacoh.~ G: Inlcr-~xailliner rdiabilily of cighl
cvaluati\'c dimensions (If lumbar scgmcntal :lbnormality. J M:tnipubti,c
Ph)'.~iol Th~r 1.1:-163. 19~)(J.

rNA"" 1IIIUNt:H'::;

MANUAL

28. Vemon HT. Mior 5: 1llc neck disabilil), indc),: A slody of rcli:lhility and
\ali,Iity. J J\.'lanipul'l\i\'c Physiol TIlcr 14:409, 1991.
29. Guyal! G. Walt..:r S, Nunllan G: Mca...uring changc ovcr lim..:: Ass:.=.ssing
u.~dulne ...s of cV:llu'llion inslrul1lCnl.". J Chronic Di$ .JO: 171. 19X7.
30. Bombardier C, Tugwell P: McdlOdologica! considerations in fum:lion:ll
assessment. J Rhcumatol 14(Suppl 15):(1. 1981.
31. Kirsdmer H, Guy:m G: A IlIclhndologic:lI fralllcwnrk fm ils~cssing
hcalth indices. J Olronic Dis 38:27. 1985.
.12. Kl'-dc K1>: 'nlc pain chan. L... ncet 2:(1, 194M.
JJ. 1\!.lrgl)lis RH. Chihn:llt IT. T;dr RC: I\.. strl'l";~;l n:!i::bilil}" Ill' lh~' p;d;,
drawing. inslfUlllcnt. Pain n:49, 19Htt
:,\-I. Marg.olis Ril. Tail RC. Krause SJ: R'l1ing !'ysh~m for usc with p:ttielll
p:lin drawings. Pain 2+:57, 1%6.
;\5. Tail RC. Chibn'lll n. Margolis RB: P'lin C:(lcnt: RelaliOlll' Wilh psycho
It1gic:!1 stme. polin sc\'crity, pain histnry anu uisability. Pain 41 :295. 1990.
36. R:lIl.~fmd BV, Caims D. Mooney V: 'n,C pain umwing :1S .m aid 10 PS)
dlUlugical c\'aluation of paliellts with low hack pain. Spine I: 127, ItJ76.
;\7. Uden A. Hstrom M. Bcrgcnudd H: P.lin dr:!wings in chronie hack pain.
Spinc 13:389, 1988.
J8. I-luskisson cC: r-,1t.'asurelllClll "fpain. LUlcc, 2:127, 197..1.
39. RC:lding Ac: CompOlrison (If pain ralill~ scales. J Psychosolll Re... 2J: 1/9.
1980.
.JO. Ohllhaus EE. Adter R: Melhouologkal prohkms inlhc lI1e'l... urcIllClll.~)r
pain: A c(Jl\lparisol1 between the vcrp:l1 r.ltil1t: scale and the visual 'lIla
loguc scale. I);lin 1:379. 1975.
41. Duncan Gil. Bu.shndl MC, Lwignc GJ: CornpOlri:.:on of verbal ;llid ,i
!'ua1 analog.ue scales (or mcasuring. lhe il1lCllSity and unp!c;\s:tlllncss {)f
cxperimental pain. Pain 37:295. 191'19.
42. Jensen MP. Kamly p. Bravcr S: 11,c meOlsurC1\lcnl (If "lini":11 pain inlen
~ity: A comparison o( six methods. fl"in 21: 117. 19$6.
.J3. Downie WW. Leatham PA, Rhim.l VM. ct .11: StuJies with pOlin r:ltin;;
scales. Ann Rheum Dis ~1::n8. 197X.
44 Huskisson EC: Mea....urement Ilf pOlin. J Rhcum:11(I1 9:7(lloi. 19X2.
.J5. Husldsson EC: Visual :lIlalll~ue sla!c!'. In Md/.al.:k R (cd): P'lin
Mea~uremcnt :HIlI A~sc'"melll. New York. 'Raven Prcs!'. 1910.
4(1. Dixon JS. Bird tit\: ReprodUl...ihiliIY ailing" Ilh'nt \-....nkal visual ana
logue Calc. Alln Rheullll)i.~ .JfI:R7. 19HI.
47. Scott J. Huskisson EC: Verticalm 1I\)ri7.(1I1I;11 \'i~ual ;mall1gue scales. Ann
Rheum Dis J8:560. 1979.
48. Ma.'( .....ctl C: Scn...iti\'it)' and a1.:curm:y of Ihe \'isual all;JlllplC s{a!c. Br J
Clin Pharlllaeol (d5. 197R.
49. Seem J. Huski!'s(lll EC: Accur<Lcy of ";lIhjccli~'c 1lH,.'Ol,.;urell1ents Ill:ale willi
or withoul pn:\'iQUS S(.ore~: An il1lptlrtam MlUfCt= of crror in serial mea
surcment of suhjccti\'c stalcs. Aun Rheum Di~ 3X:5~S. 1979.
50. Cheng RSS, P()tnemnz B: Electrotherapy of chmnit' llltisculo,.;keklal
polin: Compari!'ull of electroacUplilicturc :Uld ;11.:t1puncturclike tr.lI\~{ula
neou' eleetricOllner...c ~tillltJI"tit)ll. ('lin J P'lin 2:In. 19:-:7.
51. M:lrchin D. Lewil11 (iT, \\'yIStJll S: I'ain lIle:lSllfelllenl ill ram]olllizl'd
dinic'll trials: A cOlllparis{lu of 1\\'11 pain SC.I!c.... Clill J Pain 4: Ill!. 198$.
.'i2. ~-IcIZ.lCk R: 'lllC fo.-lcGill P;lill Que,"l;lllln;lirt.,: :-"l:~\lr pr\llx'nies ;lIJd !'lor
illg melhexh. t)ain 1:277. 1975.
53. Metl.ad R. TmgcN)l\ \\/5: 011 thl' l;llI;;U;I,gC or pain. Anaesthcsitllngy
;\4:50. 1971.
5..1. Duhui....~on D. Md7.a1.:k R: Cla"silh:"ati(lll (If clinical pain dl's<:riplillrl~ h~
nlulliple gwup discrilllin:l111 analysis. Exp Neurol 51 :..1::'0. l fJ76.
5:'1. Allcn RA. Wc;nm,lIIl1 RL 11le MPQ in Ihc Ili;lgllHsis uf headadl l'.
Hcadache 22:20, 19K2.
56. Phillip, I-IC, Hunter MS: P'lin b..;havior in hC;ld:l1.:he pali~'llls. Beha\' All:!I
Mod 19:251. 19SI.
57, Reading AE: 11n: inh:rn'll "tmclun: nf the. McGilll':Iin Quc!'liunnain: in
dy."mellOrrhoca patiCnls. Pain 7:.153. 197 1).
5X. Pricto EJ. Gcisinger KF: Factur-;lIlalytic studies l,r Ihc McGill P,tin
Que"lionn:lirc. III Mclz:u.:k R (cd): i':lin l\-!c'l'un':lII\,nt alit! ASS6SIllCJ\1.
New York, ROlven I'n: ..... 19RJ. pp (1,\-70.
.'\9. Byrne M, Troy A. Bradlcy I~t\. \'1 al: Crll~~\"'lliil;lti<lll "I' lhl.' f'lctnf stftH:lurc f)f the MP(). !'ain Lt 193. J fJS::!.
(-(t. I't=:lrce J. Murley S: I\n C1\perilllClltat ill\'e~tig,;Jlioll llt' Ihe Cllllstnscl va
lidity flf the McGill I';lin C}llC_"lilllll1;lirc. I'ain ."\9:11:', IllS\).

I--------,--------------------------------------~,~.~

,,

)
)

,;

-'

CHAPTER 4

PAIN AND DISABILITY QUESTIDNNAIRES IN CHIROPRACTIC REHABILITATION

61. llurkh;lrt.1t ('$: Tho: usc ui the t\ktllii

anhritis P:lill. I):lin 19;305. 19SJ.

(--

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,

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I
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0

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ii

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~;

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~
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:c:~

Vl....:-lh'llll.":.:

III

a,~",'..,in;:

6~. Alldr:lssik F. Bbnchard EB. 1\llk:- T.":I al: Ass...ssin;: Ih~' rc.h.:ti,c;I' WC'1l

:IS lho.: s...nSUf) comjlnno.:nl of hcad;l.:h~ pain. 1k;lIl:ldl': : I'~ IS. IIJS I.
<:1 al: 111.... OS\W~lI~ I.,\W Had, 1';lil1

63. Fairh;l1lk JCT. Couper J. Davio.:s JB.

ludcx. I'hysiotho.:r:apy 66:271. 1%0.

Ruland t-.'" Morris R: A study of th..: nJllIr.11 hiSl<If)' tlilcm 1-o;l("k pain. }';I(I
1. De"elopment (If a reliable and ~':lhili"o.: 1110..':1:-111'...' l't" ,h .lhility in hll\
had.: pain. Spin.: S: 141. 198.3.
!l." Polb~;l CA: I'rdilllin:lry valid it) ~llIdy of Ih... I':lin ()I lhility Im!.::--,
Pcrco.:pt Mot Skill~ :'19:974. 19Sl.
66. Kccofc FJ, Wilkins RH. Cook WA: I)irnltlhso.:r\,alit>n Ill' r;l1n h.... ha\'il)r in
low b:u.:k p:lin palicol\ls durin~ phy:-kal cX:lIuinatiun. 1';1111 ~n:~'it). It)X4.

:-.1. Pil"w:-"~ 1. SI'..IKC NO: 1';lil1 ;lml 1I1tl':~~ hdl;,,i,lr: ..\ t.:umpaf;lli\c slUd\".
J 1'.~ydll''''lIIlk~ ~O:IJI. 1<)76.
.
-::.. l'illl'\.~"~ I. Sl'ln..:.... Nt>: ,\I:lIllltd f"1 lh' Illtt~'" l\,,:h:I\ltlr Q\lco~ti(1l1n;\irc
OBC)). :ull Ell. Addaitk. AIISlra!l;I: Lnn .... r:-ll} uf :\ddaitk. 19S.~.
t.:1l111l'ari~(ln ,'Il")~l\ili\'c lll~':hllrcs ill Inw 1':I..:k
p:lin: SI:IIl~II~.11 ,trtKlllrC ;tnt! dinicli \:=Iidil\' ;11 initial ;1':-CSSlllCIll. I'':lin
.1(,:~:n. !,JIlI

it,. :"bill CJ. W.,.I,ldl G: A

(~.

"

1';1111

i t l

71

i7

'So

l'ilo\\":-k~ I. Ch:q'l1l;1ll CR. lh'lli c';1 JJ !':Iill. do.:Pl\~~itl!l :lI\d illl\\.'~'; b..:
11;\l"i"r ill ;I P:\l1l dini.: p'lplllatillil. I',llll -l: I:-\:;-. l'n7.
W;lddcll (i.I'lllll\,ky I. BlInd t'.... IR: CI:lli,:tl a~"~',~~I1\':111 :Illd illl ...ql1.:t:llillll
abnpl'l1l:11 illll"" h.:ha\'illr in 101, 1'.,.. " paill. 1':lill ,,1):-11, IIlX'J.
W;ultkll G. \J..:Cull~lCh J:\. KUtIlm.-l E. ~'I al: N'lnnr~:mil phy... ilal .. i~ns
inltlw had.. p:nn. Spinc 5:117. I'JSU.
Ikr~ll..:r:-'1. n,'hhill RA. I'o((:lfd WE..:I al: The Sidn..:"" 11111':1\.'1 !'r(llil..:
\'alill:uillll ,,1';( he:lhh sial us 1ll :I~lIr..: \1.:11 Clr.... 1J::'I7. 197(1.
Ikr~IKr t\1. llllbbilt R,\, Kr.... s.~ h. ~'l .11: '111": Sickll~ ...s.iill[1act I'rnlik: :\
etlllc....lllll:l1 t"llfllllllalillll ;\mllllcolh(lt.!llh,::y for Ih~' d':l'dupmclIlllf a hcoahh
~1altlS tlll~'II\llln;li,~. lin J I kalth Sa, h:}I)Y. I InCl.

or

il).

(17. JcIl~CIlIU. llr:.Jdk) LA. Linton 5J: \'alidatioll (If:1II \lh:-.:n;ltiuII m,,:thtld
of pain a:"s.....~slIlcnl in nonchrunil' h:ld: pain. Pain .31J::to'!. 19S1).
IS. Triano JJ. SchultJ. A[J: Corrd:nion or" ohjeclh''': 1Il":':I.~ur.... ~ "I' trunk lIIutinll
and muscle funClion wilh low h:ld disahility r:llil\~~. Spino.: 12:5C,1.
1987.

XO.

69. Hsieh CJ. Phillips RB. Adams AU. ct al: FlIllclilln:lI ("IUI;:OI1\CS of low
b':lck pain; COlllp"rison of four treatment ~roIlP,~ in a r;ml!ol1\ll.o.:d cun
trolled lrial. J Manipulative Ph}'siol Ther 15:4. 199~.
70, Tait Rc' I'tlilard CA. ~targolis Ril . ..:t al: IllC Pain Di,ability Imk... :
Psychometric and v,didil)' data. Arch Phy~ Med Rch:lbiI6S:-l3S. 1987.
71. Tail RC, Chibnall JT. Kr:1USC s: 'nK' P':lin Di.~:lhi1iIY Illd~": P~ych(llll~'lrk
properties. Pain 40:171. 1990.
72, Lcavin F. Garron DC: Validil)" (If:l Bal'k P;lin C1a~...iliC.lIl(ln St.:;lk ;UlIilll
p<lliclllS with low back pain nul a"o,:iated wilh d~'m(\n~lraMc organic
dise"sc. J Psychosolll Rc.~ 2.3:301. 1979.
13, Lca"in r-. G,lrron DC. V;llidity of a R~d Pain C1assilic':Hion Seak for do.:
lccling psychological di~lUrhancc :1-.. me:lsllft:d h)' lh~' \1\1P1. J Clin
Psyclml 36: 186. 198C}.

X~.

S 1.

IIcrgn.:r ;\1. B\ll-ohiu R,\. Clrt..:r WH, ~t :11: 111... Sickn.......s Illlp;lt.:1 Pwlik:
Lkvcloplll.... llt ;>lld tin;ll r...."isillllt'l a h'::lhh sl:II11S HlC:I.~uro.:. tkallh Car...
PJ:7R7, [l)S l.

S3. Pollard WE. Bobbill RA. B':I'::nt::T \1. \.'1 :11: Tho.: Skkl\c~s 11lIP:II:t I'wlik:
Reliability of a h'::llih sl;\l\1S l1lC;',lIr,', \1..:d ell\: 1-1: 14(1. 1')7(1.
R-l, D"'yl\ J{,\: C(ll1lp:lI':lti\"~' \":Ilidity 1'1' th.: Sidll~'SS llllp;ltt Prolik :\I1d
shmlcor ~c:lk, fur fllll...li,lll:11 a...:-...."m.::1l in It.\\, "a~k pain. Spin..: II :'J." 1.
19X6.
S5. Mill,lrd RW: ..\ crillt:al r~" i.... w Ill' qll:~tlolln;lir...." f1lr ;I"e... ~ill~ p;lin-I''''lat....d disahility, J Genlp lh!I:lh 1:~S\J. 1991.
S6. Bomb:lnlkr C. TlI~wdl P: 1\klhlltl"I,,~jclll\,Il~i\kr:lliun' ill rtlll~li,'nal
as~ .... ~!'m..:nl. J RhcullI:lllJ! 1.I(Suppl !:":Il. 11J:'\7.

Outcomes Assessment in the Small Private

Practice
CRAIG LIE BENSON and JEFF OSLANCE

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Determining. th~ most cosl-clTcCliw IrC.llmclll {kp~nds on appropriate lllcasur~-!.!l~L~).r tr.catlll~lli resulls. Sut.'h measurcment is called ouTcomes lIS.H'SSllll'lIf. The dcvc!()pnlcnio-r outCOIllC "ssessmcnt tools for -objccti vc measurement of a
p<ltient's response to C.lre Iws becomc a major research endeavor. for musculoskeletal problems. it is essential to assess
ohjeclivcly deficits ill hiomcchanical function. including
r.mge of motion. muscle strcnglh/cndur:'ll1cc.1l1d (;IH.liO\,;IScular fitness. Questionnaires. algometry. ;Il\U other loob .lIso
make il possiblc 10 qUiHlIiry disahili\)' and Ihc suhjeclivc cx~
pcricnce of pain. Using functional outcome assessment tools
to evaluate the progrcss of an injurcd worker or p:nicn! allow!'
a shift in emphasis away from subjective f.lctors of pain 10ward more realistic funclional mC'ISllrcs.
In lhe majority of soft tissue injuries. functional changes
arc the only objective findings on which to base treatment and
to judge progress. Unfortull'llcl.y_.lUOSLOrlhapcdic exmnil1alions rei\' on te~as that search for structural lesions (i.e., nave
.
root compression or tension). Although structural lesions arc
present in only abou.l.f9.?t oX cascs. ovcruse of expensive di
agnostic tcsts (i.e" magnetic rcson::tnce imaging) is typic.1I in
Ihc search to diagnose such struclUral pathology. I The r~
rnaining 80% of p.atients havc no idcntifiahlc.structural patho.
~/./logic-a6oormati"[Y-andrequire treatment based on the evalua
-liqn of functional deficits. Outcomes assessment that includes
objective functional testing gives third P;\flY payers. the patient. and the doctor a way 10 measure progress over time and
thus adjudic:'llC the prescribed treatment 'Ipproach.
Treatment of functional deficits is addressed W~h.J~llIlC.
lieun' D"lclivJtjon/rcsloratiun.programs. SlUdics havc demon
s(rated Ihal more than 809r of chronically disabled individual~ can rcturn to work if n.:habiliti.llion based on objectivt.:
quantification of function is used as the standard of Glre.>:
Although quantification of functional deficits is the goal. this
attempt is only in its infancy. Many physiologic paramctcrs or
thc musculoskeletal system C~lJlnol be realislically measured
quantifi'lbly. Intersegmental <lcccssory motion between articulations is palpated regularly. but interexamincr reliabililY is
poor and no quantification is possiblc. Palpation of areas of
tenderness by :.Ill algomcter docs nOt resemble mallual p'llpalion, although it is quantifiable. Visual inspection of th~ posture. g<lit. ilnd movement skills of'l patient is pan of a qllalitiHivc eX;llnin~ltion Ihal is clinically invaluable. While we

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MEASUREMENT OF PAIN, DISABILITY, AND

PSYCHOSOCIAL STATUS
Rchabiliti.llion begins with a Ihorough history from the p;;Jliclll. The history should identify various features about thc
pain. occupation. lifestyle, and psychosocial status or Ihe in~
divid\lal. Cerlain objeclive lools that complemcnt the traditional history.taking process arc shown in Table 5.1.
\Vaddclrs signs of abnormal illness bcha\'ior arc important in paticnt evaluation. The presence of three of five of
Ihese signs is signifk:antly correlated with dis~lbility.l~
Supcrlicial or l1ollal1atomic tenderness: WiJL':;pr~;\d sensitivity to
ligll1 low.:h in Ih~ lumb"r region and pain rckm:d 10 olher ~rcas.
"ud~l..Qr..x. ~;U;fllnl. or pclvi~.
Silllllilltior;: ;\.xial ](~jing (ligi"lt prc.\surc 10 tilL' ::kull) ~h(lllld lHH
~i~lljtic;llllly incrca~c low h;lI.:k paill~ Passive Hlt:l1i~)l) of lhe shou!
ders and pelvis together in a slallding--paticllt ~hl1llld not rc:prodllCl~
low b:lck pain.:/Oistractions: Differencc of 40 tort5'" between th~ ~~JpillC and seal<.:d
straight leg raising Icst~.
ncgional dislurlmnct.'s: SCll~ory or m(llm t1i:'lurhancc ("giving
way") th'll is not ncurologically correlated.
Ovcrrc~lc.lion: 11l~lprropri~llt: ovcrrcaelion. such a:, ~uartji!lg. limping. rubbing the affcclcd .In;a. bradng (lllc~c1f. !=ril\l:\cing. or sigh.
ing. arc all sigll~ of illncs:-; hehavior.

Wernecke el al found thallhesc bchavioml signs could be il11

proved in individuals in a phy:-ic:.i1 retwbilitation progr:,ull.1.l
Measuring pain intensity and flll1ctionalloss as a result of
pain <Il 2- or 4~weck intervals helps to dOCUlll!.::nta patient's
progress ull(Jcr'c;lrc~'Thc Visual Analog SCOlk (VAS) c:~n e~cl1
be ~;Scd -\vlih each visit along with a pain drawing (sec also
Chapter 4). The VAS c:m be liSCO to assess characteristic pain
intensity "right now," ";l\!er~~;d.~ain:' and \\'(~.t pain"'::--~i

73

{J

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iI'

sirive IOw'\I'(.1 objeclive quallliliC<ltion .md measurement. we

s!lollidnollimit ourselves 10 quantification alone.
Objective Ollu.:ome mcasurcments :'Ire incrc:'lsingly rc
quircd to ensure reimbursemclI( for care prO\idcd. They help
10 document Ihc pillient's status in terms of Iheir subjeclivc
complaint. functional loss. changes in acti\itics of daily Ii\,
ing, psychosocial problcms, and timc off work. They also pro
vide objective baselines thai C~lIl be used to show the palient
their progress oycr time. This feedback is a motivational aid
Ihe provider C.lll usc 10 encourage the patient.

HCNAOlLIIAI1UN

I
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I1

Table 5.1. Objectification of Subjective Factors

Pain
Visual Analog Scale
McGill (qualilyy

Psychosocial
Beck.~

SCL90R"
FA80'J

I
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I

Waddelrs behavioral signs ,-,-

LifestylclOisability
Osweslry\~'

Neck Disability Index'(.

MiVion"
Vermonl'~

RolandMorris'~

Dallas Pain OueSlionnaire:;>Q'

Sickness Impact Prolile~' n
Pain Disability Index;~
Job Dissatistaclion

i!

Apgar~~

'Especially simple and practical 1001 lor oHice usc.

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PRACTITIONER'S MANUAL

ferred pain). Finally. it helps to identify signs of neuropathic

pail1 (hyperalgesia 10 non-noxious.stimuli).

(jnlensily)~'

Pain drawing (localion)(,'

Zung 7 ' O
Back Pain Classificatlon Scale"

ut-

Average and wo~st puin should refer to the previous 6 months

in the case or a chronic patient. If mcasuremcnts arc made at
intervals during the provision of cme. it should refer to the pe~
riod since the I<I:-;t asscssment.
The mean of the threc pain intcnsity mcasurements should
be multiplied by 10 10 yield a 0 to 100 scorc. Characteristic
pain intensity less than 50 is cl;]ssified as low intensity; anything above 50 is classified as high intcnsity.17
Questiollnaires such as the Oswestry or Neck Disability
Index, pain dhlgr.lIns. and the VAS should be used Crom the
outset of care. A good rule of thumb is to obtain baselines at
the patient's initial office visit .md repeat thc outcome mca
surements a~ weeks 2. 4. and 6. After 6 weeks. most patients
are well. Whcn treating a complicated patient (one prone t.)
chronicity), however. it is rc,lsonable to continue tr..lcking
their OlUCOlllCS cvcry 4 wccks. These measurements c<ln help
immeasurably with stubborn insur.mce adjusters or utiliz<ltion
reviewers becausc they docul1lelH the patient's progress under
your <:arc.
Quantiflcatioll of soft tissue tendcrness is also possible
with a pressure ~llgotlleter.~~ This device measures soft tissue
compliance. Prc- and post-treatment chccks of tenderness can
thus be quantified. Qualifiable ~lsscssmcnt of son tissue tendcrnes.. . is also possible~'J"J by applying 4 kg of digital pressure (cnough pressure to blanch the tip of the thumbnail when
pressing the palmar surface of the thumb against a rigid surface). The grading schcme shown in Table 5.2 is adaptcd Crom
\Volfe ct aF'} ;lnd Hubbard et ~11.lU
h i.. . also of value to notc the presence or absence of rc
ferred pain (expanded receptor field) 'lssociated with soft tis
sue palpation of an ilfca of tenderncss. Documcnting areas of
soft tissue tenderness. along with their potential patterns of referred pain. serves a number of purposes. Firsl. it helps to establish a baseline level of soft tissue tenderness or sensitivity.
Second. it helps identify trigger points (+ Jump sign and rc

't

FUNCTIONAL CAPACITY EVALUATION

A key to successful rehabilitation of the musculoskeletal systcm is funclional assessment. In contrast to the clinical examination. this cvaluation is not important until thc patient is
"out" of thc acute episodc. As soon ;IS a paticnt cmcrges from
lhe :Jcute st<1ges of an injury. objective mcasurement of functional Olj{comes is nccessarj. 111is infonnation gives the daclor. patient. and third pany payor means by which to communicatc the status of the patient and to identify the goals of
c'lrc.
The chief purpose of the functional capacity evaluation
(FeE) is 10 demonstrate objectively an individual's level of
impairment as it relates (0 both pain and disability.)'.l~ This
cViJluation gives objective infonnation to the health care
provider who can then rationally prescribe treatment aild then
monitor its results. In addition. it provides (he patient with ohjectivc feedback on how their injury and/or pain aff~cts their
ability to perform normal activities. as well a.c; an objectivc
way to see their progress. Finally. the FeE provides the third
party payor with objective. quantifiable evidence of imp<lirlllent from injury or subjective complaint.
According to Mooney. an FeE is recommended 2 weeks
after injury to identify the "weak functi0nal link" (sec
Chapter 21). Trian"o suggests 4 weeks as an appropriate time
to begin testing (personal communicntion. 1(94). Harr.
Iscrnhagen. and Matheson wrote thilt the indications for func(ional testing include plateau of treatmcnt progress. discrcp.mcy between subjective and objective findings. difficulty returning to gainful employment. and voc.llioTlal planning or
medicolegal case scttlement. H FUIlCliofla{ (esting ill the subacute .wage can prm'ide ideal Olltcomes Wi lI'ell (IS help lu
idell/lf)' key fimctiolloJ pU1Jwlogies Ihal !iIIOIlIcJ b<' m/(/resJ('t!
u:itlllll(lllipularioll, addce.

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The FeE allows objective confirnwtion ()f patient staWs to

complement the patient's Stlbjcctivc sclf~repol1 of their symptoms. It also documents patient progress ovcr time, which
helps to motivate the patient to pursue re<lcti\,.ltion after in
jury. Prolonged passi\'c care (e.g.. hm packs. massage. ultra~
sound) directed at providing symptomatic rclid may only
achievc short-tcrm resuhs,\.l-'~ \Vhcn symptom:ni(', not functional, outcomcs arc the patient's only goal. incomplete hcaling. chroni<.: pain. and ovcrtrC.lllllCllt oftell n:slllt.,I.I.\~ This

Table.~

Tissue Tenderness Grading

Scheme~.>o

[.

,/)

.J

Grade
Grade
Grade
Grade
Grade

o-no tenderness
I-tenderness with no physical response
It-tenderness with grimace and/or flinch
III-tenderness with withdrawal (+Jump sign)
IV-wilhdrawallo non-noxious stimuli (i.e.. super1icial palpation. pin prick. gentle percussion)'

'Adapted from Wolfe cl OIl... and Hubbard el at:>'>

lin noninjurod lissue, a sign of neuropathic pain.

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UU I COMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

(.:011111\1 111 _,illJ:llillll

((lmpallil..'s

i" lilt' ;llb.Hross til' ":l1lploycrs ,lIld insur;uKe

;llikl:.

The "~pons medicinc" appro;lt..-h. which l1lcaSUfe~ fulH.:tion;1! impairmcll\ and lI:'\CS active cx..:rdsc to rdl:lbilit:lte in
jured ti'slIcs. is rCl,"ognizcd as the "sl:llldanJ of c;lrc" for :'\ofl
tisslIl' injuries.: t:.;,. This ,Klive approach is bel1er suit..:d 10 ;ll~
Ic\'i;ltill~ p:lill, (ulllpkiing sofl tissll~ he:lling. and pn:\"l:llIing

1\.'(ll,"l..urrI..'IKCS.

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Thc FeE shoultl be m.lI1datory for any patient slill ..:xpericlI(ill); p,lin after 6 to 7 weeks (st:c Chapter 21).1 Thc FCE
is (,;ompo~cJ of me;,tsurable functional tests and compk'ments
previollsly described questionnain.:.s iscc ClmpICl" -l). The
fUlIctional tests mcasure nexibility. strcngth .. .mortlinmioll. cntlm'lll(c. ;'lcrobic capacity, posture, and balance.
The FeE idclHifies intrinsic jmpairmenls in the individual. Oflell. the extrinsic dClTl.and~ of the work environillent arc
thl: o\'l:r\oadin.g or injurious f..tctor. A work capacity e\'alua~
lioll (WeE) or job i.lllulysis Illay be required to identify such
potl:llli,11 sources of repclitive overload or injury. The combination of an F"CE, a job "lll,i1ysis. and a WCE will help to idcl1~
lify rctunHo-work outcomes and spccilic crgollomic and excn.'ise instructions for safe sining. lifting. or other repetitive
tasks in lhe workpl<lcc.'-1.,
The focus of the FeE should bc on rdeY,lnl functions that
C;1ll be safely and reliably measured. Normative d:lta bases.
wllerc they cxist, arc most helpful. \Vhcnevcr possible. quan
lilicalion is ideal. The IllOSt valid teslS arc those Ihal most
closely resemble: the ;letual \v;'IY lhe body is used.
Unfortunatcly, validity is often ignored as evaluators become
infmualcd with highly technical tests possessing high repro
ducibilily .md rc:liability. Matheson says. 'The intcrprctation
uf the test searc should bc able to predict or reflect the c\'allIec's perfonmlllcc in a larget task."1') If'lll effort factor can be
mcasured, this information will help to unlllask .1 m<l.lingerer.
lvla,hesoll indicntcs that the best tcst is onc that is valid. rcli'11.11e, and safe..\'1 Tables 5.3 and 5.4 pro\'ide thc imponarn :lSpeets of functionaltcsls and the kcy functions of thc IllUSCUloskeletal system lhal are necessary to c\alu<ltc.
An FCE docs \lot requirc great cxpense of time or money
in Ihat it can be. accomplished with low technology instru
mcnls such as a lapc measure or inclinometcr, A "low-tech"
approach CiHl be accomplished in nbout 20 minutcs of ofl1ce
tittlC. Highly technologic dyni.lmetric assessment of low back
function has becomc the gold standard of lumbar spine functional USSCsslllcnl. Because:: il is reliable and reproducible. it
servcs ..IS an cxcellclil outcome assessment tool. The validity
of it number of technologicillly advanced tests, howcvcr. is
questionable. Grabiner el al demonstratcd that norillal
strength Ille.lsurcmcills ;,lIone do not necessarily correlate with

01

i
Table 5.3. Critical Factors for Functional Tests
Valid/relevant

Normative database

Reliable/reproducible
Safe

Cost! practicality

75

Table 5.4. Key Aspects of Musculoskeletal Function

Static (Maintenance 01 Posture)

Posture
Balance
Dynamic (Production and Control of Movement)

Mobility.1lexibilily
Strength
Coordination
Endurance
Cardiovascul~r

lilness

normal fum:tion,"" Using elcctromyogmphic (EMG) evaluation during isometric trunk extension, they demonstrated dccoupling or asymmelric lumbar paraspinaf muscular activity
in pmients with low back pain who were considered nonnal
on dynamomelric tcsts. This dccoupling was also useful in
differentiating pain and noupain subjects.
The study by Grabiner and colleagues points out th"11 musculoskeletal function involves coordination as wcll as
strength during performance of a specific task. Simply because u patient passes a battcry of technologically advanced
tests docs not necessarily mcan their spinal funclion is normal. The EMG tcst not only points out the limitations of hightechnology dynamomctric testing of muscle strength and
endurance. but suggests that overl}' harsh criticism
of 100.,.'er technology evaluations of coordination may be
unjustified.
As Lcwit puts it ..... in many fields of medicine the importance of changes in function is now well recognized.
whereas in (he motor system.. where function is paramount.
this fundamental aspect is rarely considered. However, the
functioning of the locomotor system is extremely complex, ... and diagnosis of disturbed function is a highly sophisticated proceeding carried out. ns it wcre. in a clinical no
mall's I:.lnd..... l
In the Presidential Address to (he Cervical Spine Research
Society Annu.i1 Meeting in Decembcr of 1991. LaRocca criticized his colleagues for jumping to a psychologic dingnosis
when they cannot Hod a structUl:.11 C<\llse for a patient's persistent pain: ..... The error here is the autornmic leap to psychology. It assumes that all organic factors have been considcredo when in reality the clinician's npprcciation or the
complexity of such factors in often severely limited.'~~
Newton and \Vaddell said, "There is no convincing evidence
Ih;,1t isokinetic or any other iso-measure has greate::r clinicnl
utility in the paticnt with low back pain than either clinical
evnluation of physical imp<iirmclH, isometric strength, simple
isoinertial lifting or psychophysical testing...~:t
At prescnt. the quality of high technology rests is nol
demonstraled sufficiently to lead to the abandonment of lower
technology tests of spinal function. Many low technology
W:'lyS to identify functional pathology arc reliable (sec
Chapter 8).~11 Often. if the musculoskeletal function of a patient cannot be quantified, qualifiable tests may be performed
that give insight illlO valid muscle imba1::lOccs. joint stiffness.
postural dysfunctions, .1I1d movement incoordination.

-:R.::E::H.::A.::B::I.::L-:1T~A~T:.:IO:.:.N:..O.:::..F.:.T~H::E:.:.S::P~I:.:N.::E:.::
A-:..:..P:.:R:.:A.:::C~T:.:1T~IO::::.:N:::E:.:R:.:'S:.:.M=A:.:N:.:U~A:.:L

76=-

In 1987. the NIOSH Low Back Alias idclltilicd 19 tests

with signilic<llH reliability <.7-l Cohcn'~ Kappa and >.79 cocflicicnts for interclass corn.:latioll cocf1iciCllt [ICCI j.W.I,(,
;vloffroid and colleagues round 111;11 ~3 or 53 NIOSH tests
could discriminate between subjt.'cls with and without ]0\\"
back pain."'.(Thcy also found that the SC\'l;l1 .str~lngcsUe.s.1::i.to

!lether had a sCllsilivilV of :'\7~;,--;:llId it sp~'.itkil\:~oL9J.s:~/rhc

;nost i1l1!1ort<lnl 1l-1c~i;:~H:c~i~~~!s \\,('rt.'
SYlllll1~.try, sll:cnglh.
passive mobility, <Ind dYllalllil.: mobility. Rissancn and co-

or

\vorkcrs found thaI lH)lluyn<ll11ol1lctric lests ClllTC1<ucd h~'ttcr

with pain and disability than did isokinctiL' tcsts."s Thcy COll-

Fig. 5.2. Dorsolumbar extension.

eluded. "The non-(I\"namomctric tests arestillJJsel"td ineJinical practice in ~Jih~~i~;~h;I;I~~~;of

aecur;!tc ll~~';~
ell' ~lrcllgth cyaluatil)1l lllcthods,""s In allother stlld~, i-brdillg
and l.'llllcaguc\ found a battery oLll)\\' tcchllolog~ lc"ts safe.
rl.'li;lblc. and valid I'll[' as"c""ing physical funetil lllin.:;. in patient..; with chronic pain,li! Alaranla and co-workl..'r.; ~hnwed
t"eli;lbilily and cswhli;-;hcd a normtltin.; databaSL' fllt" h\\\ lcch-

more

Fig. 5.1 DorsolumQar flexion. "Inclinometer used is the Duater

from JTectl (324 West 1120, North American Fork, UT 84003).

110h'S)" les!'> on more than 500 indiYiduals,7!

."\"sessing impairmcnt i.., crucial to rating t11'..' k\ ~'1 \.'r per\.'1..'111 Ill" illlp;!innclIl ~\ patient !J,IS surfered. II is al.;,' lill: ollly

<.;HAP'':'R 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

\)hjc,.:II\ .. way 10 ~Il()w pro~r~ss and 10 dOl'lIlllCnl the Ilt.:'cd for

(unhl'r <rl';l\lllL'tI!. It i~

:lbsolulcly l'ssl.'lltial ill cases il\\'oh"ing

Illl'di\"('k'~al challL'llfc. hut it is also IlSL'fuIIO doculllent ;i11 in,mall,,';.' ,:Jaillls. whit'lt arc c:oming umkr greater and grc:.Hcr
SLTllllll~ :\s standards af\,,' e1ucidatcd. these industries will rdy
till 1111l\;':[";;l1 OUICOlllL'S ;lssCssmcnl
tl!L';\,.U: ..'UlC:llt

is

;lh... "ht!l.'IJ'

key to this

tools.

;1IIt!

l)uamiliahk

FUIH:tioll:l1 Tt'sls
Durin.:: fUIll:tion:d

Sensors arc 7.crocd and paticlH is requested to ncx maximally. the new angle is recorded
..::. If hanlstrings afC t"ight. patient may b~nd knccs"'~
_
Note: if lesser of wai~glaisc._:.!.1J:&~Sexceeds trunk
ncx.ioll, thell test is invalid:q

ErrCII.'i;rl/l

proCC%.

(~~til\g.

thc clTcl:(s of movcmcnt and posipain. thc painful or painfrce range. and
thl" I.,'fl;.'..:ts or rcpc~ltt.:d tcsting should be determined.
Sl."IlSilrl. ily hI various movcmcnts ,llld positions. along \vith
any \\l,'i:;ht-hcaring illlolcr<lncc. should ilIso be dctermined.
This inl(lrmillioll helps to cSI,tblish the functional or training
r.LlIgt: !lIthe p:llicnt (sec Ch.lpter 14). Evaluotion of posturc.
g<lil. ilnd muscle length arc not discussed in this chapler. but
this a,,;.'o;Sl11CI1( is L'ollsidered important clinically (sec

77

(Fig. 5,:!)

Starting position is the Silme as for tlexioll

P.uicJ11 is requested to extcnd maxim'llly. and the angle
is rCL'ordt.:d

litlllllll lh~ ht.:h;lVi~lr of

Cl1apll'r~

6 ;Illd IX).

STAND,nG

Lumbar Spine Ral/ge oj ~/otiol/

.,,/lil/etc jh'xihi!ity) (Fig. 5. I)

P~lticllt

st:lnds with knccs straight ,lIld feet slightly apan

S;.'n~ors arc pl~lL'cd on thc sacral apex and TI 2 spinous
proct:ss (lise skin marking pencil)
-':\ \ hk,,:.. ~:
,"''''llI,:n.

~:-:

~,]{I

ul',I.,I...,I"'\:""lrl,llillrl r,.rll" un lit... hmcliunal C:lpKily C\':.h/:lliun h~' S.

,,'o>ll:Ihk fr'"11 xon""'}.'-72fi.'>.

Starting position is lhe Same ;,IS for flexion

Palienl is requested to side bend maximally to the
right/left
To minimize rotation. patient is inslructed to slide fingers along the side of their'leg
Angle is recorded
QI/lIllt ificat iOIl

Ohjf.'l:ti\l. Quantifiable Tests '

I-'I('X;(lI; / erector

Lateral flexio/l (Fig. 5.3)

Final angles arc recorded

Normal vaILlcs~1
Trunk nexion, 60 v'"
Trunk extension. 25""--Trunk lateral flexion. 25"

PIIl/)OSe

Screening tests for erector spin.ac (ncxiotl) or quadratus

lumborum (Iateml flexion) tightness
Screcning tcst for lumbar joint stiffness

Fig. 5.3. Dorsolumbar lateral flexion.

Ht:HAtjILIIAIIUN Ur I HI:.

TllOradc Spine Range of J\1otioll (Flcx;Ol1IExtcllsitm)

(Fig. 5.4)
Patient swnds with knees straight and li..'t:l slightly apan
.:...-Scnsors <Ire placed 011 II and 1'12 spinous processes
(usc skin marking pencil)
Sensors .m.: zeroed and p:ltiClll is n.::qucslcd Iu lkx

i
1

1
I

~~INl:.:

A PRACTITIONER'S MANUAL

QuwHijinlli(In
The 1\\'0 ;lngh::s im: l'lllllbinl'd for t\lI;t1 lllC;lSlln":1l1l'lll
Norll1;l1 ,";l!ue. (l!J"~:

SEATED

Trunk Rotatioll Rauge oj IHotitm (Fig. 5.5)

Patit.'01 is sCOIh::d slfOlddling the tahle
Paticnt \Urns shoulders and torso as far as possihle while
avoiding trunk lkxioll or cXlCnsion (l11ay lise Slid.; 11('~
hind back 10 hdp \'isllali~c asymmetry)

If asymllletry of trunk rotation is present

If less Ihan 9ft' of trunk rotation is possible

II

Qlf(llltUic'{lrhJlI

Possihle ill st"l1dill~ position \vith tfunk Ocxcd as tiL"

scribed in A,M.A. Guic.1l::lines~~

QlIal UiCllliOJI
Pasvfail
(:::'.Fail if less tll'lll 90 of (ruJl_~ rotation is possihk
If asymmetry is prcsc,li
... -,._, -.-..-~
PlII'I1('Sl'

Pku.::c one sensor aL!:.L and the olher on the {)('..:ipUI (or
strap to head with" Velcro slntp)
Patient sits creel
Patient i'i requested to flex neck maximally and ;lIlglc is
recorded
Patient is requested to extend neck m,lximally and angle
is recorded

Il

IAI/enl! Flexio/l (Fig, 5.7)

Patient and scn~t1r po~ition :->.II1lC as'ncxionfcX1L'IlS1t1!l

Patient i~ instructeJ to side-bend nmximally to the IdI
and right: angles arc recorded

1
I

Rotatioll (Fig. 5.R)

0'"fn A.M.A. tests. paticnLis_-supilll;;

g~'!Vily_ indin~lIllL'h:r

i~~15!-=.d~

Fig. 5.4. Thoracic lIexionfextension.

P..l1iCIll TOWles hl.:'ad flllly and angle is rccordl.:'d

t,
'd

~--------------------------,~i

"

To itlcntify if ,Isylmnctrk tfUllk rot:Ltioll lllol1ilily is

presellt. indicating probable thontcolumbar joint dys~
function
een-leal Spine Rauge of /\!o!iou ~V,!.f,.\
F!ex;oIlIExJ('II.\ir", (Fig. 5.6)

Note

,,.

111;\:\-

if1lally. the new an~k is n:cordcd

SCIl:,orS an.:: zeroed :!gain after patient r::lt1rns to upri~h:
poswrc <lnd p:lIicnt is asked to extend maxim.lIly and
final angle is recorded

.......

""AP i ER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

79

I.atcr:ll Ikx ion 45'

Rotatioll ~S'

Fig. 5.5. Trunk rotation.

Quail/ /fica! it)1/

Final angles me rcconkd

Norll1:d

\'altlc~"~

Fkxioll 51l"
Extension 7(1"'
Fig. 5.6. Cer.ical fJexion/eXlen$ion.

---_ ...__._-_.-...

uv
REHAt;llIIAi ION OF THE SPINE: A PRACTITIONER'S M .., \NU ..\ L
~-----------==---=._----_._--

Sl'lI"',>, \.. ,.I.....lh.:d 01:\ tahk :llId tlll'n pl,II.:~d (Ill prll,illl:d
d>t.d l.lId Il( II,,: fl'lIll1l'

(If

Wll11,'

h(lldill~

Ill'",.! knee toward ch.:st. dOC!llr :ll'plil,,''-

pa""'l\l' t1n:qm,,''-''tlr\..' Itllhc IC~ll'd lhigh... I\dlll\.: ;11l~k i,

I\l't'i',l...:d
\\,jlh i~li~h p;l .... i\ll~ l'~ll'1Hkd,

Ihi::h
di ... t.d

,\!ld IlIl'1\ h'l'tlll! klll'l'

,'lid

or libi:t

r':'.t'l'o int:lilltlllll..'I,r till

.. ,Ihtll' 1111

"ll~k h~ pl:Kill~

Fig. 5.7, Cervical laleral flexion,

')
SUPINE

flip Flexor (PSOfiS [Fig. 5.9j,Recllts FemQris lFiA. 5.101>

Flexibilit), Test .,I1.H.-I~_"I_"7.(,CJ.(..."",

>,)

ModUi<'c/

,"

71101110...

Tc,\"!

table is r~qtlircd for accurate 11l~<lSUrCJllClll

tahle ~lIld brings knee 10 che ... ,
linnl)' to natl~11 low back
DOL:lor helps p;UiCllt ilS'-llllH..' supine position
Allow tcst~d kg. to cxtcnu orf table
A

IJ

firm

P~ltic01 sils at edge of

Fig. 5,6, Cervical rotalion,

CHAPTER 5: OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

81

Norll1 .. t1,II, II,"

Hip cXh:n,iOll - lO e
Knct' lk.\i.ioll Y()'"

,
Identify
Identify

/,\

pSO;I'- ... horlcnillg

rlTIU, fcmori~

shnrlL'lling {lltlrln:d i:-

till

kill'\.'

lkxinnl

,,

If hip llcxcs without klll'L' extensioll

i 0
!
!: 0
I," ()
!

I, n
"

lhi~h ahdlll.:lipll

If hip Hexes wilh kllL"c cXh:nsiull (reCIll-> femoris)

Ir hip flext . . with thigh ahthlt:lioll (TFL I
No(('

\Vang ct al~~ (est th..: p:,oas hy ~xll.'I1(.Iing thL' hip \\"lJih.. kL'l'pill g
the knec cXlcmled. They lllcasurc the 1\':C!U:, fCllloris hy e'xlending the hip with the knl,.'l,.' bent al a 90' angle. For hOlh
tests, they pl,lce Ihe inclinollll.'tL'r jll~t supcril1r 10 the p;lldlaL'.
Straiglrt l.eg Rai.'(;' (flam.\"i,-iIlJ,: Flexibility J 'Fe..:t
(Fig. 5,11 )JJ.J~.~I.~J.;<II.t.1I.M.r.r,

I, 0
i~

! iJ

Iq

Fig. 5.9. Hip extension and psoas.

I Ci
'<""';>'

;~

1.11"

(psoas)

Patient lies supine on a linn tahle: Sl.'ll:'>llr is pl<lccd mid

tibia ,lIld zeroed (or strapPl'd to lower h:~ with Veknll
Patient's calf is placed ill (rook of doctllr'~ elbow
Doctor holds inclinol'llL'ICr in placl.' \\'illl one hand
while opposite hand st;,hilizcs oppl':,iIC pelvis IiI'
Jhol1la~: lest is p~siti\'L'. pla~p'il1o~_t~~_~~ OPPOSilC
knccl
P,lticllt's leg is flexed \\'ithout flermitlinf any knee flexion (0 occur
Angle is recorded whl..'l1 pelvic

rockill~ j,

apparent

QU(/l/lIjicm i{ J!I

Record angle of hip llcxiol\

Normal is 70 to 900J':."!.<"
FlI!'f)().\'('

Establish hamstring nl,.'xibility

Fig. 5.10. Reclus femoris.

Q/({llrtijic(tl;(1/,

,',
'ii

(J

I {)
]1

':'".'

1;-

(~

i 'J"
J

:"

,,

Hip ;Illgk is recorded <lflcr passive overpressure into hip

extension
Knee angle is recorded with addition of p<lssi\'c overpressure into knee flexion
Add hip i.mglc to knl:l' angle 10 obl'lin rectus fClllori~
Illcasun;lllcn{

Fig. 5.11. Straight leg raise and hamstring.

REt'U;,~illlAl ION

OF - ... :: SfJIN!:.: A PRACTITIONEH"S MANUAL

PRONE

Knee Flexio/l (}{ladrin'/ls) Flexibility (Nach/a,\ Tcsf)

(Fig.5.12)-I55li
Patient i:-. 11]"(111':

\111

lahk

Doctor pla('l'~ ~\.'l1~or on mid"l1in and .l-I.'n}l'~ 1\ I ~tl!LT

nate position i..; Pil ankrior "hill ;lftcl' hl'ill~ II.'i"<'l'd 1(1
bottom of whk Dr dcsk)
Patient's Klll..'l' i.. passin.:ly lk\l'd
Angle is I1\C;l"url.'d at poinl .ill..,! herm\..' lumbar '1111ll' hl.'
gins to extend ur hip r;\iscs up
Quail! ijicafioll

Angle of knee lkxioll is recorded

Normal is 140 to 150"'~

Purpose
Measure flexibility of quadricl'ps lllusCleS
flip Rotation Range of AJ()(i()fI~I. I~',f,I, (Figs. .5.IJ and

5.14)
Patient lies prone with IHllltl''-.tcd kg in
and tested leg at ry' abduction
Doctor firmly stabilizes pelvis

~()

abduL'liull

Patient's knee is placed in 90';> flexion so that sok faces

the ceiling
Sensor is placed midtibia (laterally for measuring external rotation and medially for internal rotation) and zeroed
Doctor passively internally/externally rotates kg until
opposite pelvis starts to move
Angle is recorded

Quantification
Angle of hip internal/external rotation is measured
Nonnal~I,.Ol

38 to 4Y' internal rotation

35 to 45" external rotation

Purpose
To quantify hip internal/external rotation mobilit~
Fig. 5.13. Hip internal rotation.

Note

Fig. 5.12. Quadriceps.

A.I'v1.A. guidelincs test hip rotation whik patient i~

supinc. with kn;::e extell~ion and no pelvic stabilization"l
May also be tC"lcd with patient scated~(,",q
Supine test with hip and knee at 90" may be used to estimate mobility. Also allows for testing of hip capsule
integrity (capwlar dysfunction manifests with pain in
internal rotation in this posilion)
Gastrocnemius Flexibility Test-1-1,-1~ (Fig. 5.15)
Paticnt is supine \vith feet olT edge of tabk
Sensor is zc!"o-.::d io vC'l"lical planc and lhl'n placed {)11
sok (11" !"pol

VI IM"- I

en

:J : UU II...oUMt:."

Foot is maximally dorsincxcJ. 11~;lking. :~i.lfC ~;,~ Pl::~ ~:::

hcel fully (knl'l' is kcpt in eXlension)

Angle

!,

i~ Illea:-illfetl

~'lay a!:-ill hl'

QUi.lnliry gaslrncl1cmius flexibility

I!
I,

I
I

Oil

011

Angle or dorsilkxiOIl is n.x:onkd

Normal is 25 to 30"

~
I

pmllc

QfltlUfijinl1 it"l

'I

(\1'

Palil..'nl is prone wilh kilt;\,: ht.'1ll hl 90"

Sellsor is I.el'nl'u to horizontal pblll.: alld tlll'lI pl:ll"l'd
sule of ('oot
FooL is lllaxil\l;dly dmsilkxL'd. Ill<l"il1~ ~1I1\: III pull
IlI.:d rully (klll'l' is kepi at l)()( )
Angle is IllL'a:-.urcd

Qfu,t/riJkClt;t",

,I
l

ll' .. h.:tl Wiih patll'IH "l;llldill~

Soleus Flexibility "['cst H.J~ (Fig. 3.1 (1)

Angle of dorsilkxion is recorded

~orl1lal is IOlt\ 15 . 1

83

A::i::it:.::;::;Mt:.N I IN THE SMALL PRIVATE PRACTICE

II

Purpo,\'t.'
'"'~'"
<....J

Quantify soleus nexibilily

Notc
i~"

May also bc lcs[cd with paliclH 'tanding

-~.J

!I

Qualifiablc Functional Tcsts

STANDING

One Leg Standing Te.~t~~(II.t." (Fig. 5.11)

P,aticl1t stands on Oll~ root with eyes opl'n
Foot on raised leg is .al knct.: Ie\TI
Arms arc relaxed al the side
Patient n~5_galc on a point on wall
P"ticl1t lhcn closes eyes and ;,Hlcmpts t\) m:tinlain hal-

am::c for 10 seconds

QIUlfitijiC:lIIiOll

Record seconds until patient

lo~cs

hal;\Ill'('

Reaches out for stahility

Touches foot 10 floor
Slides supporling foot
With forcl: rlatforl1l~"
Pwpo.'iC

.....0 entify need for proprioscnsory rc-education

........--Scrccning test for gluteus medius weakn\.'ss
Stand to Kneel (Lunge Coordillation) Test (Fig. 5.t8)
Paticnt st:lnds with fect abOll! ~houldcr width apart
Patient is instruclcd to perform a lunge Itl kneeling position
One foot steps forward with knee lkxinf. to <,)C)o and
back knee just touches nom
Back should remain straight wilh ,Iflns a! Ihe side
Qua1ltificatioll
NOlle. except wilh Chattanooga lumhar 1I1t1tion 11l0niIOf
Fig. 5.14. Hip external rotation.

__..~

:-':.:'-,,'_.'_"_.-_'-_.'_'_'_"_'-=~:-":,,:~_.'.::.:'_.' :.:'":..:0:-'_.'_...:.:":.:,_.n.::.:c:.:n:-n:.:::v:.:,.:,:-,:.:,v~,,:.:~:.:n v:.:.::":-'M.::.:":.:U::M.::L

Fig. 5.15. Gastrocnemius.

QI(ll / ification

Patient should do a deep knee bend with their back

straight to about 90"' of knee llcxion

Pass/fail

Positive tcst if patient flexes trunk while performing tcst

Also note:
Balance of forward fOOl
Strength of quadriceps

QWl!lrijica tlon 71

Record number of repetitions patient can fX.'rform

Alaranta ct al has published normative dm,llxlsc for different ages and genders. ~ I

Mobility of hip joint and flexibility of hip flexor" of

back leg

Quolijicwioll
Purpose

Pass/fail

Positive test if patient flexed their trunk or ..:annot reach

90'''> knee flexion

Qualifiable tcst for balance, coordinmion. hip extension

mobility, and quadriceps strength

Squat Strength/Coordination Test Mt 71 (Fig. 5.19)

Patient stands with fcel about shoulder width apan and
is instructed to perform a squat

No!e

If heels raise off floor (sokus tightness)

I
I

I
,

!'lIr.!'! ":'
()U;tlili;thk l~~t fllr h:l!:IlIL"\'. ,,','rdin;tlilili. ;L!.!dn..: ql'"
'IrlI\~lh. :'(Ik'Il'"

IkxihililY

SEATED
.~

.J

l'a"/bil

S !loll!dcr .'\ htlll('riIJII Coordiuotio/l "/('Sl ~ I.'," \ Fi g. :'. ~111

Palil.,.'lll i, "l';l\...-d willi I..-'Ibm\ lh"l'd 1090 11' 1111lil llll-

1\I,ili\\' 11."1 if 'clpubr \.'k\;liil>1l or ftilalilill 11;lll'r:lllyt

PIXllr... 111 lir,! .~(l !ll (lO"

W;Lllh.:d f\1\;llillll

P"lil-'lll

i", iU"lnh:h:d In

:-J{l\\"I~ :,hdlH,,:t :trll1

hh:lllify 1\1,,,,

llf

normal glcrll1hullh:r,d rhythm <lllriblll-

;I!lk III \I\\'!"acliviIY or lIPP\.r trilpl.:/.iu:- andlor k\':l1Or

"\..';lpU\;1I': 111\1 ... d~"

Fig. 5.16. Soleus.

 "., ....... I , ..... ,~L..,l .... ''''MI'lVhL.

QIIlUltijin'titm
NOlle
Quu/Uicarioll

'-"

Cir'lde I "hie to p;.rforlll A. B. and C

Grade II able to rL"rfOnll A ,l11d B
Grade III abk 10 p..:rfOrill nnly A
Gr'ltk IV unahlt.' iO perform A. B. or C

!
I

Purpose

Evnlu..ltc lumbopt.'hic coordill~ltion and control

Lower abdomin<tl strength test

I
f;

I
I
$

II
I~

~ --f~--~~!~~~~ -~~~ -.~~~

II
~

.~

)
.i
~

I
i
v

Ii
x

.1
~

Fig. 5.17. q4leg balance test.

..,'

iI

~~.~~~

SUPINE

'

Peb'ic Tilt (Supine '/look LyillJ:) (Figs. 5.21 and 5.22)

Palicm is supine with kn~("s bellt
I)(lt:ter plact.:s hand under lumbar Spill~ ,1111.1 instrut:ts patit.:nt to lirst arch. then llallen low back without r;lising
bUllocks off the lable (A)
Doc~or l1l:.ty cue movement ur offer counter resistancc
to facilitatc coordination
P.llicnt then asked 10 hold had l1:.lt (posterior pelvic tilt)
while sliding legs to c:Hcnt!cd position (8)\7
Pa\ielll then asked to mise bUlh legs while holding hack
1l;1l <kgs s!l(ii.lld he hl'lcl for 2 to 3 st:collds) (C)

Fig.

~,.18.

Lunge lest.

CHAPTER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

87

(]tutt/ ti li(( I t i (11/

Alaranta lh:tcnnined a normative l1awbase for both genders and most age groups," Test is performed holding
duwn both feet _md recording llumber of repctilions
ulIlil f:lilurc.

QU(1I (tina ;(111

I
I;

Pass/f;\il
F;.til if unable [0 perform 10 repetitions without h~~b or
)umh;\r spine rising off t'lble

~)

Pilr/u}se

QU;'lI1tify rcctus 'lbdominus slrength/cndurancc and coordination

f)

i 0

Head/Neck Flexioll Strength/Coordination Test Jl:rA.7:

(Fig, 5,24)
Patient is supine and is instructed to bring chin to ctH~st

~"
~,

Back of head should be only I to 2 em off of table

Overpressure may be added at end point

1)

()

Note

<)

If chin juts forward during movement

I
II

If shaking occurs during movement

If chin jutting. or shaking occurs with ovcrpr6:,urc

'y

added

Ii
f,

jJ

Qualllijicmion'll,n

!
~

,0

Strain gauge mny be used'::

Record time p.uicnt can hold a position wilh head I em
off the table and maintaining constant force of the h~ad
into a pressure eufrll

()
~')

Fig. 5.19. Squat test.

Q lUll ijj("(ll io"

Pass/fail

()

Trunk Flexiun Coordinlltio/l (II/(/ Strength JI,f,ll.(,!(,I"',lI

(Fig, 5,23)
P;.lticnt is supine with knees bent. arms forward, across
chest or behind neck (without pulling)
DoclOr may cont_l<:1 palicrIl's hcels or pl<IlC hand under

I
.~

~~: ','

II

the palicms lumbar spine

Paticl\l is instructed 10 perform posterior pdvic tilt and
to raise trunk. up until scapulae ;.Jre off table and thCll
hold for 2 seconcJs
Paticlll shoulcJ hold pelvic lilt while lo\\:cring back lO
(<tble
Patient is asked to pcrform 10 repctitions
Last repetition is held for 30 seconds

'"

()
"j

i fJ

.~

.~

';j

I ::J
~

.,<

To identify if nel:k nc,'(or weakness or incoordin:llil..'l1

If hecls rise orf tablc (posilive test)

If Cimnnt maintain pelvic tilt (positive ICSt)
If excessivc shaking m:curs
If IK';1l1 i~ fonvaHlllt' trunk

Cl

i~

present

In particular. to identify if deep neck flexors art' weak

;'lIld sternocleidomastoid (SCM) muscle is overa('lj"c

Ste,.,wcleidomastoid Strength Test (Fig. 5.25)

Patient is supine and is asked to wHite head to one side

Then to raise head lip while mainwining rotatif1n and

Note

II 0
~i'i

Purpose

hold for 2 to 3 seconds

~ (J

"'t

Fail if chin juts forw;.srd during mo\'cmcnt

Fail if cannot hold head just I to :2 elll ofT of tai,"lk but
wiscs up further

NON!

If can reach full rotation

If cannot maiI1lain rotation \vhih: lifting head
if t.:;lOnot lift Ih.';I{!

' n... ' , ....... , .. , ' ..... , 'V'''( VI""

I Me ~t"INt:: A

PRACTITIONER'S MANUAL

'")

.,,

-,.'

Fig. 5.20. Shoulder abduction test. Correct

(A and S, and

incorrect (C).

Qualltijintfioll

None

To idcntify wcakn.:-ss of SCt\'1 Illtlscks

Respiration Coordination Test ~l (Fig. 5.26)

Supine patient is asked to take in a deep brc~lth

QlUlJjJicmion

Pass/fail
Fail if cannot lift head or rnaiIHain head rotation
Grading
I-Normal
I1~Hcad

i.. lifted. but without full rotation or il canl10t

be mainwincd for 3 seconds

III~Hcad cannol

be lifted

)
Note
Doctor ob"ervcs for excessive chcSI breathing
Also n(Jh~') hHeral chest excursion
Note jf ~c:alel1c muscles arc visibly ~\l,:tivc durillf rt'spi
r;ltion

. . . . "1\,.... I tH

~ : UU Il,;UMES

ASSESSMENT IN THE SMALL PRIVATE PRACTICE

89

Gmcemric Tc.'i(

NOlll'

(jlluIUi('(u;()/l
Pa~~/f;lil

Fail

irdl~~t r;li . . c~

more [h;lll abdomen

1'111"/10.\'1'

'I'll idcntify
bn:;tthing

prc~t:ncc

of paradoxic breathing (chest

diaphragm)

predomillatc~ (I\'cr

SIDE LYING

(lOll

Hip t1bduc(ilm (Gluteus Medius, TFI.., QL) CoordillaTest ~l,(.(, (Fig. 5.27)
Patiem side lying with lower knee nexcd and upper leg
extcnded
Pelvis placed in slightly umucked position

B
Fig. 5.21. Pelvic tilt (hook lying). Posterior (A) and anterior (B).

Upper leg is raised into abduction and held for

2 seconds
Note
If patient can raise leg
:.. Shaking or twisting
.~......A~lX hin..flcxion or hip external rotation
Excessivc hip hiking
Posterior rotation of upper ilium
Quantification
Only with dynamic electromyography
Qualification
Posslfoil
Fail if cannot abduct leg without hip flexion. if foot
mises less lhon 6 inches. if hip externally rolates.
pelvis rotates. or hip hiking occurs

Isometric Te.'il
Pre-position leg in abduction without flexion and ask
pOlienl 10 hold leg for 5 seconds
NOle
If shaking occurs
Hip flexion, external rotation. pelvic rotation. or
hip hiking (positive les!)
Quantification
None
Qualification
Passlfoil
Purpose
To identify coor~ination of hip abduction
To identify tightncssJovcractivity of quadratus lurnborum (I;ip hiking)Cfe-D~9r fascia latae..an~L_p_~O~l~
(hip flexion and external rotationj~ thigh adducwfS
~Iimitcd abduclion range). and pii-1fonnis (extemal
rotation)
To idenlify poor hip join( mobility (decreased cxtension)
To identify weakness of gluteus medius

j
Fig. 5,22. Double leg raise with posterior pelvic tilt. Correct (A) and incorrect (B).

.. ~

REHABILITATION OF THE SPINE: A PRACTITIONERS MANUAL

Note
If patient (all raise trunk
If patit'nt twists b;l\:b\;mJ (recruiting. obliqul.': ahdollli-

nills )
Sh"lkin,::
QuaIlIUh'(/[/II/i

I;

NOJ1t.'

>

I!

."i

!i

Fig. 5.23. Trunk flexion tesl.

II

-"j

I
~

.";

Fig. 5.25. Sternocleidomastoid lest.

)
A

)
-,

...?

tl
,V

)
Fig. 5.24. Neck flexion lest. Correct (A) and incorrect (B).

Truuk Side Raising Strength Test6~ (Fig. 5.28)

Patient is side lying with knees bellt and upper arm fully
adduclcd while hand of lower arm rests on upper shoulder

l
,

DOt.:1Or anchors bOlh feel

P;llicnt
~lrIns

~lltcmp[S to

wise trunk ofr wblc witholll using

for assistance

Paticl1l i~ askl.:d lU hold for 10 s('('omJ!;

Fig. 5.26. Respiration lest. Correct (A) and incorrect (B).

CHAPTER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

II

91

Ii

Fig. 5.27. Hip abduction test. Correct (A) and incorrect (B).

B
Fig. 5.:8. Trunk side raising test.

Qual Uica ri Oil

Pass/fail
Purpose
To id('lllify ~trcnglhf:.aabilily of trunk side bending JIlUSek:,- (qu~ldr;ttus lumboflllll)
PRONE

Hip Extension Coordin(lt;(}IlIStrellgth~1(Fig. 5.29)

Patient prone
Patient attempts to raisc Icg into cxtension with knee
held in extcnded position
Positive lesl ifercctor spinae musculature contracts before gluteus maximus
,:.) Doctor should observe activation sequence of (I} harn~
~rings <Inti gluteus rnaximus (2) contralateral lumbar
cn:clor spiOjlc <mel 0) ipsilawral crc.etor_~pinac
Palpation lIsed only [0 confirm rcsuhs

r.

(A) and incorrect (8).

Qlwntijicalio/l

\Vith dynamic ck<':lromyography

Ql/{/lificaliol/
Pass/fail
Fail if erector spina~ comracls before gluleal max.imu:,
Record activation sequence Of liring order of gluh:al
maxil1lll."'. hamstrings. lumbar erector spinae. thora
columbar crcctuf spinae (ipsilateral ~\1H.l contralatcr:ll)
Note if contralah:ral shoulder/neck Illusculature contr~lC(s
Purpm;('

idcntify incoordination of hip ~x[el1sion

determine if gluteal rnaximus is weak or inhibited
determine if l.'rL'ClO( spinae is oYL'rac!ivc
detcrmine if hamstring is ovcral,.'livc
To dctermine if hip joilll h.IS rcd\1l't.~d extension l11ohil~
ily or if psoas is :,hnncncd

To
To
To
To

Ht:HA~ILIIAIIUN

,
Trullk Extension Strength Test .. .M11l (Fig. 5.30)
Patient is piOne with hands bt:hind head and elbows
held horizontally
Patient is instructed 10 Ii n chest off table (about 2
inches) 15 times (with 1- to 2-sccond pause) nod hold
15th repetition for 30 seconds

..

OF THE SPINE: A PRACTITIONER'S MANUAL

"

QlluliJinltiOtI
Pass/fail
Pass if p:lli~nt can perform 15 repetitions and
position lor :~() seconds

th~n

hold

Purpose
To cst~lbli:o'h baseline mcasurclllclH of trunk cxt~nsion

Note

If patient can

strengthlendur;.mcc

r~ise

trunk into extension

Shaking or twisting
If feet raise up off table

Quantification
Strain gauge tcstingl3.7~
Alaranta et al described repetltIve and isometric endurance tests. " In the fonner, patient nssumes slightly
flexed position and raises trunk to neutral position until
no more repetitions are possible. 'l A normative database
has been established. The isometric test is a predictor of
recurrences..!1 Alaranta ct 31 reported both reliability and
a nonnative database for this timed endurance test.

OTHER TESTS
Simple tests that identify whether a certain movement provokes symptoms have been found useful c1inicnlly. Morc :ltlvnnccd upproachcs have proven valuable for cstablishil1~
trunk flexor/extensor nllios. lifting capacity, neck tkxor
strength and cndur<1nce, mld cardiovi.1scular litncss.
Provocative Testing
Movements that provoke. relieve, or are staWs quo with respect to presenting symptoms represent .1 reliable WilY to tcst
paticnts.15 These tests have been used clinically to classify patients into different treatment groups.,n This cvidence \"~lli
dates the McKenzie system of prescribing exercises based on
the response of pain to various loading strategies (sec Chapler
12). The specific tests adjudicated nre discusscd in Chapter
18. Being able to provoke pain with active trunk movem~nts
in more than one direction has been found to be a predictor of
chronicity."
Strain Gauge Testing of 1hmk Flc.xionlF..'1cnsion Strength
A simple. low-cost protocol exists for quantifiably measuring
isometric trunk flexion and extension strength. A ratio of

1.3: 1.0 extension: flexion is normal for this

lhough reliabilily is questionable.

-'\

.,
f

tcst.'U-.l.~~ ~11

Lifting
STRAIN GAUGE TESTING OF ISOMETRIC LIFTING STRENGTH

Fig. 5.29. Hip extension lest

A simple. low-cost protocol following the NIOSH guidelines

exists for quantifiably measuring lifting strength.5~

B
Fig. 5.30. Trunk extension lest. Correct (A) and incorrect (8).

'-=

-~

CHAPTER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

ISOTONIC TESTING OF LIFTING STRENGTH

Mayer and coworkers developed the P.LL.E.

(cst.~)

and

Matheson developed the E.P.I.C. test (sec Chapter 8), both of

which arc low-cost, quantifiable methods. They orrer standardized protocols with nomlativc dalabasc.~ established.
Neck Flexor StrengthlEndurancc .

,j ")

Ij

f)

I ()
J.

could differentiate headache from nonhcadachc sufferers.1!

Trcleaven and colleagues described the same distinguishing
features of poslconcussional headache patients. Xl Trcleaven
and co-workers showed that observation of supine. neck flexion. as just discussed. was as reliable as thc strain gauge for
identifying neck flexor weakness.
Cardiovascular Fitness

.~

I 0
0
IJ

II

Watson and Trott found that decreased isometric strength and

endurance of neck flexors along with a forward head posture

C}

,!, 0
li

'"}

II

\;",
~.

Simple protocols exist for measuring aerobic capacity using

treadmills, bicycles. and other ergometric instruments. sa.1I1
High Technology Tests
High technologic quantification of functional deficits can cost
from S10.000 10 Sloo.ooo. Usc of equipment from Dynatron
ics. Lido. Cybex, MedX. etc. can isolate specific movcments
and results arc highly -!'I.:pl.:at:!b!~ and reliablc. Costs makc
these units prohibitive for most small private practitioners.
Elcctromyographic units arc also cost prohibitive for the average field practitioner. although in medicolegal practices or re~
search settings. such equipment can be beneficial.

"

II

.~

0
0

,~
~

.)

0
",)

,J.
ii

ti

{)
(~

u
~

* ()

I ()

I
<

J.

t:~':l

Of;

,~

Work Capacity Evaluation

It is the duty of the occupational physician to rate impairment.

determine functional limitations, and establish the patient'S
work capacity.8~.8) Translating functional capacity into work
capacity has been a great challenge. Fishbain et al outlined the
reasons for this difficulty: (I) normal values for functional capacity arc needed for the individual (for age and sex and type
of worker): (2) many functional capacities arc diflicult to
translate into job skills or trailS (i.e., isokinctic abdominal
strength): and (3) it is hard to translme functional capacity
inlo a "demand minimum functional capacity" for a specific
job or job category.~\14
To correlate functional c:'lpacity with work cap<.lcity, the
Dictionary of Occupation:'ll Tille (DOT) may bc used as the
standard of physical demands of a specific job or job factor.K~.K~.K(. Twenty job factors detailed: standing, balancing
walking, sitting, carrying, climbing. squatting, lifting, kneeling, stooping, crouching, crawling, reaching, handling, fingering, feeling. pushing. pulling, talking, seeing. and hearing.
A sl:'Hldard WCE delineates a worker's readiness to return to
work based on their ability to perform job factors. lll
The DOT lists the job factors lhat arc important for most
jobs in the United Statc~s.s~.Il(. According to Fishbain et ai, "the

93

DOT thus, has defined the demand minimum functional ca~acity of most jobs in the U.S."l\\ Jobs arc funha categoriz.ed
as scdcntaI)', light, mediuIll, heavy. or very heavy according
to Ihe maximum weight lifted during lifting or ci.lrrying.I'~Il(
Unfortunately, strength factors have not been defined for any
other job factors. An additional problem with WCE is thm a
one-time test docs not reflect an indiviclu'll's ability to perform a task O\'l:'r the course of an 8hour day.s,1
These problems aside, tiS many job factors us possible
should be included in the FCE. Silting tolcrancc can be
tracked as an outcome. \Valking can be evaluated for pain
provocation (sensitivity) and ex.amined qualitativcly. Lining
can be evaluated as described by Matheson (sec Chapter 8).
Squatting can be assessed using Alaranta's lcst or ns shown in
this chaptcr." Standing can be evaluated for pain provocation
and qualitativcly with postural analysis (sec Chapter 6).
Stooping can be assessed with trunk flexion range of motion
tests and by pain provocation (see Chapter 12). Balancing can
be ~valuatcd quantitatively with the one-leg standing test.(,<}
Kneeling Ciln be assessed with the lunge test. and rC2ching
with the shoulder abduction test. Carrying can be ex.amined
with specific protocols.8S.S9 Pushing. pulling, and other job
factors can be evaluated as well.u.s<}
During functional testing and exercise training. it is im
portant to evaluate an individual's performance potential for
activities of daily living (AOL). athletic activities. and demands of employment. Many of the lraits just described
should be objects of rehabilitation that can guide the functional training of patients. An individual who can sit. stand,
balance, walk, squat, climb. carry, reach, grasp. kneel. etc,
with minimum discomfort and adequate strength, endurance.
nexibility. and coordination is an individual who is not im
paired. He or she therefore has little or no limitation in ADL
or work capacity. Functional restoration should strive to promote the development of these functional traits as the final
goal of a successful rehabilitation program.
CONCLUSI07>
Functional restoration addresses the deconditioning syndrome. It docs not require expensive testing or training equipment. Small practitioners in private practice C'lI1 begin to tr.lin
patients with customized exercises progr:.lms lIsing simple
equipment. Measurable functional outcomes are of growing
importance both for patient motivation and reimbur.;cment.
Directing the focus of"thc patient toward functional outcomes
rather than pain relief is essential to this process. This approach is appropriatc in the subacute phase of care as well as
with patients with rccurrent or chronic pain.
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~9...:4

FUll~'lhlll:III\:"lur;\linn \\ nil

.r~.

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5.

1
1
i

...:R~E::.H:.::-:A::B::.IL::IT:.:A.:;T.:;IO=N...:O:::F~T:.:H-=E~SOINE; A PRACTITIONERS MANUAL

\\:t,lddl I;: .-\ 11\."\\ dUll,.: 1:10 ...1.'1 !tlr Ih~' tf,:llllkllI ,II h.\\ .j-.".I. paill.
Spill" I: t'.~.l. IIlS7,
II'Hl DI.. 1,.... mhagl1l SJ. '\L:h..Ptl L:\: (juiddlll~" lor fUI1,1:"Il.,] ,':IP:Il'ity l'\ :,!LI.IIIIIII "t" P':"I'!.' ,,:::, lIl\'lli~';\1 lll1ldili'Ill'. J Orlh"r SP"II' I'ily'
nll'r IS I'S~. JlN:>.
.q_ ;\lil\'hdl 1{1. C;lrUl"nl;~l J..i~'llih f ,I Illullk.ll!." In;cllhlll:-' .Ill \1l,,'n
,i\,' .1,11\,: .... \~Ili"l. 1'11';.:1 .. ';: :",'r Ibl' lll':lllll~'lll ,.1 :Il'U'" .. '11 ,l"n,' aud
b,,\'I, Inlur,,:~, Spill" 15:::'1,~. l'"lI1
.':' ...\ndlI~"'I\ GB.I. I'I'p': .\Ill. h~:llnY"r J\\": EP1dl:llliplll,-~:- 11: l\,p" .\IIL
hyllh':l'r )\\'. And,'I,,"I: (; ,,',hl: (J..'n11';lli"ll:d I.n\\ 1I,I,k 1'.:1:1. \,,w
'llrl... Pr.\.:~"r. 19Sl. pp 11';-II.t.
.'11. Fr~lIl\':,r JW: Ejlid,ll\h,i,,;:-. hI Fr:lllu:o:r j\\" Gnrd"H SI. ll'd,):
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.~YIllPhlll\' ;ll1d ah!i"Ilt:l IrPIll ,\url.. Spilll' IS:5S7. ItJ9.'.
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..:xl'ilalilln in suhj.. . ClS wilh 1"\1 h;ll'k pain. Spilll' li:1211J. I<I<J~
.11, L"wil K: ~bniplllati\'1,' Ttl . . r.:py in Rdl:I1'i1ilalit11l (l[" lh..: \11'h11" ~Y'I""ll1.
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;lIld \alidity. J M:mipul;sli'c Phy"iol1l1l,'r 15:343. 1992.
:'0. Ct..."idy JO. Lopc.:s :\A. Yvn::Uing K: Tlt\ inllllcdi:lt.... dk.. l "f lll:llllpU
lalion \"l:rw... llltlhili/,;:lion IOn pain ,lllli r:IIl';;~ of motiol\ in ll,, 'l'nl,';ll
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15:570.1992.
:'1. Toppenhcrg R1\1, Bullod-. ~II: Th.... inll.'rrdalion of .~pitl:11 <"111"\. ..... I'l'I\'il.'
lilt anu !l\u'cllo.' lengths inlhl.' :Jdn!c.Wl,'nl kl1\:Lk. A\I... I J Ph:-'ll'lhl'r .~~:6.
1t)~6.
5~.

Knill. S: :..:iIOSH lifling ;:uid::lille..... Am Ind Hy~ .'\"u~:.1 ..l_~.,l.: I. I'J~~.

5 .. , :-.-I:tycr T. Barnes U. Ki:-Iuno .". 1.'\ al: I'r\':;f,."i\e i,uin.. . rti.l! htllll:: ,'\ :11ualiorl. I. A st:llltl;lrtli/.cd rrtlil ....lll a11l1 1I\'rm;lli\'I.' datal1a.'l'. ~!,llll' 1.~:'J9.'.
19H5.
5.t. Guide<" 10 the E\;llu:llion III i'o:rm:lIll,'nl !ll1p:lirllll1I1. :>rd E,:. Chlla:;ll.
American ~kdic;tl Assodo:llfm, 1l)~K
55. N.Ulscl D. Jans..:n R. CrCfIlo:la E. 1.'1 :II; Elk~ts of l..'erviL,,1 :IJ.llhlll\lllb un
lateral-flexion pa...si\"c cnd.r~lllge asyrlllllt:tr)' and un hllll,ld l'r..'~~llfl. h....arl
rate and plasma cateehol<llninc lewis. J Manipulali\"I.' Ph:~i,,1 Th.... r
14:450.1991.
56. Ellison JB. Ro....... S.I, S:lhnn,mn SA: Pall":fll.~ rotation ran;: .. "f Ilwliol\:
A comparisoll between hc::1thy xuhjel'ts :Illd palicn .... Willi 1,'\\ 1-.1,1.. pain.
f>hys 'Oler 70:SJ7. 199U.
57. Reid DC. Bumhalll RS. S;JhllC LA. cl ;11: Luwcr eXlrelllil~ Ik\lI'i1il: 11;11terns in c1:l..."i....:,1 h:lllci d:ltlcef\, :lt1d lhl'ir ....nrrel:lliun It.' 1.It.f.ll hil' :lml
knec injuries~ Alii J Spc)n, .\ktl 15: ....17. 1t)~7.

or

f)

.'.k'>.

..J

,)
..
'-

CHAPTER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

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58. B;SIr:lnd J. Gillquisl J: The (r.:quenc)' of mu~l(' ligll1ncss ,lOll iiljuri~'s in

socc..:r 1l1;1~crs. Am 1 Sj'I('"S ~kd 10:75. 19$2.
59. Inamur.t K: Rc'lsscssmcnl of Ihe Illclhod of an:dysis of ch,.'(;(cogmviw
I;.r::Iph and Ihe one fool les!. Aggn:ssologic 24: 107. 1983.
60. Nelson RM: NIOSH Low Back AlIa... of SlandJrilcd Tcslsll1lo:asun:s.
U.S. IXpanmcnt of Health ;md HUlllan Ser\'ices. Nationnl Ins[i[Uh: for
(kcup:lIional Safe I)' :llld H...allh, December 19$8.
61. Hir.Is..J\\'J Y: l...efl fOUl to suppon hum;l1l stand in:; and \\'alking. Sci :\m
(Japan) 6:~~. 19S;1.
62. M;lycr T. thad)' S. Ihw:lSMI E. CI ..I: Nunillvasi\'c ntcasurcmcnl of ccrdc:lllri-pbnar llIUliull in nomla) suhj\.'Cls. Srin.: IS::!191. 1994.
63. Youdas J, CLre)' J. Garrel T: Rc:liahilil)' t,f me3.!'ourcmcnts of cervil:al
spinc range l)f mOlioll-comparison of Ihree methods. Phys 11ler 71 :98.
1991.
64. Gajdosik RL. Rieck MA. Sullivan DK, Cl :\1: Comparison of four c1ini
cal tests for :lssessing halllqring muscle length. JOSPT 18:614, 1993.
65. Gricc A: l.umbar cxercises for kinesiological harmony and stability.
JCCA. Del:. 1976.
66. Nelson RoM. NcslOr DE: Standardized asscssment of indu:miallowb:lck
injurks: DeveloJllllcnt of the NIOSH low-hack atlas. Top Trauma Acutc
Care RehabiI2:16. 1988.
(17. ~'hlffroid MT. Ihugh LO, Henry SM. et :II: Distinguishable groups of
llIusculoskdetal low back pain pilticnts and a.<;ymptomalic control sub
ject:. based on physical m~;'i$UrCS of the NIOSH low back alias. Spine
19:1350.1994.
61'. Riss::mcn A. A1J.r.mta H. S3.inio P, et 011: Isokinctic and non-dynamomet.
ric teSls in low back pain patients related to pain and disability index.
Spinc 19:1963, 1994.
69. Harding YR. de C Williams AC. Richardson PH_ et al: The developmcnt
of ;1 b:mcry of Illca.<;urcs for assessint; physical functioning of chronic
p;lin palienlS. Pain 58:367. 199~.
70. Trdea\'en 1. Jull G, Atkinson L: Ccrvi(':lllllu~culo;ke1ctaldysfunction in
post-concussional headache. Cephalgia 14:273. 199~.
71. Alaranta Ii. Hurri H. Hc1io\"aara M. ct :11: Non-dynamclric trunk perform:lllcc tcst~: Reliability and nonnati\'c data. Scand J Rehab Med 26:211.
1994.
n. W'ltson DH. Trott PH: Cervic;11 headache: An ill\'estigntion of natural
hC:ld po~ture and upper cervical lkxor muscle p.:rformancc. Cephalgia
13:272. 1993.
n. Tri;mo JJ. Skosth:rgh DR. Kow;alski fl.UI: The u:,c of inslrumenlation
;and Iaboralol)' ex.:uuinalion procedures hy Ihe chiropractor. Inlialdeman
S h..-d): Principles and Pr.3.clice of Chiropr:lCtic. ::!nd Ed. Norwalk. CT.
Appleton & l..lnge. 1992.

95

7-t Sill:lkl \1. (inl"'''':, N: Bad :-lfl'n;:lh..-nin;: n.l....:i,,:s: Quanlil;lli\-..- c\'<llu:Itiun .'f :h..-n dli"-.I':y r.,r \'tllll,'n ;If:...d -111'(1:\ y..';I1". Ardl Phy.. ~h:d
Kt.hahl -O:lh. 19S9.
75. Ikliull ..\. Cil111I"a MT. Erh:lrd RE. ct al: Evidclll:l: rur U.\I: uf all 1:.'l:I<:n_
sillll-m.,t'olli/;lliull C:lh.:gnry ill ;ll:lltc low had: ~ylltlrtlnh':: ;1 prcSl,:ripli\"!,:
valid;IIlI'n pilllt sHuty. I'hy.. Th..:r 7:':21(,. lIN.\.
7CJ. Erll.JrJ RoE. D.:Iiitll A. Cihulka MT: l<datiH' cffl:l'liv":llc~s "r ,Ill 1:.\len:-illll rr.,;:r.lI11 ;ulIl :1 ~tllllhirll'l.l pro~r.llll til' 'll'lIlipulaliun ami lh:x.iull amI
cXh:n~h'n ..:\\t<.:i~.,:- in pati..:nt\ wilh ;I":UI..: low had: s~mlnJlIl"', Phy\ Thcr
74:1093. Iq9~.
77. '-Icll:;.inf ..\ L. LilltHII SJ. ":'a(.,O:II1;lrk r...t: A prI1sp..:cti\'1: siudy of p:lticnl<;
with acutc o;lck ;lllllnl..:k pOlin. Phys TIl..:r 7~: 116. 1994.
78. Bcimlx1m DS. i'>1()tTi.~scy 1l1C: A review or the Iitenlturc related to trunk
muscle r..:rt"orlllallc,,:. SpillL' 1.1:655, I t.l8!\.
79. Trelca\cn.l. Jull G. Alkinsoll L: Ccrvicalilltlsl:uluskckwl dysfunction ill
po-sl-concussi(Jn:r1 h..:adachc. Ccphalgia 1.1:27\ IC)94.
80. Parker DC: A l\l':W suhmaxilll;ll trc;ll!lllill ror prcdiltillg V02
ma~: Ratiomllc mId Y~llidalion. I\nn Spnrls l\'k~l. Sllhtlliltc~t fill' puhH
cation.
81. Aslr.md PO. Rooahl K: T..:~thook of W,lrk I'.hysiulogy..\nl E\J. New
York. ~lcGraw-Hill. 19S(J.
82. Sp.:=klor S: Chronic p:lin .md p:lill.rdatcd disabilitks. J Disaoility 1:98.

1990.
33. Fishb:i.i" DA. Khalil TM. Abdcl-~'lol)'A. el al: Physici;ln limitatioll when
assessing work cap:lCity: A review. J Back MIl~culoske1ct Rchat:oil 5: 107.
1995.
84. Batistol \1E: Dis.lbility cvaluations: EXpecl:llions of insurers and payor!'.
J Dis,lbilily 1:168. 1990.
85. U.S. Department of Labor, EmploYlUent and Tr.lining Admillistr,llion:
Dictionary of OCI.'up'ltional Titles. 4th Ed.. Supplcflll:llt. Washinglon.
DC_ CS GO\'crnmcnt Printing Office. 1986.
86. U.S. Do:partmcnt of whor. Emplnymell! and Training Administration:
Selected Characlcristics of Occupations dcfin..:d in the Dictionary of
Occupation:ll Tilles. W;I.~hingtol\. DC. U.S. Go\'ermcnt Printing Office.
1981.
87. Isemhagen SJ: Phy... ic:lltherapy and ol.:eup;lIiol\;1l rehahilitation. J Oceur
Rchabil 1:71. 1991.
88. Fishbain DA. t\bJcI-Moty A. CUller R. et ;,1: t\ lIlethod ror 111":;lSIII'11Ig
residual funelional capacilY in duoni<: low back pain palil:nts l>ased on
Ihc diclionary of Ol:Cululional tilles. Spicn 19:972, 1994.
89_ Moonc~ v. ~(athssol\ LN: Objecti\'e Measure!llent of Soft Tis'::'u..: Injury:
Fca..<;ibility Sludy Examiner's Manual. Industri~ll Medic", C(\llllLil, 51"le
ofC.1iifornia, 1994.

6 Evaluation of Muscular Imbalance

VLADIMIR JANDA

I
I

I,
I

10

I
I

I
I
,AA

I
I
~

Muscle imbalance describes the situation in which some muscles b~come inhibited and wsak, while others become light.
losing their ex.te~sibililY. M.~crat.cly tight muscles arc usually..str.OllgGOh!.1.IJ.JJQDP~L although in the case of pronounced
tightness. some decrease of muscle strength occurs. This is

called "lighlncss weakness:' I The trealment of tightness is

not in strengthening. which would increase tightness and possibly resuh in morc pronounced weakness, but in stretching.
oriented toward influencing the po.nconlractile bUl retractile
connective tissue of the tnuscld-..trctching of tight muscles
also results in improved strength of inhibited ant<ig9D.iBic

mu~s, probab'iiii~ediated via t~~~~herring!.Q~~s-.I~~~:.~ e

ciprocal hmcrvatioih
The terms muscle tightness (stiffness, tautness, loss of
ncxibility) and muscle spasm should not be confused. A de
tailed differential diagnosis is necessary because each condi
tion requires a different type of treatrnent. 1 Unfortunately, a
precise and adcquate analysis is often neglectcd.
The tcndcncy for somc muscles to develop weakness or
tightness docs not occur randomly; rather, typical "muscle
imbalance paucrns" can be described. Further, the develop
ment of these pauems can be predicted clinically and. there
forc. preventative measures may be taken.
Muscle imbalance docs not rcmain limited to a certain
part of the body. but gradually involves the whole striated
muscular systcm. Because thc muscle imbalance usually precedes the nppcarance of pain syndromes, a thorough evalua
tion can help in introducing preventive measures.
Muscle imbalance develops mainly between muscles
prQ& (0 develoP..!J.g!!t'I<!~'i.c~.(f!lc;!2?s surae, hamstrings, one-joint
t'!iJ?~.~gg_~tors, r~~_s_~~rr:t0ris.' iliopsoa~, tCI."!~sH:.f~~fiae latac.
piriformis. quadratus lumborum, erectors of the spine. pee
tor~TI~nl.ajor"andminor, upper trapczius--and levator scapulae.
s"t~_f!!Q.C;.I~idoIJ.lastoidcus, short deeprneck extensors. nexo~~ of
the upper extremities) and muscles prolle to develop inlfibiti01;-(iibiaiIS-an"terlor; vasti, in particular the medialis; the entire gluteal group; abdominal muscles [the obliques, however.
are controversial): lower stabilizers ohhe scapula; deep neck
nexors {they tend to spasm, however, which is oftcn misdiagnosed]: mainly the extensors of the upper extremitics).
Although muscle imbalance involves the whole body. the
imbalance is more evident or starts to develop gradually and
predictably in thc pelvic region, whcre we speak about the

pelvic or distal crossed syndrome. <lnd the shrtlldcr girdle!

neck region. associated with a proximal or shoulder girdle
ero~sed syndrome.

(Th~, proximal cross_cd, syndrome is char<lcterized by

dcveiop~ncnt- of].~hiilc~~~in-illc-"ul;rc~ trapezius. ~tor.
and pectoralis major and. on the other hand. inhibition in the
deep neck flexors and lower stabilizers of the scapula~.
Topographically, when the inhibited and tight muscles art
connected, (hey form a cross. This pattern of muscle imbalance produces typical changes in posture and motion. In
standing, ele\,?:~l and protraction of the shoulders are .cvidcm. as well as counterclockwise roHuion and abduction of
the shoulder blades and a p'ush-forward head position. This
altered p~s"ture is likely to stress the cCTYiCocranial and the
cerviso.!!!t?racic junctions~l~;lddition. the stability of the
shoulder blades is decreased and, as a consequence. all movement patterns of the upper extremity arc ailcred.
The distal crossed syndrome is ch.lnlcterized by tightness
of the hip nexors and spinal creclQrs and inhibition and weakness of the gluteal and abdominal muscles. Again. connection
of tight and inhibited muscles form <l cross. This imbalance
results in an anterior lil~()r.thc pelvis. increased flexion of the
hips, and a comp.g.l.l.~ato.rY "t~Yp~r1()rdo:-;is. TIllSsltuatTQ'~ is' a
"prcsumption to overstress of both- i:;Ip'~ioillts as \vell as of the
lower back.
The examination of joints must pr~ccdc llluscle c\-aluation
of flli:I~"c1cs.
-----~ "". - " . .
In clinical practice. it is advisable to st~lrt by analyzing
erect standing and gait. This analysis requires ex~rience,
however. and an ob~ervation skill in p;.trticular. On the other
hand, it gives fast ~\lld reliable information that C:lI1 :,a\'c time
by indicating those tests that need to be performed in detail
and those rhat can be omitted. The observer i~ at'fordl.:d an
overall view of the paticnls muscle funclion <lnd i:, encouraged to think comprehensively about the patient's entirc
motor system and not to limit attention to the local 1C'\'cl of the
lesion.
Evaluation of nluscle imbalance in a patient with an acute
pain syndrome is unn::lia~J~~nd I1!US[ ~_~~~e~.~ken ~1i!!Jie
saution. A precise evaluation of tight muscles illld movement
patterns can be performed only if (he patient is or is. almost
painfree. Its usc is typical in the chronic phase or in p<Hicnts
with recurrent pain after the acule episode has subsidcd.
97

"---'-,---.

."~."

-,-~,

REHA81l1TATION OF

~o

,-= SPINE: A PRACTITIONER'S MANUAL

IJn'll l'O.\-/tT/t.,. ,;,. ~ lI1use/ex "::1Il h~ lested only hy thor-

U,'/)('/" rra{)(,':.ills (Fig. (\.1) i... h:"ll..'d with thl:

P;l\lt'lll

"-upille.

the head p:lssivcly tk\yd ;.tOt! illl'lillcd 10 Ihcl."lllllralatcl':t1

sid~: Fr-oin Ihi";Z-j;-u:..ilit;n. II~c- ... iullll-d~i-ill~(Ik i;-ri~;hl..~T.~~;lall y.

N(fnh~l1y. a soft b:uTil."r i... at tilL' I..'nd or tile pnsh: \\hl'll the
1ll0VCIl1('ut i:- rcstricll'd. il is hard.
L(\wo,.S("OIJll!ac lFi:::. (l,:!1 i...... ,aulillt:d in:1 silllil:lr man
lll'r. only (hL~ had is ill ;lddili\~J,~,r{.1,1_;11.\':~!I,~lq.1_l,'~.~,!n~r:ll;l!c{alside.
Peclomli.\' 11/0)0" I Fi~. (1.:\) i... \J..'stt.:d with thl' patient
supine. the ;lrIll I1U~\ctl p;'l:-.si\'dy inlo abdm:liull. The tnlltk
must be s(;Jbili".cd hcf(ITI..' the :mll i... pl'lced into ;lhdllL'tion hc
cause a possihle (\Vbl of lilt.: trunk might mimic 11k' normal
range of 1ll0VCllH:nl. Thc arm should reach the Iwril.Ontill
level. To estimate Ill!,; d,l\icul"r jJllrtion. the ilnll is alll1\\Td to
hang down loosely :1I1J the ex'lminer pushes Ihe :-.houh.kr
downward. 1 ormally. {lIlly;'1 slight soft barrier is felt.

P'\!p;ltioll. L\ .:i~:,!ii\lll or till' .\IO'lIo('/CitlOIl/c1S/oiti is 1I0l

rdi;lhk hCi:;WSl' it ~'r\'''l'S loom;lllY ~l'.:;rnellts {I;ig. (lAl.
lIil'110pl"." lilt".:, .. ,:.... lhg. 6.:'1. n'!'wsll'llloris (Fig, ()J))
;lrl' !L~lt.d with thl' ",:::..'l1t in:\ llHldilil.'d Thomas position. Till.'

\l\1:;h

prl"l"IlI,:d llIodilic:lh':1 ,11"'0 allows l'\,llnin:ltioll or till: ....hon

f'"::); addrw/ors ,lIh: ::::.' [I'llsor fiISf';" !:if{/("
Till' p:lIil'llt i... 'll;~:tll' with thc tm~(l on the plinth ,1I1d till.'
ll'"ll'd k~ h)\\sl'l~ h_::,~ill~. The 110111l>,te(l leg is 1ll:lxilllally
Ikxl,.'d to sl"hilit:I,.' Ill;: ;'l.'his and tlall~n Ih~ IlImb;II' spine. TIl('
Ikxion pllsitioll in (h~' hip joint indicatt:~ the tightness or thl.'
iliop,oa", th~ nhliqu;.: position of th~ lower kg indicates Ihe
tigh\lh:~S of the IS:'lU'. ThL: inability' 10 ;lchicvc passively thl.'
hYPL:I\~.\tcll.'iioll ill Ill:.: hip joint .111\.1 thl.' in<.lbility 10 a<.:hicvc full
llexil)ILOf the kncl.' I i.~5~) conlirms the lightncss of thc iliop."Ilas

anJ tilL:

n.:etlJ~.

r;:-,pcctivc!y. Limil:Hion of a passive hip

.'.l"
Fig, 6.1.

Upper trapezius.

Fig, 6.2.

Levator scapulae.

"
.oJ

Fig, 6.3,

Pectoralis major.

CHAPTER 6 : EVALUATION OF MUSCULAR IMBALANCE

99

Fig. 6.4. Screening test for sternocleidomastoid tightness.

Fig. 6.5.

adduction to 15<J or less indic.ltcs the tightness of the tensor

fascia lata (Fig. 6.7); abduction less than 25 indicates shortness of the short one-joint thigh ..lddllctors. This lest can be innucnccd by the stretch of the joint capsule. however. and thus
the more specific (cst should be used to confirm lhe tightness

of the adductors (Fig. 6.8).

Confirm.nion of tightness is clear when excessive soft lisSllt.: rcsis,!al1cc and decreased range of motion arc encountered
on applici.ltion of pressure in the following directions:

Hip flexion-less than 10 [() 15-iliopsoas. A simultaneous extension of the knee joint points out the shortening
of the rectus femoris.
Knee flexion-less than 100 to 105-reCLus femoris.
Compensatory hip flex.ion Jll~\Y occur during the tcst.
Hip adduction-less than 15 to 20-tensor fascia
lata and tht: iliotibial ballc!. An associated deepening

Iliopsoas.

of the groove on the outside of the thigh is noted.

Hip abduction-less than 15 to 20o-shon hip adductors. The tendency toward compensatory hip flexion
should be controlled during the ICst.
J-!wrlJlrillgs (Fig. 6.9) tightness is evaluated by the
leg raising test. To avoid the inllucnce
tht: eventually
light iliopsoas on the position of the pelvis and thus 011
the range of hip ncxion. the nomested leg should be in
l1exion. Under these circumstances. the noonal range of
mOlion is 90"".
, Thigh adductor,, .Ire tested with lhe patient lying supine

or

_.

at 'O:C edge of the plinth (Fic. 6.10). The passive abduction

in the hip joint should be at least 45.... Iight.._~~~~lgs
1l13y__c_onLribulc..JQ,.J~.~_ mngc limitation. If this situation
occurs, bending lhe k;~~--Siloufd-ilU.:rease tht: range of
movement.

lUU

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

M. !);rUilJ'llli,1 i, !~"\L'd willi tlw paliL'lll ~llpill"'. TilL' Icst~d

h:~ i~ pla~(.;d willI Ilk' hip.~\lilllll\ 11,'\1\1l1IHJl tl\,Cr(,()". Il1m;!X-

imal adductioll. and 1!1;.' pl'h-i" j" ,,!;thili/.l'd by jlushing 11lL'

knee in lhe loll~ :l:-.i .. \\f lhe fl.'lIl11!" lFi~. (1.11 K ThL'll. lh~ iUh.:r.
~
Ilal rotation in thl..' hi;' I ' jlcrfornh:d. :'\onn;lIly. soft gr:l<.lually
illlTca~in.:; rl..'SiSI;llh:~ i ... llOh:d ;li ti ...: clld of IhL' rangL' of molion. Iflh\.: llIuSl.'k I' il~llI. lhl' l"lhl.I\:dillg is h;m.l ;\Ild Illay hI.'
assoCi;th;d wilh p:llll ,h.cll in tlh: hUH\II.:b.
QuctrintfUS [limi
,Wl i~ diflil"uh to L',x;lI11inc because ((10
many :-:pilh: "'1':;1Il~1l1 . . I..'llh:r tht' play. III prinl'iplc. passive

/ ..

Fig. 6.6.

trunk side bending i~ (csted while the patient assumes a sidclying position (Fig. 6.12). The refcI~J),S:_~""p.pin.t.is (IJ~.Jcvel of
tilt..' inferior angle of thc scnpula. which should.be q~~~S(~ frolll
IhJ... HOOf 1~'.!_~)Ollt ~ inches.
.')/);1101 at(tl1l.~ ~Irc again diflkult 10 examine. As a
~cfl.. ':lIing h:sl. fllf\'~lrtj

hending

ill ;'1

short sit ;'Illows obscr

\'~lIi'll1

of th.: ~r;'IJu;)1 (.Ufvallln: of the spine (Fig. (l.I.').

).,ll>re rdi:lhk. 110\\1.."':r. is Schober's test. AllY incrCilSC of
distance 1I11i.kr :' elll should he considered as limiti.ltiull of
the range of motion.

Rectus femoris.

)
.C'

.J
J

Fig. 6.7. A screening lest for tensor fascia lata

tightness.

C;HAPTER 6 : EVALUATION OF MUSCULAR IMBALANCE

101

Fig. 6.8.

Screening test for the short hip adductors.

iog of activation of the most important muscles that take part

in a particular movement and in the degree of activation of the
primc movers and their synergists. In this respect. the beginning of thc movcment is more impm:tant than the cnd of the
movemcnt. Poor quality and control of movcment can be of
major importancc in either the production or perpclUation of
advcrse stresses on the spine. Although the movement pattcrns arc individualized, the typical abnormal patterns can be
observed.
_
In principle. six basic movement paltcrns give o\"eral1 in- !
formation about the movel.
lalitv of the articular sub- ;
ject: l~ip ~hyper)e)(tcnsion. hip a~duction, curl'tfi>. pu:-> 1 up. j
neck flexIOn, and shouldcr :.tbductlon"
"_J
Hip extension (Fig. 6.16) is examined in order to analyze
onc of the most important phascs (related to low back p'lin)
9f the gait cycle-l!Y..percxtcnsi~l of the hie. The patient is
prone. During straight leg lifting. the relution bClwecn the
activation \?.!..~l~~ gl.~teuSJ:na~ill!.l.ls. ha!n~lri_!lgs. spin_aJ" extensors--:-ancrstlOulder gird!~__ "~n~"s"c1~_~js observed. The first sign
of altered pattcrn"in"g' is when the hamstrings and erector
spinae arc readily activated during the movement and contraction of the gluleus maximus is. delayed. The poor~sl pattern occurs when the erector spin'lc 011 the ipsilateral side or
even the shoulder girdle muscles initiale lhe mO\'~mt:1l1 and
activation of the gluteus maxillllls is weak and substantially
delayed. In this situation, the entire molor performance is
changed. lillie if any extcnsion in the hip joint is noted and
the Icg lifl is achieved through pelvic forward lilt and hyperlordosis of the lumbar spinc. which undoubtedly o,'crstrcsscs

~
,)

'!.:.

'''1;

Fig. 6.9.

'C.

,''\

<~

7iice".~

Hamstrings.

surae <Irc tested by performing passive dorsiflcx

ion of the fool. Normally, Ihe thcmpisl should be able to

achieve passive t1or7'>illcxion to 900 (Figs. 6.14 and 6.15).
More detailed description of the tests is available e1sewhere.:\

EVALUATION OF,INHIBITED MUSCLES

To examine tht.: inhibited muscles is difficult, because the
classic.1i muscle strength testing docs nOI give sufficient ,lnd
reliable information. The focus of this evaluation is less on
the strength of the p<lfticular movement and more in sequcnc-

_~

Ihis~gion.

Hip abdltC:rio!l (Fig. 6.17) gives information about the

quality of the laleral muscular pelvic brace and tlHls indirectly

j\

io
t-----------

102

REHABILlIAIIUN Ut- I Ht: ::1"'11\11:::';

Fig. 6,10.

1"'" "'" I I

1 IVI'O"'"

,~

Thigh adduClors (A): tesl if hamstrings are

tight (B).

I
A
-~

ahOUI thr..; stabilization of the pch'i~ in walking. II is tested

with the patir..;nt in the si(lc~lying position. The gluteus medius
and minimus together with the ten~or fasciae latac act as
prime l1lover~ while the quadrmus lumborum stabilizes the
pelvis, The lirst sign of an altered abduction pattern is a ten~
sor mechanism of hip abduction: in~tcad of pure abduction,
thc,.movc}llcn( is combined a~ abduction. lateral rotation, and
,Jl{xiun..:The poorest paUern of hiIJ al)uucllOll occurs when the
quadratus lumborum acts not only to stabilizc the pelvis. but
also to initiatc the movement through a lateral pelvic tilt)This
pattern again can cause excessive stress to the lumbilr and
lumbosacnll segments during walking.
Trunk cll!'lup (Fig. 6.1 S) is tested to estimate the interplay
between the lIsu<llIy strong iliopsoas and the abdominal mus~
des. With the patient supine, the test involves active plantar
llcxion of the feet against resistance. Initially, the examiner
observes the paticnt'~ spontaneous pattern of silting up. If the
iliopsoas is strong and domimllll. curling movement of the
Irunk is minimal anti the movement will be performed with an
almost straight back and anterior tilting of the pelvis. The

movement is thus performed mostly in the hip joint rathl..'r

than by kyphosis of the trunk.
P/lsh /II' (Fig. 6.19) from the prone position gives iJlrl'r~
mation about lhe quality of st<lbilizmion of the shoulder hl.u.k.
If slabiliz.ation is impaired, the scapula glides over the thorax.
shifting upw<lrd and/or rotates. and/or winging of the scaplll:I
occurs.
l1i'od.flexioJl (Fig. 6.20) is tested with the patient supine. Till'
slIbject is requested I{) raise the head slowly in the usu.lI w'ly. If
the deep neck flexors arc wC;'lk and the slcnHlCleidolllaSIOitlc:u:, i:"
~trong. the jaw juts forward :ll the beginning or the 11l0Vel1ll'lH
with hyperextension in the cervicocranial jUllction. The tesl pl'llvides information <lhout the intcrplay between lhe stenHx:lcidl\~
mastoidcliS <md the deep neck flexors. This information is es:"~ll
ti~1 in cSlilll<lting (he dynamics of the cervic.:al spine.
SIIol/ldcr abduction (Fig. 6.21) provides information
about Ihe coordination of muscles of the shoulder girdle. It i~
tested while the patient is silting, wilh Ih~ elbow flcxl.'d h\
control undesired rotation. Shoulder ahtltH.:tion is a result l'l
thrce components: 'lbduction in the glenohumeral join!. n\la~

.,

CHi,?TER 6 : EVALU,UION OF MUSCULAR IMBALANCE

103
Fig. 6.11. Screening test lor piriformis
tightness (A); palpation tesl for piriforrnis
tension or irritability (B).

Fig. 6.12. Screening lest for QllZldratus lumbo

rum tightness.

104

REHAIjILlI AIIUN UI"" I Ht ::::'1"'11"'1:::

Fig. 6.13.
lightness.

f'\

t"hAIv

1illUI'H:n .... IV'''''''....... '"' ....

Screening test lor ereclor spinae

"',

')

Fig_ 6.14.

Gastrocnemius.

-,

Fig. 6.15.

Soleus.

()

. ii'

.. J>

,
....i

CHAPTER 6 : EVALUATION OF MUSCULAR IMBALANCE

105
Fig. 6.15.

Hip extension.

Fig. 6.17.

Hip abduction.

Fig. 6.18.

Trunk curl up.

Fig. 6.19.

Push up.

,vv

lion of the scapula, and elevation of the shoulder girJk. Tlte

; decisive movement is identifying im:oordil1;11ion is lhe devalion (hm normally starts to occur at ..thou! 6()" l}f . lbdtKliml. 'Ill

6
I .111 individual with shoulcJcr dysfunction. e1c\'aliOl~ 51.u'ts C~lr
\.Jic:r or may even inilialc the movemenl.
ANALYSIS OF MUSCULAR IMIIALANCE
IN STANDING

In "Ul an.dysis or sl:.Illuing. all ;ltlcmj1t is maue to diffcrcn~

tialc bc(,,,,'cclI possihk provOL:<ltivc CIUSCS. including structufal variations. age. altered joint lllcl:hanics.mel residual
effects of pathologic processes. In this chaptcr, only mm;
cular changes arc described. In muscular analysis. the Illain
concern is with size. shape. alllI tone of the supcrficial
muscles known 10 react by hyperactivity and tightness or

by weakness and inhibition. The role of deeper muscles

may lleed

10

be

l".'Olllli

:::;.'l! Ill' lh:~;lh,:d III ,uh~-=qtll:lll l\llIS~'k

Icll~th

lesls.
Tht' Il/lric-III is .lin; hH'lTed .fi'(l1Jl behind ilnd ;1Il oYl'r;dl
Impression of posture ;... dCh:rmined. Allcnlion i" 111\.."11 dir~l."(I".d IowaI'd Ihe 1")P~i;:,)ll or Ih(' pelvis. l'\,.\,:ausc ;Ibnnrlll;lii
lies of other slrueIUf\,'''' "w:h ;IS Ihe 11l1ll1';lr spine. ~;li".Toili:ll':
joinls. and lower lind", .:r;,'. ;IS ;\ rule. rl.'tll".'\,'!\,'d in p;:h"il' po:-.ilion. An il1cre;lse or lk....... "sl." in :-agillallill. a lah.:r;t! :-.hifl. :111
oblique position, rol;tih'll, and lorsioll :-houl<.l bl..' \,lbsl.'rwd.

The peh-ic crossed s: nJi\ll11l."

Illay

.. ~

01.' rc:-pollsible for tht.: in-

In.. .

creased anterior tilt of

pelvis. This condition is usually associated with il1l:rca~l'J lumbar lonJosis. The pch'ic (wist is
usually associated wilh . . hortness of the piriformis amI/or iliopsoas: an oblique pthHion or (h~ J1d\"i~ i.. i.ISSlleialcd mostly
with leg length asyml1l~lry. Shortness or thigh :'H.lc.lu... tms and
liglllI1CS.S. of the 411aur:..:llIs 11II\\borlllll and of 'th~ . iliopsoas

Fig. 6.20, Head flexion "correcr (A) and,

"incc"cct" (B).

.,
..J

- . . ...J

--",

CHAPTER 6 : EVALUATION OF MUSCULAR IMBALANCE

--_..

107
~._--------------

Fig. 6.21.

Shoulder abduction "correcr (A) and

"incorrect~

(B).

I:

Fig. 6.22.

Soleus lightness on the right.

- - - - - - - " ..

""

Fig. 6.23.

..... .....

_....__..-

....

RighI thoracolumbar ercctcr spinae hypertrophy.

..........

i
I

I
I
,

I
1
.

I
i

108
shonen the leg, whereas ligllll1CSS of th~ piriformis makes 1111..'
leg longer.
Next, the shape. size. and IOlle or the hutto!":k ;[t'l: observed. Usually, thc gluteus is hypotonic and inhibited 011 thl'
side where the sacroiliac joint is hlocked.
The hamstrings arc usually well de\'e1opcd. hUI it is important to look at their bulk relativc to lhat of thl.: glutei. b~
C,lUSt: wh"':Ji i.b,,; ::lttcr is inhihited, lite hamslrings (ln~lI be
c.:ome prcdomin;'lllL This (hangc is rc'ldily cvkklH if the
impairmcllt is unilatcr.l!.

..,,

Tlll' ,hal'l.." III IIll lin,' ,II" 1111.: llll'tli;t! ;"pect \11' tilt.' Ihi~1t
~i\y, impllrl;lIU inl"llflll..::"1l :lhtlUI Iill' lhi~h ad,.hl\lof~. III indi,idll;l!, wilh addul,,h'; \l~hllll''''S. the llllC-joilll :lddllclor"
hll'l11 :1 di'lilll.'1 hlllk ill ;:1,' lIppl'r (lIW lhird 01" thl' 111i~11. Thl'
ollc-.il\iul ;ldduetol"s al\'. ;!..; a ruk'. shun ill p:lti~'llb wilh
painful hip j()inl anlit.lll':l ....
()11 I he (;11 r. difkl\'ll; :.;(1\ HI lllll:-ol hI.: 111:1dt: IWl \\ ~'l'l1 1111: ~;l";'
IrnellL'mill" allli th~ :-\lk"... _ If Ihl' whok tric... j" i... ,I!(Irt. Ihl,,:
Adlille..; tendon Sl'l,:Ill' l"';-,'adl'r. ;md if the SOklh j, li~lll. III
addition. Ih.: lower k~ k:,\lll1l'S l'ylindrk (I'-ig. (l.~~).

Fig. 6.24. Abduction and winging <?Ilhe

right scapula.

I
~

()

:;

'~

)
Fig. 6.25.
scapulae.

Tightness of the levator

)
,)

.... " .... VM.

IVI~ Vt<

--------_ ..__._._---_... _... -

109

MU::i(.;ULAH IMBALANCE

Fig. 6.26.

C::

:~ie

;lb(lornmal dorni

:lancc.

Fig, 6.27.

High arm cross.

Cart..'!"ul cX;lIninatioll or the back llluscle.. . is warranted.

The bulk or the ae<.:lor spin;lc \hould he compared from side
to side a:-; well iI" from the lumbar to the thoracolumbar n:gioll. TI1\:n.: should ht.' no c\'idcllt dilTcrcncc bct\\lCCll sides
and regions. PreVaIClll.:c of thc thoracolumbar portions or the
rector i:-; ;t poor ~ign. It may be indicative or poor muscle stabilization ill the lumbosacral region (Fig. 6.23).
Tht..' illh:rs<.:apular span: and the position or the shoulder
blade=, give infornl,ltiotl ;lhoUI the quality of the lower stahilizcrs
111l..: scapu!;,!. If these muscles ,Ire weak and/or inhibited, slight 'lhdlH.:tioll. ekvation, and winging of the slwull.lcr
blade <Ire ohserved (Fi~. ().24J.

or

Fig. 6.28.

Touching the hands behind the neck.

Tightncs ... of lhe upper trapcl.iu\ ,llId kv"tol' s<.:'lpulat..' (Fig.

6.25) <.:;111 be "'Cell 011 the llc~k ,houlder lim;. III ;m;'IS of tigllt
ness. the c.;5~nt(Jur sU;liglllens. If tightnl..'.';o;"of the !l;valOr prt:dominalcs. the' COn(~Hlr ur the 11i.:<.:k line 4lppl::lrs as it duul\k
w;lve in the.: <':fl,;";J of insl..'nioJl 01 thl.: lIIH~t..k Oil th~ Sl:;lpUlJ.
This straightening uf the ned: . . houldt..'f lille is sOlllctilllt.'S lkw

110

sl:ribcd ;IS "Gothic ~holllth:r" ill tll;ll H i... rl:lll1l11:-~'~'Il\ llf the
form or Gothic chull:h l(l\~'CC
Vie\\'illg rhe pmi('/I! FOI/1 ,!lc' /""111, lhe q\l:llil~ pf Ihe ahdominals is obscrn.:d lir:a. Id\':lll~. 11h..' :thdoillilla! \\:111 i" nal.
A sagging and pn,lIrudcd ahdoll1l'l1 may 1"I.'I\""l'1 '::l'lh.:'r:dilcd
weakllc~s of thl..' ahdomill:lb. \\'!il'll Ihe ohliqul" .n... dllllli-

lli:-lilll..:1 ~11"'\ " .~

dpparCll\ t)11 thc l,tlCra] "idl' or the

a pll.. . sibk 1.!t'I.:rca'L' ill the slahihllil;': i HIll'! ion Ilf Ihl' r,', u in Ihe allll.'rop{lsh.:rior din:l'l iOll. ;1Il
illl!".n.tll\ r:ll'ltlr hlr 'i.>til/alioll oflhc "pine (Fig.. (1.2(1).
nh' l\\p :lll\,.:rilll ;:',:;:lllHlsCk's Ihal (:Ill inlluCllCl.' lllc llllllbll:~~1', I,' pu.. . ltl.l ;11~' :::: lel..... llr fa~\.:i:lL bl;IC alld the rcclus

11,111',.

1\'1,',; iili ...

lilldin~ 01-;: ..,,\.',,-

h'l!!\,n,. :--';tlnJl;dl~. lh,' "~df,.

III' Ih..: h:II... "r is nlll dislilH.:1. lis

\ I'olhhi~. nlllpkd \\ i::: :hl' ;IPlh.':lr;t1l(~' of a ~nlO\'e 011 the
bll'r;l! . . ill... 01" lhl' Ill:;:: usually indk;lll.'S that this 11I11s(k
i~ ,l\l'l"ll"'l'd and ...htll":. Wlh.'n thl.' rcctus feilloris is tight.
Ih,: pn.. itioll uf Ihl' p.!i:.:lb 1ll00\.'S slightly upward and ;.Ilso
l;tlt.'rally ill Ih,: lot ...\. ..1 -.:,Illl..un\:nl lighinl:Ss of the ilimibbl
1r;h:1.

Tightness (lr 111\;

i..,:luralis

IIh Ir..:- pftllllinClI1 lllu ... (k'

Fig. 6.29.

Extension of [he elbows.

llIiLJor is charactl.'ri"l.cd hy :t
rodly and thil:kncss or the ~1I1tcrinr ;'IX-

illar f{lld.
\lll(,:11 information ,:~ln he uhtaill!.:d from observation or
th..:- ;lIlt":-fior asp.x:t of lh;.: necK ;uH.lthroitl. Nunnally, th~ SICl"1lI l ckil!llm;lstoid 1I1l1 ....:!;? i.. just visibk, ~!-qm!n~.I!.~"'\;_9rtl\~ ill...,.:nitlll of tht: IllUS(.:It:, f':~rtil'ularly its davicular purtion. is a
~i~n (If tightlless, A ~l"(\(\\e alon~ thi:- musdc is an carly sign
of \.:.::tKm:s:- of the d:.::;..'p necK llc;'\ors. Straightening of Ih~
throat lin!.: is usually ~ ~ign of increased tone of the suprahy
oid muscles,
.\ddition:lIly. hc,Jd posturt:' should be observcd, prom a
Ilw"cular poim of \'ic\\. ~I forward head posture is attribulahk
10 \\"caKllt:ss of the lkcp neck Ilcxors .mtl dominance or e\"t:11
lightness of the slcrno~:kidomastoid,
From this brief lh::--criptioll. it i evidcnl tlmt Ilcglect~
ing the analysis of lb~ musl.'ular sy tcm in standing leads
to a lo:"ls of a suhq,.tnti:d am~)lllll of information. Only Ihl.'
m;cin t:hangcs or mo,! frcul.'lH lindings an.: melltioned in
thi . . dt:lpll.'r: IHl\\'c\"er. other kss common signs bring addiliOlWI daw.

)
)

,
j

)
Fig. 6.30.

Hyperextension of the thumb.

J
,]

1'.\l'l\:i~\' d,'~"

()
\111,,1.:1..-;0.

\";Ill

h\.' iun)I\".'d

!i1 llIany

(lfhL'!' ;lfIL'!\lI1S. One

{If

Ill:..'

:-.ilU:llilllb I ' ... 'lllSlil11li()ll;t1 h~ ;',-'n1Hlhilily. Till'

va~llt.:. IHHlpn1gn:ssi \ l" \'lilli..:;l1 :o..yndnlllll'. It. 'I rl':llly a dis,:;.,\".
i.\ lit' 1l1lKllll\\1I (lrigill. 11 i_, ,:haral"tcfi'l.cd j\~ .: '::lIl.:r:lll;l.\il~ ,II

lll\lSI (\Hllllhlll

li"'SIlC:'. 111 p:lnintlar ill' li~;lIl1l,,'ll\:'. l\'lust.:k <;-~'1l~11l ill ;L!"k\'h:d

illdi\'idll:d ... u"llally i.. ltm. ;llld e\"en II \'i~\":"'H' "'1n.~ll~lhl'llIll~

C)

-~ 0
I
I, 3,.

hypCflWphy. The

muscle

EllOV!..'l1h:1lt ::: lnillb is l.:ompari.llivdy iuncascd. In Spill,,' of

joinl illst;l('il::~. it has llot h~~ll conlirmco that "hypamobilc"

'UhjlTh

arlO ,,,,,r\.

pr(Jll~ 10

t!c\'c!0P

musl.:lllo~kdclal

pain syll-

dn 11lllS.
('llll,lllt,i:"Il;1! hypl:fI1Hlbility involves [hl: l:rHir~ hody. <11thuuglf ;111 .:~~":, may llol hl' ;llTcClcd 10 Ihc ";lIn~ cxlCnl and
:-.Iiglll a:-.~ Illi,':;:lry l:<1Il he oh,crvcd. This . . yndmll~ is nuted
more frlqlh.ii!l~ in women ;lIltl it typically involves the upper
part of thl' ~\'\I~. With ;tging. hypcrmobilily decreases.
Paticl1h \\ Ilh cOllstitutional hypcnnobility Illay develop
II1USCIe lighl!l(,';s as wdl. although it is never so evident.
i\,tostly, Ihi, li"i"hlllcss is cOll"idered ..I I.:olllpensatory l1ledlanistll to . . t;lbilil.e:. in panicular. the: weight-bearing joints.
Thcn.::forl', 'lrctl.:hing. if necessary. should be performed
gelllly unu lllliy in key lllu . . t:Ic . . 1hal ..lfe: supposed [0 be dcci
sive in ;1 p:mh:ul;lr syndrome. Because the IllllSCIe:; gcncri.llly
afe wC<lk. th;:~ may be easil~ o\'erused ano. therefore. trigger

or

i 0

i0
~

10 t'\ llknt

points in mu:-d~s ~nd ligamems develop c;:lsily.

Assessment
hypermobility is in principle bas~d on estimation of muscle [one by palpation ;md range of motion of
the joints. in clinical practice. orientation tests usually ;lre suflicicnLln the upper pan of the body. the most useful tests <Ire
he~d rOHltion. high :trill cross (Fig. 6.27), touching the hrmos
behino the neck (Fig. 6.281. extension of the elbows (Fig.
(l.19). and h:, paexh.:nsiol1 of the thumb (Fig. 6.30). In the
lower pan of \h-: hody. the bcq choices <lrc the forward bend
ing test (Fif. 6.31). lateral tlexion test. leg raising tcst. and
dorsiflexion e,f the foot (Fig. 6.32).

~ ~.
')
~,

k<ld

Illl!

hlllL' is \k... rl.:~;:d when a:,sc:.scd hy palp;ltion and the range of

,C)

-~

I:<j
t

SUMMARY
Fig. 6.31.

The lorward bending test.

j\'hl.""h.:: illlb;:lJn,c is an c . . 'cmial comp0J)cnt of dysfunction

or' thl' lllUS'lllo_~kcletal syslem. Important ap-

synorume:~

Fig. 6.32.

Dorsiflexion of the fool.

proach~~

ill Ihe o\'crall therapL'lIli . . progralll lie in lh~ recognition of factors that p.:rp.:lll<lI.. .' tilt' dysfunclion ;l11d norma!
ization. This fact is :ruc rL'g:lrdk~~ llf whether lllllSl'k imbalancc is considered I,' callS': thL' jl'int dysfunction ,)r 10 occur
p~lr..llcl 10 it.

HEFEREfI;CES
bnda V: ~l11~dt' ~lrt'n;:lh in rdalimll\lll1U~ch: Ienglh. pain and mll~ck
i111halalll.:~. III H;tr1JhRindahl K (cd): M\lSck Slr~llglh, Ncw York.
Chur..:hill Li\'inpllllh.'. 199,1.
bnda V: r..1 usck ~P;I'lll-;l pmpl1scJ 11n~c\lurc for diffcrclIlkLl di:lI~no
,j,. J i\1;1Il1l:11 i\1.:,1 (,: 1.::(" 1991.
~

lUllla V: i\tusd..: Fun,lion

I
I

Tc~tjn~.

Uultcrworlhs. L(lndon. 19S;\.

')

,)

ii

,,

jj

J
~

,J

Ji
ft

I
~

,
)

',)

ii

.~

-.J

i~

II
~
~

iil
!;i

,J

, ,i
.v

ulagnosis of Muscular Dysfunction

by Inspection

I
--:,

LUDMILA F. VASILYEVA and KAREL LEWIT

t. r';
~

This chapter is devoted to the art of iDspcction. On thc basis

of work by Janda concerning 11l0VCIllcnt patterns and that of
Travcll and Simons dealing with the musculature. the authors
show how much can be g~lincd by inspection. It is no coincidence that findings prim:triiy concern muscles, for [hey .Ire
most in;portanr for the shape of (he hum:tn body. Their hyperactivity ;:md shortening rcsllhs in visible hypcnonus. their
weakness in flabbiness. These clmngcs not only arc patent but
also significantly change posture. Le.. body statics. and. of
course. move me III paucrns_
The aim of this chapler is to show that changes in body
shape or statics (Le.. body contours) arc so specific and relcV:\nt thm often it is possible by mere inspection to identify the
single muscle involved. movements affected. and related joint
dysfunction. This proficiency speeds up the difficult and laborious diagnosis of dysfunction of the motor system. The
importance of diagrammatic sketches and photographs is emphasized.
The focus of this discussion is on inspection. i.e.. with visual charactcristics. If used judiciously. inspection allows us
to assess changes in individual muscles. thcir relative weakness or hypemctivity. and/or shortness. This }nfomlation is
important for the a~$essment of not only muscle function as
sllch. but also body "t;.Hics. kinematics. and joint function.

DIAGNOSIS BY VISUAL INSI'ECTION:

AIMS AND I'OSSilllLITlES
Main concerns when assessing the motor system arc as follows:
I. Identifying dysfunction

By analysis of body contours; first. bony prominences

.1Ild their relative position examined from in front. from
the side. from the back, .and from .above
b. By comparison of findings with "the norm" (or a
model)
c. By identifying the arcH of the most important asymmetry
d. By drawing horizonlal and vertical lines through the
most important points to locate maximum distonion
(see Figs. 7.1 to 7.4)
2. Visual criteria of dysfunction of individual muscles
:t. Attachmcnt points arc closer togethcr if the muscle is
shortened or hypcractive. or further <lpart if it is weak
<l.

b. Of particular importance if these points are connected

by a single joint or belong to the same motor segment
(Inspection alonc, howevcr, is not sufficient to make a
complete diagnosis of dysfunction, e.g., joint move~
ment restriction)l
3. Inspection is ncvertheless most important in directing our
attention to the most relevant lesion
Thc dysfunction that is most important tends to dctennine
the asymmetry. I.e., deviation from midline. and should be
distinguished from compensatory excursions.

Normal Body Statics

The main criterion of normal body statics is to maintain balance with minimum expenditure of energy.2 The visual critCri<l must be assessed from the front, side, and back and from
above. In all thcse views. vertical and horizontal reference
lines connecting important points can be established for use in
measurements and comparison. If body statics are normal, the
lines should be parallel (horizontal or vertical).-'
BACK VIEW (FIG 7.1)

The Spille
The plumb line from the occipilal protuberance passes
through the spinous processes (at the ccrvicothoracic.
thoracolumbar, and .Iumbosacral junctions) to the coccyx between the feel.
The most important horizontal lines arc:
b. between the ear lobes (tips of the mastoid processes) (2)
c. between thc acromia (3)
d. between the lower margin of the 12th (last) ribs (4)
c. between lhe iliac crests (5)
r. between the posterior superior iliac spines (6)
g. between the isehial tuberosities (7)

3.

The Upper Extremity

h. The plumb line from the greater tubercle to the
humerus passing through the olecranon and the middle
of the wrist (8)
I.
The horizontal line between the major tubercles (the
lateral angles of the scapula (9)
j. between the oleerani (10)
k. between the styloid processes of the radius and
ulna (II)
113

9
6

l4
.10

~~m~~

iW~--jf\-\-lH-6

._1.3
7

14

.~5:=-

t~

J.!L.

Fig. 7.1. Important reference lines for the assessment of body

statics (back view).

The Lower Extremity

I. The plumb linc from the lower scapular angle through
the midpoint of the iliac crest between the femoral
condyles to the midpoint of the calcaneal tuberosity (12)
TIl. The horizontal line between the greater trochantcfs of

Fig. 7.2.

b,

c.

SIDE VIEW (FIG. 7.2)

a.

The plumb line from the external auditory canal to the

acromion. following the axillar line to the midpoint of
the iliac crest, the greater trochanter to the lateral

condyle of the femur, (he. tibia down to a point a linger's breadth in front of the lateral ankle (I)
The horizontal between the occipital protubcr;ulI..'e and
the lower margin of the zygomatic arch (2)
The line between the medial cnd of the spina :,c;'lpulae
through the head of the hUlllerus to the medial end
the clavicula (3)
The horizontal lines connccting two poilH:' in the
course of each rib: one 011 thc vcrtical below Ihe midpoint of the clavicle. the other on the vertical trl)\l1 the
lower angle of the scapula (4)
The line from a point just bellm: the anterior :,uperior
iliac spine to the prominence of the posterior :,up,,'rior
iliac spine (5)
The line from the upper edge of Ihe palella I" the I,>"er
edge of the lateral femoral condyle (6)

or

the femora (13)

11. between the femoral condyles (14)
o. between the condyles of the tibia (15)
p. between the malleoli of the tibia and fibula (16)

Important reference lines for the assessment of body

statics (side view).

d.

e,

f.

\.-HAY I "H I ; UIA(jNU~IS

115

OF MUSCULAR DYSFUNCTION BY INSPECTION

4
3

6
Fig. 7.3. Important reference lines for the assessment of body
statics (front view).

Fig. 7.4. Important reference lines for the assessment of body

statics (view from above).

Fig. 7.5. Normal body

ies (diagrams).

stat~

116

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

g. The linc from the upper edge of the tubcrosit<l5 tibiae

tn the upper surface of the fibular head U)

tion (Fig. 7.5). Typical changes from normal body stillics are
illuslrntcd in Figure 7.6.

or

h. From the lower edge

the outer malleolus to the aiI;lchment point of the Achilles tendon (8)
I.
The plumb line from the external ~ludilory canal
through the hC<ld of the hUlllerus. slightly in front of lhe
ulnar epicondyle to the midpoilll of lhe wrist or the
sliglllly llcxcd first interphalangeal joint of (he foreliilgcr (9)
FRONT VIEW (FIG. 7.3)

The plumb line from the center of the forehead passes

through the jugular notch of the sternum. the xiphoid.
the navel. the pubic symphysis. to midpoint between
the feet (I):
b. The first horizontal line passes through the lower edge
of the auricles (or the lower edge of the zygomatic

<l.

c.
d.
c.
f.

arches) (2)
The second line through the acromia (3)
The third through the lower margin of Ihe last rib~; {Ill
The founh through the anterior superior ili<1c spines (5)
The plumb line [rom 'he midpoint o[ 'he c1"vieul<t
pilSSCS through the midpoint of the patella and of the
,alocrural joint (6)

VIEW FROM ABOVE (ASSESSMENT OF ROTATION) (FIG. 7.4)

u. The line connecting both auricles (I)

b. The line connecting both acromia (2)
c. The line connecting the anterior ends of the ribs (3)
d. The line connecting both greater trochanters (4)
e. The line connecting Ihe outer condyles of the fcmora (5)

DisturIJcd [lady Sta'ics

The main criterion of static function is that muscles maintain
bal~tIlcc with minimum activity. Therefore. vbual ~vidcnce of
increased tcnsion or hypcrtonus is of !lrc~H importance.
NOiieei.lblc signs of IllUscul;'lr ilnbaiance also imply aSYlllllletry. and thcrdorc vism!} signs of hypotonus and <lsymmctry 01"
tonus arc also significanl. Direct signs of dislUrbcd equilibrium. such <IS a forward-drawn posture or deviation to onc
side (sec Fig. 7.6). illustrate clearly that the patient would
indeed lose his or her balance if muscle activity did not
prevent it.
Because muscular imbalance manifests in individualll1u~
c1es and therefore (primarily) in cenain regions. but is followed by compensatory reactions in other areas that restore
b<llance. it is most important to determine which muscle
(muscles) and which region arc plimarily affected and when~
compensation takes place. Unfortunately. pain rek!ted to ovcr~tmin may occur in both areas and is therefore ~\ most unreliable symptom, It is logical to infer that the direction in which
the body (with the ccnter of gravity) deviates should be an important guide line. The horizontal lines in the illustrations
serve ,IS an additional guide to show the direction tow~1l"(1
which equilibrium will deviate. If these lines ~\rc not parallel
('owing 10 spinal curvature, the side where these lines diverge.
or in the case of several curvatures where the sum of divergence is greatest. corresponds to the direction toward
which the patient would fall if muscular contraction did nN
prevent it.

f. The line connecting the midpoint of the heel with the

second toe (which ought
'he midline) (6)

lO

Disturbed Statics in Dysfunction of Individm\1 Muscles

or Muscle Group~

be symmetric in relation to

These criteria in a shorleJwd tII11xde include allachrncl1l

points that arc closer togcther than norm<ll and increased
prominence of its contours owing to hypcrtonus. In a u'(,ilkcne,1 IIJlucie. criteria include increased disl;lncc betwcen

Drawn on the basis of the data and illu~trations described

in lhis chapler. the diagram in Figure 7.5 represents normal
conditioll~ and is used for registration of muscular dysfullc-

-~

;;

Fig. 7.6. Abnormal body

statics (diagrams). a,b: Muscle dysfunction. Dotted lines
stand for dysfunctional muscles. c-f: Disturbed body stalies. Black, devialion from the
vertical; gray. divergence 01
horizontal lines; angle 0".
open in the direction of body
deviation. g. h: Joint dysfunction. Black. restriction; gray.
hypermobility (see also Fig.
7.36).

'\

"

~L
B

:
j

f i

CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION

.<
<

:.Iltachmcnt points and flattening of its contours owing to

hypotonus.

The imbalance just described results in the <lsymmctric

position of the salient parts of the bones to which the muscles

attach. It

.1150

goes hand in h:md with articular dysfunction. I

Those cases in which the attachment points were closer tog.ether were ..ssoci;ucd with a preponderance of movement restriction. Hypcrmobility was found in neighboring segments
of joints where movement restriction was fountl.

Diagnostic Criteria of Body Statics

These criteria include the following:
The direction in which the body deviates from the nann

,,~

Diagnosis of the region (muscles) primarily affected

Diagnosis of the individual muscles affected
Dirlgnosis of the individual joint dysfunction in the re-

I,

gion of affecled muscles and attachment points

Diagnosis of hypcrmobilily. in pal1icular in lhe vidnil)'
of movemclH rcstriction

i 0

I,,

o"'~

... ,}

r}
Assessment of Disturbcd Motor Pattcrns
~

.J

NORMAL LOCAL MOTOR PATIERNS'

i ")
'<.;

i, )

The crilcria for normal local patlcrns, such as in onc exlrcmity joinl or concerning one section of lhe spinal column. are
as follows:
Movement
Movement
Movement
Movement

:)

(1

is carried out exactly ill lhe. u(;",;!"(;J direction

is smooth and of a constam speed
follows the shortcst possible path
is carried out in its full range

117

Dircclion of movcment is dctermined maiotty by Ihe <lgonists and also by thc synergisls
Precision of movement is guarantecd by the I1cUlralizers
Fixation of auuchmcm points is guaranteed by lixator
muscles. excluding motion in the vicinity
Smoothness of movement is guamntccd by the eccentric
contr.lction of the antagonists
DISTURBED LOCAL MOTOR PATIERNS BECAUSE OF
SHORTENED MUSCLES

The shortened muscle is also hyperactive <IS a rule. Its irritation threshold is lowered and therefore it contracts sooner
than normal; i.e., the order in which muscles contract in
the normal pattern is altered. If. therefore, the agonist is

shortened, the relationship to the synergists, neutralizers, fixalars, and antagonists. is. out of balance and the local paUenl,
I.e., Ihe direction, smoolhness. speed. and range of motion.
are disturbed in a charnclcrislic way. (See subsequent section
for discussion cC'ncerning visual assessment of individual
muscles.)
If Ihe synergists. neutralizers. and fixators arc shortcned.
it is again the short synergists. neutralizer. or fixators that conlract first and distort the pattern. If the antagonist is shortened,
the entire pattern is altered and substitution occurs (see discussion concerning weak musclcs in subsequent section).
DISTURBED LDCAL MOTOR PATIERNS BECAUSE OF
A WEAKENED MUSCLE

The threshold of irritation in Ihe weakened muscle is

raised and therefore. as a rule. the muscle contracts I:.Her

\~

,\,..
-I ,)

!J

I, )

,)

,J J
~

,,

~)
~,',

~
%
'"

:~
f"

q,

II

"j

{)
()

Ir

f,

.'s

Normal
movement patterns
(diagrams).

Fig. 7.7.

U
t.':\

~~---,-----~-------------------------------'<~J

REHAtilLlIAllUN OF THE SPINE: A PRACTITIONER'S MANUAL

110

than normal or, in some cases. not at all. Hence. the order
in which muscles contract is nltered. :.IS is coordination. The

dr;'lwn by a dott~d lin~. Agalll. 1m tile s<.lkl: III \.:iarity. tht:

changes havc purposefully bcen exaggerated.

most characteristic feature, however. is substitution, altering

the entire' pattern. This change is
weak muscle is the agonist. If.
and/or the fixators 3rc weak. the
there is ;:\cccssory mOlion~ if the
range of movement is increased.

particularly evident if the

however. the nClItr;i1ii'-cr:-:
bi.lSic pattern persists but
antagonists arc weak. lhe

Gluteus Maximus
GENERAL CHARACTERISTICS

This l1H1sdt' h,l~ a It:ndcncy 10 he inhibitcd or weak.

'.'

COMPLEX MOTOR PATTERNS'

FUNCTIONAL ANATOMY

The criteria for complex motor patterns arc as follows:

Points of

Typical synkinesis in distam regions with primary

:JUachmcnl:

movement in other parts of the motor system

Smooth propagation of motion from one region to other

Origin

Inserlion

I. Upper part of the innominatc

2. Lower pari of thc

I. Tbe supcrlicial
tillers cross over
Ihe gre:lter lro-

sacrum

part' of the body

A constant (optim4J!) rcl;'llionship between lhe speed of
1t100ion initialed in one region with the speed of synki~
ncsis in other regions
If local pmlcrns arc changed. synkinetic patterns rCIll<lin
inHlel. as long. as substitution docs not take place

.,

3. Cocc)'x-I<lteml surr;l(c
4. lumbodorsal ;lpOneurosis

2. The lower pari (\1

Ihe lihers atlach

6. The fascia or the glu-

(he gluteal tuher-

DISTURBED STATICS BECAUSE OF WEAKNESS (FIG. 7.8)

1. Upper p:Jrt of the innominate dOTSOl1lcdioc;.sudall)'

:Ht:lchIllCllt

VISUAL CRITERIA OF DYSFUNCTION OF

INDlVIIJUAL MUSCLES
A key c1emcnt in diagnosis is a sct of tcsts that show wcak~
ness on the one hand and tightness on Ihe otheLf ' In this sc<"~
lion, we show how both sho;tcncd lTluscies Hnd wC~lk lTluscles
call change body posture and in particular the contours of the
human body. \Vc also provide the visual criteria of somc musc1cs prollc [0 such change that arc noted frequently in clinical
practice.
In this chap[cr. ccnain key muscles th<lt arc prone to shortening are <lddrcssed. The)' ;'Ire the biceps femoris. the tensor
fasciae I~ltae. the piriformis. the quadr;'llus lumboruill. the
upper trapezius, and the sternoc!eidoIll<lsIOideus. f , Muscles
with a tendency to weakness thai arc discussed .Ire the g(ut~us
maximus ;:1I1d the reclUs abdominis_ A more comple.; list is
given in Chapters 2 and 6.
In the following illustrations. the nonnal position is in
black and the ;'lhered position. the result of dysfunction. is in
white. Where the abnormal hides the normal. the normal is

poill1s on
("(llltr.lctil1ll:

2. Sacrum: 1(I\\,cr p,lri

mediodorsoc;l\Idally

3. Coccyx: mcdiodor...C1caudally

Possible
change ill
position ,...(

I. Innominillc: i1ntcn;r-

ana{(lInie

2. Sacrum: '\lHc\'cr~i(.rn.
ipsilatcml flexion. and

MTLIClllres
(owing tll

..ion. cXlcTIlal rotaliun

rot;.stion 10 the same

\ide

wcakncss"l:

3. Lumbar spine: hyperlordosis with SCOIII)\;",

toward the ipsil:lIcral
...ide
.:I

Lower p;lrl of Ihe

...acrum ;.md cocc)'x:

contrJI"tcr.a1 devi;llioll

Joilll
mohility:

Sacroiliac joint:
IpsilalCr;tl movement

;!l

osit)' of the 1i..'lllUf

given in Figure 7.7. Deviation from the normal patterns can

be registered on the diagrams.
For the sake of clarity. the findings in the flgurcs to follow

pull at the

,.. J

10 the i1iutibial
(ract.

). Sacrolubcnlll"; li~;lInclH

(eus medius

Direction of

,..

challlcr ,Ind atl:lI.:h

The results of assessment of local molor patlcrns arc

arc cxaggcr.Hcd. The most important ~)robablc objection to

such CXi.lggcralion is that it is farc under clinical conditions
that only one muscle is dysfunctional. although one muscle
is usually the most affected and relevant. Hence. the results
arc artificial, in a way. We believe. however, that it is itllpog~
sible to understand the complex clinical picture without
knowledge of the significance of a single shortened or wcak~
cned muscle.

fi

I",n1'\t"

I t:.N

I :

119

UIAt.,;iNU1;iI1;i OF MUSCULAR DYSFUNCTION BY INSPECTION

Fig. 7.8. Disturbed statics in a

weakened gluteus maximus.
Front view (a) side view (b),
back view (c) view from above
(d); 1, pelvis; 2, femur; 3, gluteus maximus.

;r

120

REHABILITATION OF THE

DI~

CHANGES IN BODY OUTLINE BECAUSE OF WEAKNESS

(FIG. 7.9)

Front vicw:

1. Increase in

tf'-lllSVCrSC

diameter of pelvis,

mainly in c<ludal

is lowered. anterior suo

pcrior ilia,=, is depressed

3. Ramus sup. as pubis is
lowered and protrudes

anteriorly
Side view:

bar

verse diameter of

1. Buttocks protrude postcriorly and pel ....is is

naucncd anteriorly
2. Increased lumbosacral
lordosis

I uR~eD MOTOR PATIERNS BECAUSE OF WEAKNESS

cxten~or~

become

m(\fC activ~

(see Pig. 7.12).

Biceps Fl'Oloris
GENERAL CHARACTERISTICS

hip.

2. Upper margin of iliullI

t-'HAc..;lllIUNI::H~ MJ-l.I~U"""L

1. Increase in truns-

2. Gre.lIer trochmucr

portion

If there i~ wcakness of lhi~ IllUSCIe. Ihe halll'\trings and hlln-

In!'cnioll

Qrigin

~I-'INI:::

is displ:lccd

This musclc has a Icndcn.. . y III bc(.;olllc shoflcncd and ovcr.1ctivc.

upward and
protrudes
3. Valgosity 'It knee;
patella is shined
medially

FUNCTIONAL ANATOMY

Puints of
attachment:

1. Anterior shift

I. Long head: poslerit1!'

aspcct of i~thial

mainly of distal
"J

pan of thigh. fOfward protrusion of

knee
2. Slight flexion of
all major joints of

tuberosity

f!ethcr form

Short head: lataal lip

mOll

it CUIll-

tendon lhal rum:

of linea aspcra of

along latc"ll condyle:

femur

:lIld eSlablishes

partite

;l

lri-

'lIlchor It) bl

era! aspect of libular

head

extremity
Back vicw:

I. Long head is joined

hy short hcad and \ll-

1. Increase in vertical dinmClcr of ipsilateral

buttock

2. Gluteal line is lowered

3. P.S.I.S. is closer

10

sacrum
IMPAIRED BODY STATICS BECAUSE OF SHORTENING
(FIG. 7.10)

Changes at the ipsilateral side:

Direction of
pull al lhc
attachment

Qrigin

Insertion

I. Ischial tuberosity is
pulled in caudal-Imcr;:ll

I. Fibular head is
pulled in craniu
dors.1! direction

dorsal direction

points on
contraction:

Possible
changes in
position of
analomic
'L

Fig. 7.9. Changes in body outline because 01 weakness of

the gluteus maximus. Front view (a), side view (b), back view (c).

J. Flc;r;ion adduction
and eXlernal rt1I;I(ion of leg bdow

knee (vcnlrof1h.~
dial shift of di:H.1I
end of thigh)

structures:

Joint
mobility:

I. Innomini.lte retrol1cxion
adduction and imcrnal
rolation

I. Hip c;r;tcnsion (Iighteniog of sacrotuberous

ligament)

I. Knee. joint: Hex

ion. exlernal rola
lion. anutorsiOIl in
relation Iu Ihigh.
(i;r;alinn of tihiofibular juilll:
valgosity

\",n",t"

. Util::i
It: H I '. UIAl.,;iN

OF MU SCULAR DYSFUNCTION BY INSPECTION

121

1\

r .'

O"'.JIi,
l"._

1/

fM

Disturbed body

Fig. 7.10.
e of a short~
statics becaU~emoriS. Front
e
ned biceps .
(b) back
side view
.
.
view (a). .
m
above
(d),
fro
view (c) view
r" 3 tibia; 4
. . 2 femu, .
1. pelvIs, .' ps femoris.
libula; 5. blce

,j

1 <:<:

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING

(FIG. 7.11)

From
Vic\\':

Ori~in

!lI'l'rtioll

I. Decreased transvcrsc
diameter of tlppt.r pan
of bcmipdvis
, [nnolllin;lh: is hl\\"crcd
and com:a\"e: antcrior

I. Increased tr;llls\'c,":'e di;ullelcr (If

lllwer pan of

:mpcrior ili:lc spinc

raised: upper edgc of
pubic bOlle is r..lised
and less prmninen!

I1
1

I,
~

Side View:

%1

I. Pelvis is drawn forward

;md its dorsal outlinc
flattened

i
!

,.

hemipdvis
L:lleral cOlltour (If
thigh at lcvel (II'
trnchalller is more
prolllincill
Knec lics morc
medial and su dnes
patella: medial

-'1

condyle protrudes

{,.

Bilek

I. Increased concavity of
pelvic outline above
buttocks and increased
prominence of buttock
ami g.rc.lIcr tuberosity

View:

I
j
Ig

I. Distal end of thigh

is thrust forw;ml
and patella
protrudcs

I. Protrusitlll of IlH>
dial fClmw.l1
condyle
2. Dor.-;a[ protrusioll
of libul;lr head Jild
of biceps muscle
Icndon

~
!l

Fig. 7.12. Hip eXlension in a patient with a shortened biceps

femoris. Back view (a). side view (b).
DISTURBED MOTOR PATIERNS BECAUSE OF SHORTENING
AND OVERACTIVITY

This paucrn may include an altered activation sequence of

muscles during extension or the hip joint (Fig. 7.12).
The order of muscle contraction during hip extension is
I. Hamstrings
Glutcu~ muxillllls
J. COlltr~l<ttcral erector "'pinaL'
4. Ipsilateral erector spinae

2.

"

\)

DcI<lycd activation of the gluteus maximus may occur

when the biceps femoris is o\cractivc.

,
f

Tcn.wr Fasciae Latac

GENERAL CHARACTERISTICS

This muscle has a tendcncy to becomc shortened and over

nctivc.
FUNCTIONAL ANATOMY

Points of
att:ldllllent:

A
Changes in body outlines because of a shortened biceps femoris. Back view (a). side view (b).

Fig. 7.11.

I. From ,Interior part of

OUler lip of iliac crest
to ;,mtcrior ~upcrior
iliac spine

I. Antcromedinl h:lldimlus fibers lerminate

in I~teral palcll:lr
retinaculum

2. Posterolateral half of
musclc tcndon :11taches below knee
onlo later.lliubcrclc
uf tibia via iliolihial
truet

-"'(
,oj

I '

123

CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION

I
1
~

Fig. 7.13. Disturbed body

statics because of a short~
ened tensor fasciae latae.

Fronl view (a), side view (b),

back view (c). view from

above

(d);

1.

pelvis;

2.

femur; 3, tibia; 4, tensor fas-

ciae lalae.

!. i1

(~

',,",,

'

\J ''''

p~Ai

124

REHABILITATION OF THE SPINe.: A PRACTITlQNt:H"::; MANUAL

IMPAIRED BOOY STATICS BECAUSE OF SHORTENING

(FIG. 7.13)

DISTURBED HIP FLEXION MOTOR PAITERN BECAUSE OF

SHORTENING (FIG. 7.15)

Changes at lhe ipsilateral sith.::

Din:Clioll (If

Origin

Direction of
pull at the
attachment
"

I,
8

points

I. Caudolah:nHlnrsal Pill!
at ;llltcrillr :'\lp~rior

I. Cralliolalcro-t1ursal

spine
'"'I

Oil

pull ,il proximal end

of tibia
VClllroll1<:di;d dc\'i:lresull

or muscle's

tendency 10 approx.
illl.lIe tibia toward

pelvis

Possihlc
changes in

J. Innominate- ahductioll.
;mld1cxi(lll. ami cxlcr-

J. Vcntronicdi.11 dcvia

position of

nal rotation
2. Flexion. uddllctiotl. and
internal rotation of
proximal end of thigh

thigh: abduction.
l1cxion. and eXler

structures:

Joiu!
mobililY:

I. Hip j\lint: Ilcxiull.

;lhductiUl\. internal

J. I-fip joint: abduction.

ncxioll. intern:ll
rotation

l"(ltaliol1
2. Knce joint: l1exion.
abduction

GENERAL CHARACTERISTICS

This muscle
active.

Poinls of

lmal end of tibia

attachment:

I. Knl;C joint: stabi

lii'.:ltion. Ilc:-.:ion. rot:ltilln

I. Increased trJnsverse diametcr of upper part of

I. Increased transverse diameter in

hemipclvis
2. Lateral contour of
thigh fonns
straight line: tensc
fibers nf iliotibial
band visible
3. Lateral (emordl
condyle protrudes:
p.neHa deviates
laterally.

protntdcs anteriorly
3. In addition. tense muscle belly of tensor fasciae latae fonns round

protrusion

Side view:

I. Pelvis dc"i.nes posteri-

tendency

to become shortened and over-

FUNCTIONAL ANATOMY

llal rotation of pmx-

In<icniOll

hcmipclvis

hits

liun uf disl;tl end uf

Origin

2. Iliac crcst is raised and

rnt;lIes: pelvis shifts toward ipsiJmcroll sidc

, Lumbar spine extends and side bends
3. Hip flexion and :lbduction
~. Lateral deviation of paldla and toes

Piriformis

CHANGES IN BODY OUTlINE BECAUSE OF SHORTENING

(FIG. 7.14)

Front vic\v:

I. Ipsil;lter31 innominate is lowered ;lIld

lion of thigh is

contraction:

;lIl:ltomic

~"lovC1llelH

nexed ;lIld pro-

at level of hip joilll and

trudes anteriorl)'

J~rtiQn

I. Anterior lateral surface

of sacrum between
first and founh sacral
for:lmen
2. Pall of fibers aHach to
margin of greater sciatic foramen at cap!'ule
of sacroiliac joint and
sacrospin:tl ligament

I. Fibers run through

grc;ltcr sciatic
for.mh~n

to

and alt;leh

grc;lt~r

trochanter of
femur on medhll
side of its superior
surface

,
.J

.'

I. Knee slightly

orly; relative concavity

Ori<1in

_.~

increased convexity at

level of coccyx

')

'.J

2. Increased lumbar
lordosis
Back view:

I. Superior deviation of
posterior superior iliuc
spine appears deeper

and at greater distance

from sacrum
2. Ischiill tuberosity. however. approaches
sacrum

I. Protnlsion at level
of contr;\cted mus-

de: pelvis is inc..'-lined to the

Si.lnle

side
2. V':llgo:-ity at knee
omd abduction of
tibia

.j

Fig. 7.14. Changes in body oulline because 01 a shortened tensor fasciae lalae. Front view (a). side view (b). back view (C).

L
<..

>

CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION

125

I
~:

10

i
I
~,
\1

:j

Fig. 7.15.

fasciae latae. Side view

!i ()
10

,)

(al,

front view (b).

IMPAIRMENT OF BODY STATICS BECAUSE OF SHORTENING

(FIG. 7.16)

Changes at the ipsilateral side:

Qtigjn
Direction of
pull at attachmcni

I. Latcrocaudo\'cntral
pull at lower part of
sacrum

I. CraniulIlcdio-

CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING

(FIG. 7.17)

dorsi.ll pull <It

greater troch:.lOtcr

poim on

producing approxi-

contraction:

Illation of ~acrum

Fronl
Vic\\':

and greater
trocharlil.:r. causing

i
f,

Hip flexion in a pa-

tient with a shor1ened tensor

Q.tigin

Inscrtion

I. Anterior superior iliac

spine lies higher and
is less prominellt
2. Upper edgc
pubic
bone devi,llcS craniamedially

I. Latcral cOntour of gre.ucr

trochanter is nallcncd
2. Leg is in abduction and
external wt,Hian
3. PatcH,Uld {()C$ arc dcvi.
ated laterally
4. On changing weighl 10ward ipsil.ltcral leg. position of loes rcmains unchanged. but \'algosily at
knee bcnmlcs cvidellt

I. Pelvis is thrust b.\(;kward and both sacr:d

I. Knee .\flO ta\ocrunll joilll

ur

laicrovclllral deviation of caudal

part of pelvis

Possible

changes in
position of
anatomic
structures:

1. Sacrum is tilted hack

<lnd bent to opPo!loitc

side, resulting in flex-

ion of sacrum
2. Pelvis is thrust back:
tendency to "f:lll"
compcIlS~l1C,

tient

slall(.I~

the pa-

on COIl-

tralatcrallcg.

Joint

mobility:

OUI\vard roWtiOll

and flexion; leg

and knee deviate
10

side and for-

witrd with ten-

Side
Vicw:

dency to varosity

backward
3. To

I. Thigh: abduction.

I. Hip joint: Olll\vard rota-

tion, abduCli\lII
2. Sacroili<lc joint:
cOlllprcssi(lll

al

arc slighlly ncxed

kyphosis amI lumbar

knee

lordosis arc reduced

Back
View:

I. Trans\'cr.;e diamch.::r
of hcmipclvis is reduced: poslCrior superior iliac spine lies
ne,lrer to S.lcrum ,Hld
is more prolllinclll

I. Knee deviate!' I:llerally:

laleral cdge of popliteal
rossa in a lllorC dorsal
and mcdi'll in more vl.:ntr:.ll posilil\l\

RI:.HAIjILlIAIIUN VI- I HI:. :;)t-'INt:: A PHAG

126

1IIIUNI:.H~

MANUAL

Fig. 7.16. Disturbed body statics

because of a shortened piriformis.
Front view (a), side view (b), back
view (c), view from above (d); 1,
pelvis; 2, femur; 3, piriformis.

"

...

_~~_~

... , .... , ...'

V'~"'"

.v,.. u, " ........

&;; ......

,V,,,

127

," ",

I \)

Fig. 7.17. Changes in body outline because of

a shortened piriformis. Front view (a), side view
(b). back view (c).

Fig. 7.16. Hip flexion in a patient with a shortened

piriformis. Back view (a), side view (b).

~
~-::

l.}
.

it

~~)

~
I,"_..:::.--oL-__-,'J

10

DISTURBED HIP FLEXION MOTOR PATIERN BECAUSE OF

SHORTENING-HIP FLEXION (FIG. 7.18)

Din:Clion of Mm"Clllcnl

Visual Crill'ria

Shcarill~ force at
s<lcroiliac joint wilh
compression
., Extcmal rotation.

I. I)l1r;ll~ ~;1it. P~llil.;l\l raises ipsilateral

I.

abduction. Ocxioll at

Insertion

inrwmin;ltL' wilh intcfIlal rotation

.., FI:llICIK'd lateral outline at hip
3. Leg is fined. abducted. and in olllward wlalion with (Onl and loes de-

Front
View:

I. Tr;.lIlsn:rsc diameter of
ipsihlterallowt:r part
of thorax is diminbhed
2. Waist is narrower

I, Increased transversc diamcter of ht.:lllipeivis .

mainly lower part

2. Antt.:rior superior ili"c

spine deviates latt.:rally
and is more promincllt
3. p.lticnt puts weight
mainly on ipsil:ltcral leg:
contralateral leg is ab-

viated l:llcrally

hip joint

Quad~atlls

CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING

(FIG. 7.20)

Lumhorum

ductcd
flexed

GENERAL CHARACTERISTICS

The qu.tdr..ltus lumborum ll;ls "l lendency to become shorlcncd

and overactive.

Side

I. Increased lumbosacral

View:

lordosis

FUNCTIONAL ANATOMY

P(lims of
au~chlllcn[:

I. Vertical iliocostal
fibers: medial half of

12th rib
2. Diagonal iliolumbar
fibers: End of fina three
of rOUT lumbar tmllsverse processes
3. Di3gonallumbocostal
llbcrs: 12th rih

1. Posterior part of
iliac crest llnd iliolumbar ligament
2. Iliac crcst and. frequently. iliolumbar
ligament
3. All lumbar transverse processes

Decreased sagittal diameter of pelvis

2. Sacrum with coccyx tiled
dors<tUy ;md protrudes:
ventral contour of pelvis
I.

---..

- J

is nattened
Back
View:

I. Lumbar spine deviutes

to side. resulting in
scoliosis
2. 12th rib and innomi-

,_
IMPAIRED BODY STATICS BECAUSE OF SHORTENING
(FIG. 7.19)

.md slightly

nate approach lumbar

spine: transverse diametcr of trunk at
waist diminished on
that side: lateral contour more concavt.:
Frequent compen
satory thoracic scolio$is to opposite side

I. Apex of sacrum with

coccyx and ischi.l1
tuberosity approach thigh
2. Transverse diameter of
buttock is diminished
Gluteal foid is r.tiscd
4. Posterior superior iliac
spine closer to the
sacrum

,.

Changes at the ipsilateral side:

il

'I

I
1
I
.~
'~!

Ii
i
:~

t!

Dirct:\iOll

Q.rigin

of pull

I. 12th rib caudolllcdially:

\riln~Vcrsc processes
later;.lly

I. Iliac crest: craniotllediodorsally

I. Lowering of 12th rib.

I. R<lising. external
rotation. and
rctroOexion of innominate

at attachmcnts on
contraction:
Possible
changes in
posi\ion of
anatomic
strUctures:

Joint
mobility:

increa~cd

hunbm lordosis and thor:lt:ic kyphosis: IUlllbar scoliosis to

Samc and thoracic scoliosis to oppositc side

DISTURBED HIP EXTENSION MOTOR PATIERNS BECAUSE OF

SHORTENING (FIG. 7.21)

i. Fixation of the 12th rib.

increased pressure on
intcrvcrtcbr.tl .md lum
bosacr.tl joints
2. Thoracolumhar hypermobility

I. Flexion and adduction posilion of

hipjoillt

---~

'-J

The quadratus lumborum contracts before the hamstrings and

lhe gluteus maximus.
Direction pf Movement

Visllal Criteri,j

I. L.umbar spine: extension.

I. When <ltlcmpling. to extend leg.

p;lticnt lirst t.::c:tel1ds and side
bends lumbar spine instead of
hip joint
2. Innominate of same side is
r<liscd and (hura:c: is lowered. arpro,Jcbing the pdvis: "S"-scolinsis results

side bending
2. Pelvis: laterol1cxion and
antcnexiol1

~
~

I
.~

,~
'1'
:li

,B
~

,,",

'nu' v.;:).;:) ur- MU::;iI",;ULAH UYSFUNCTION BY INSPECTION

129

.> "

i 1"')

~ .......
I

\. .J

()

.,e

In
,,~
i n
I
,

!
~

I
i!

0
~J

1
,

i~
~.

'"'!t

,J

.,;,),

.7

r}
1

]
i

4~~r::;-

-"'~

<
~i

2-~'
4

Fig. 7.19. Disturbed body statics because of a shortened quadratus lumborum. Front view (a). side view (b).
back view (c), view from above (d): 1, pelvis; 2, lower rib; 3. lumbar spine: 4. quadratus lumborum.

nl,;;, ,,, ... ,,-,."1 ,v,,. v r Inc .;) ... 11'\1(:; f'I t"'N""'l,..; 1IIIUNt:N;:;:' MANUAL

I
,;

>
,;
o

.ff

Fig. 7.20. Changes in body outline because of a shortened

quadratus lumborum. Front view (a), side view (b) back view (C).

~)

:d
'<;

i
)

1
~

t<
~1

l
i
~

II

?i

j
~;

II

Fig. 7.21. Hip extension in a patient with a

shortened quadratus lumborum. Back view (a),
side view (b).

I
~

~"

'"

---.,,.--

al..._

, _ ,,,>,,;>,.. Vv.,:) vr

DISTURBED TRUNK FLEXIDN MOTOR PATTERN (IN THE

STANDING POSITION) BECAUSE OF S: :ORTENING OR OVER
ACTIVITY (FIG. 7.22)

The. quadratus lumborum contracts before the iliopsoas and

rectus femoris.
Dirl'ctiun of r-.1Q\'cment

Visual Crileria

I. Lumbar spine: extension.

side bending (s;,unc side)

I. On trunk anteflexion. lumbar

spine goes into extension and
bends to same side; thorJcic

2. 111Or;lcic spine: flexion.

side bending (opposite
side)
3. Hip joim: nexioo

131

MU~VULAH uytil-UNCTtON BY IN::iPECTION

spine goes into flexion and

bends to opposite side
2. Flexion lakes place mainly in
hip joint; enlire body shifts
forward

IMPAIRED BODY STATICS BECAUSE OF WEAKNESS (FIG. 7.23j

Changes at the ipsilateral side:

Qris.in
Direction of

force at
atlac1ullent
points of
contraclion:
Possible
change in
position of
anatomic

structures:

I. Ctrlil;tginous end of
5th-7th ribs :lIld
xiphuid caudally

I. Pubic bone

I. Rib" and canilages

with xiphoid deviate
crani;,lIly and contralal-

I. Caudal shirt of

crally, resulting in ex
tcnsion and side bend

pubic bone pro-

duces anteflexion
of innominate
2. Pelvis deviatcs

ing of thoracic spine in

Opposile direction
2. Compensatory scolio
sis and increased
kypho;;is in upper thoracic spine

dorsally and con

tralatcrally result
ing in incrc:tscd
lordosis of lumbar
spine and in scoli
osis Iowards ip:'ii
liltcrul !'ide

Rectus abdominus
GENERAL CHARACTERISTICS

The rectus abdominus has a tendency to become weak.

Joint
mobility:

l. HypcmlobililY at thoracolumbar and lumbosacral junctions

Cr;,l-

nially

t. Hypennobility:lt
symphysis: pelvic
obliquity

Fig. 7.22. Trunk flexion in a

patient with a shortened quad
ratus lumborum. Side view (a),

back view (b).

I._(}_....
-~

4...
_ _"""'7'"

_._

Inl:: .::Ir-ll'o1l::.

J\

t"MP,\,jIIIIUNt:.H":;j MANUAL

)
A

----~

. .1

.,

-)

Fig. 7.23. Disturbed body statics because

of a weakened reclus abdominis. Front view
(a). side view (b). back view (c).

..

__

.~------------

_,,, ....... "

, ..... ,,...~ .... v.::U;;;)

MU~I.;ULAH UYSFUNCTION BY INSPECTION

ur-

CHANGES IN BODY OUTLINE BECAUSE OF WEAKNESS

(FIG. 7.24)

Front
Vic\\':

CJ

Side
View:

Back
View:

Qrigin

Insertion

I. Increase in vertical di.lmcter of abdomen

2. Trunk deviates (0 contralatemi side

I. Increase in tran~\'cr~c diamcter of lower part of

I. Increased protrusion
of abdominal wall;
sternum is lifted and
xiphoid is close to
skin surface
I. Scoliosis toward ipsilateral side mainly in

lumbar region

pelvis
2. Pubic bone dcvi,lIcs
down ano w sidl:
I. Incrcased lumbar lordosis and prominence of
end of sacrum

I. Innominatc is lowcrcd

and waist is flattcncd;

deeper on oppositc side

DISTURBED MOTOR PATIERNS BECAUSE OF WEAKNESS

As a rule. the psoas substitutes for a weak rcctus abdominis.

The iliopsoas. erector spinae. quadratus lumborum. and rcctus
femoris may all become overactive when the rcctus abdominus is weak or inhibited.
Directinn of Movement

Vi... ual Critcrin

I. Lumbar spine: eXICIlSio!l

,,;i;", ;Ji~I"'Jn~.\ioll iO

I. While stooping, the paticn(s

lumbar spine remains lordotic as
the patient side bends 10 the
SClme side: flexes thoracic spinc.
and side bends to the opposite

same side
Thoracic spine: flexion
wilh side bending to opposite side
2. Pelvis: l:lleroflcxion to
opposite side
3. Hip joint: flexion

GENERAL CHARACTERISTICS

---

This muscle has a lcndcncy to becomc short..:n..:d and over"clive.

IMPAIRED BODY STATICS BECAUSE OF SHORTENING
(FIG. 7.25)

Changes.H the

Direction
of pull at
attachment
points on
contraction:

ipsilater~1l side:

Qrig!ll

Insertion

1. Occipital bOlle: cmllJovcntrally and slightly lat-

I. Acromion: in eraniollwJial direc-

ti(ln

er'llIy

2. Uppcr ccrvic:il spinc:

mainly Iater.lIly ,1Il0

slightly caudoforw'lro
Possible
changes in
position of
anatomic
structures:

1. Head deviates to side,

forward. and into
rClroflcxion wi.h rotation
to opposite side resulting
in increased cranioccrvical lordosis

2. uter.ll pull at spinous

processes results in lateroflexion on upper cervical spine coupled with
rOl<ltion in opposite direction owing to C'IUdolateral pull

I. Clavicle with
acromion deviate
CfaniOllledially
2. i\lcdia: pull produces compression
of clavicle against
sl~mum

3.

compens:lIc.
some side benJin,g.
;\1 shoulder girdle
hl opposite side
Wilh r\Jt,ltiull (() ipsilataal side

T(l

3. To compensate, some
scoliosis at cervicothomcic junction (0 ipsilatcr.11 side with incre'lscd
kyphosis

sidc.
2. Also flexes hip and entire body
is shifted back

Joint
mobility:

133

I. Fixation at cervical and

upper thoracic spine; hypcrmobilily at cr:lntocervical and cCfvicothoracic junction

I. f-ix;uion a[ s[erno-

c1a\"icular: hypt:rmobilil)' at acf<.\mioclaviculm joint

Fig. 7.24. Changes in body outlines because of a weakened reclus abdominis.

Front view (a). side view (b). back view (c).

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

134

A
-",

Fig. 7.25. Disturbed body statics

because of a shortened upper

()

trapezIus. Front view (a), side view

(b), back view (c).

)
)

)
,

~)
-

-"

.J

0
~J

~.-,'

Fig. 7.26.

Changes in body

outline because of a shortened

upper trapezius. Front view (a),
side view (b). back view (c).

,J

'~_A'
1

CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION

135

CHANGES IN BODY OUTLINE BECAUSE Of- SHO,HENING

(FIG. 7.26)

f-rolll
View:

I. Hc.u.l inclined to ipsi

lateral and rotatcd 10

opposite side; car is

"

1!

It
~

.. ' ...".
U

Side
Vic\\':

j;

;~~

verse diametcr
2. Acwmion dcviale:-;
mediocnuli:llly
3. Prominent upper contour
of shoulder; fi:1Ucncd
outline of latcr.J1 part of
dnvicula

I. Head is thrust forward

I. Acromi<;m dc"iah::s em-

.lIld benl back; ipsilater;1I car points anteroinferiorly

I1

II
~
,
~

\,

Back
Vic\\':

")

;1

n
t1

l]

""',

,~)

I. Shoulder girdle is raised;

decrca<;ed transverse diameler
2. Raucncd latcr.JI contour
of neck and shoulder
3. Lateml outline protrudes
at level of acromion

contralatcr..tl in cervical ;)nd ipsilatcwl cer\icothor.lcic region

DISTURBED MOTOR PATTERNS BECAUSE OF SHORTENING

ON SHOULDER ABDUCTION (FIG. 7.27)

'>

i,;

\~,:fI

The upper

Jj
Ii

I. Head and neck indined to ipsilateral

side
2. Contralateral car is
raised and more
visible
3. Horizontal fold (sign
of cx:tension) .It emniocervieal junction
4. "S" scoliosis noted-

nially
2. Increased dislance between acromion and

dosis and prominent

cervicolhoracic junction

{)

tr~lpczius

~)
<c''}

Direction of Movcl1lelll

Visual Criteria

I. Acromioclavicular joint:
move men1 of shear between clavicle .1Ild
shoulder blade
2. Head: extension. ipsi-

I. Elevation and oUlward rolation

of shoulder and arm
2. Head is inclined to ipsilaler.11
.tnd rotated to contralateral side:
head is thrust forward and in ex-

I ,
i

Fig. 7.27. Arm abduction in a patient with a shortened upper

trapezius. View from above (a). back view (b).

DISTURBED MOTOR PATTERN DURING CERVICAL EXTENSION

(FIG. 7.28)

The upper trapezius bilaterally contmcls before the spinal

extensors.

contracts before the deltoid (clavicular

portion) or the supraspimltus. creating a dysfunctional scapu~

lohumcr:lI rhythm.

humeral he'lt!
3. Flattened cervical lor-

:<1

i)

ipsilalcml sidc and is

r;liscd: decrcased Irans-

seen ,lI1d lowered;

other car IS partly hiddell <lnd raised
2. Nose devialcs contralater.Jlly

()
,)
'-.

I. Shoulder girdk rt)lah;S 10

": ~

...J

,ff 0
i$ ()

lateronexion.

h
'Ii

U
\,)

1\,:
~,

~~)

Y
:}

tJ
,,
~

c(lntralat~

eral rot4ltioll
3. Cervical spine: forward
shift. ipsil,Her:tl flexion.
contralateral mlation
4 Shoulder girdle: upward
dispiacemcill

tension
3. "C" scoliosis of cervical and
upper Ihomeic spine

Direction of Movement

Visual Criteria

). Head eXlension: ipsilatefonex:ion. contralateral rotation

2. Cervical spine: forward
shirt. latcronexion to the
same. rotation to OPPOsile side
3. Shoulder girdlt.:: clcv,ttion

l. On back bending the head. pilticnt side bends it 10 same side

and rotates it (0 Opposile side
2. Cervical spine drawn forward.
inclined to ~'lI11e side and rolated to opposite side
3. "C" scoliosis of ccrvicolhoraci-.:
SPIIlC

4. Shoulder rai~cd and rotated with

ann and sC~lpula to same side

_________________________
1'>0

=...

---'~

~.~ ~_'_

Inc:: ;:''-II''t:;}J+,

(,l1ll,:ill

Stcrncoclcidomastoid
1'\l.v,ihl,;

GENERAL CHARACTERISTICS

c!l;lIlg,;, III

The sternocleidomastoid 11l11~dc has a (l:IlUCIlCY 10

l1C(OmC

pnsili1ln hll
Clllllr;IlII' III'

shortened and ovcracti\t::.

"

{\;I\"Il.1':

I, Hcad: l1('vialc:-> forward to opposilc sidc

(if

',~

and rOl;:lh:s also In op-

posilc siul'

\hllllldcf

2, Ccrvkal spine:

1~1l,.lk I', ';rlle sid~;

FUNCTIONAL ANATOMY

lordosis limited ttl

craniocel"vic,d junc-

lllWI'IJI'~' 'If lal!.:ral

Points of

\'1111

allachm~nt:

1. Cl:\\"iclilar division:
sternal end of clavi-

I. Both di\'isinn:- attach

cle
2. Sternal division: anterior surface of
manubrium sterni

mastoid prnccs:- and

to lateral

SlITf;.!I:c

10 hller"l half

('If

of

r_)~.idc

with

lion: cCf\'ic<l1 verlC-

brae are thrust forward ,\nd <Icvi.He to

opp(lsitc side

I. 1(1'''1''';11' ,n ;11 sh:rnn-

su-

perior nw.:hallinc of
occiput

"I

""'11I1<1,;; ::nd ;lrlll

Joint
ll)obillly:

ddVi'.llh: ~rid Slcl'II'" ,,..1;;: :'Ilnls on

- ',:1111'" ',1':': 'J/ith hy-

.>.

I. Rcstriction al cranioccrvical ,md cervi-

cnlhnr.lc;c junction

Ih'"n"i, .,';, 'lllUJl-

IMPAIRED BODY STATICS BECAUSE OF SHORTENING

1"'Ik .

(FIG. 7.29)

Changes

"lcl"llal ~lld

1;II\nl, '':"'UIUi.:f I!.irIlk p....;,':'l hack

11\;ul,'.:: ':;<1,; sli,t:hl
'"lall',I,

t-'HACTITIONER'S MANUAL

al

the ipsilateral side:

Q.tigjn
I. Sternal eno of ckl\'icle: craniodorsolat-

Direction
of pull at

I. :\'taslOid

rnl{:c!>~:

cau-

dovcl1lrolllcdially

crally

points of
attachment:

or

2. Medial surfJcc
manubriurn slcmi:
cran i odorso I ate rally

()

,
f

Fig. 7.28. Head extension in a patient with a shortened upper

trapezius, Side view (a), back view (b),

J
""
.J

~
~
>

D
\
6,-'
,'- .. - ,.r.; .

"\
j

.~ -~

.'

.,

Fig. 7.29.

,i

-.,

'.

Disturbed body statics because of a shortened slernoc1fwlf'llIrltllnhlllllli I

I'Jr<' I

I,

II / '1/

"'J,
. (CJ (the
I
I I,I,;/{ /b}. t)(:lck Vlrm

shoulder blade has been left out on purpose).

_ _ _ _IIIIIIIIliiiI Z

J..

l;HAPTER 7 : DIAGNOSiS OF MUSCULAR DYSFUNCTION BY INSPECTION

137

I,
,

Fig. 7.30. Changed body oul

lines because of a shortened
sternocleidomastoideus. Front
view (a). side view (b). back
view (c).

CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING

(FIG. 7.30)

.!.illWiill.l
Front

1. Decrease in transverse

Vicw:

diameter of shoulder

ginJk. less prominent

shoulder outline

2. Both heads of shortened muscle and upper

and lower clavicular

fossa clearly seen

under skin
3. Shoulder irdlc wim
thorax slightly rotated

I. Head deviates to ~idc

and rolales 10 oppo~i(c
side
2. Ear on thai side i~ lowercd. turned forward.
well visualized
3. Lateral conl<.ll!f of neck
on ipsilatcml side flattcned and at right angles
with shoulders

to same !oldc
Side
Vicw:

I. Sternal end of clavicle

wilh manubrium slcrni
r:liscd :md tilted back.
xiphoid process on
olher hand prolmdcs
2. Acromion with shoulder and ilrm lowered
and thnlst back

I. HCild thrust forward.

chin r.. iscd. occiput

I. Luer.Il angle of

sC;lpula lowered. inferior ;lI\glc raised. arm

close to trunk

sion at cranioccfYlcal
I. Occiput

dcvialc~

to op-

posite !'ide; ipsilateral

mastoid process lower
and anterior. contral;.tteraJ raised and poslcrior
2. "C" scoliosis of cervical
and \lppCr thoracic spine

DISTURBED CERVICAL FLEXION MOTOR PATTERNS BECAUSE

OF SHORTENING (FIG. 7.31)

The slernocleidomastoid and

i....

.. _

_._

will

sllb~titu(c

for the

Directiun of Movement

Visual Criteria

I. Ell;tcnsion at COil and

CII2 ipsilatcnd inclination wilh rotation to <:011tralatcr.tl side
2. Allie and JatcruOexion
of neck

I. HC;ld of patient is lowered. chin

..,

-----.,.-_._--------_

~calcnc~

longus colli.

~..J

~f fJ

ster~

lowered

2. Ipsil:.slcral cur rOlated

forward and lo\\-ercd
3. Reduced cervical lordo~
sis. but increased c:'(tenjunction

B'lek
View:

Fig.7.31. Head anteflexion in a patient with a shortened

nocleidomastoideus. Front view (a). side view (b).

thrust fOr\vard and to opposite

side
2. Ipsilalcrnl car lowcred and dcviates (0 opposite side
J. EXlension of upper cervical and
llcx.ioll of low~r cervical spine

REHABILITATION OF THE SPINE: A PRACTITiONER'S MANUAL

PRACTICAL APPLICATION

Case History
Patient K., male. cOlllpl:\ill~d of gnawing p:lin in his h:ft
shoulder that I.Idialcd O\T!" lhl' ;1I11crior Surl"KC of the thor'lx.

ANAMNESIS

Six months prcdously. \vhcn paticllt K was Iihing <I small n>
frigerator. puin started in Ihe right bUllock and mdiated down
the posterior surface of his [high. Pain disappeared within a
fortnight without treatment. He then began to complain of
shoulder pain. mainly while standing. which grddually worsened. Standing with feel apart lessened the paui. but pain intensified when he held his feet close together. Pain disappeared when lying on thc llonpainfu1 sidc.
ANALYSIS OF BODY STATICS (PAIN-PROVOKING POSITION)

FrQut View
The changes in body staLics an: illusLrated in the diagrams in
Figures 7.31b to 7.32b by vcnieal'lfld hori1.ontallincs. Figure
7.32c illustrates muscle dysfunction. The vertical line 0) d~-

viatcs frol1l1h~ (ideal) midline to the left, with maximum dc~

viatio[1 at the level of the navel. the point at which the (zll
leTed) vertical line between the legs and thaI from the head intersect. 111e horizontal line diverges toward the left to the
right} with maximum divergence between the lower margin of
the rih cage (4) and the greater trochantcrs (6).
Note, hOWC\'CT. the divergence to the right of the line between the acromia and the lower margin of the rib cage. As
dcvi.uion from tlie plumb line is dearly to the left and divergence of the mentioned lines is grealer to the left than to the
riglll (sec angles ex and {3), it can be inferred that deviation of
lhe pelvis 10 the left is primary and deviation of the shoulder
girdle Lo the right is secondary (compensatory).
Side View
Pigurc 7.J3b shows forward deviation of the patient's body
from the plumb line. particularly noticeable at the legs. Note
lillie deviation of the trunk, but, again, forward deviation of
the neck. The horizontal lines diverge mainly in front, mostly
between the lower margin of the rib cage and the crista iliaca
(4,5). The horizontal lines between the spina scapulae and
c1;wiclc and the lowcr margin of the rib cage (3,4), cor
responding to the mainly straight thoracolumbar spine.

1O--:::::;;;~t--").
12'1

't,

16 --+----\-'--.. \

17-~~4Jf,

o
;;
i.)

.I

I,

,
!

"B
,.~,
."

A
Fig. 7.32.

Front view of Patient K. in the pain-provoking position: photograph (a). diagram (b). and diagram of dysfunctional

muscles (e).

~
~

f-------,----------------------------------------

....... ~,

'C'"

VI/,\UI\lU;:.I:;' U~

MUSCULAR DYSFUNCTION BY INSPECTION

139

11

---<.:}

11

+4---19
+--18

12

, __
-_-17
16

13
-1+-16

14

'5~=-L!

Fig. 7.33. Side view of Patient K. in the pain-provoking position: photograph (a). diagram (b), diagram of dysfunctional
muscles (c). and (d) photograph of upper part of profile.

14U

REHAtjlLllAllUN Ur 1 Ht: tWINt:: A !'JHAG

converge dorsally. It can be inferred thaI body statics (balance) arc disturbed. with a tendellcy to fall forward. The angle
between the lower margin of the rib cage and tilt:: crisla iliaca
is therefore primary ,md the :-;houldcr is the secondary compensation.
Back Vicw
In Figure 7.34b. lhe paliclll stands with his legs apan. i.e.. in
the relief position. Lillie dc\'j;'lIion from the vertical is seen
between the legs; deviation is limited llluinly 10 the cervi

cothoracic spine. with ;,\ maximum

:.11

the lc"c::1 of the lower

angles of the scapulae. Maximum divergence of the horizontal lines is between the biacrumial line and the line connecting the. klwcr margins of the rib cage (3,4). The line between
the troclwnters is now almost parallel lO the lowcr margin of
the rib cage (4.5) (compare Fig. 7.32b).

ANALYSIS OF MUSCLE FUNCTION

(pAINPROVOKING POSITION)

Vie ... (Figs. 7.32c

7.34c)
What can he secn on thc body outlincs is in keeping wilh the
disturbance of stati~s (sec Figs. 7.32b to 7.34b). The pelvis
deviates to the left and tlte spina iliaca antcrior superior appears highcr; the trunk devialcs to the right and the shoulder
is lowered. The head is slightly inclined to the right with left
rotation.
Closer inspection reveals outward rotation of the left leg.
which is adducted; the right leg is flexed at the knee. Note the
tension of the sartorius on the right and protrusion of the shon
adducrors on the left,..The shoulder is closer to the pelvis on
the right and the thorax to rhe left, which is in keeping with
increased tension of the obliquus externus on the right where
its attachments to Poupan's ligament and the iliac crest arc
seen. The abdof,TIcn protrudes more on the left and hypertonus
of the pectoral muscles is visible on the right side. Also 011 the
right side.-ffic mpple I~ lowered, the outline of the pectoralis
m.illQr ~.l.Jhe. axilla is sharper. the shoulder is drawn lorward
and protrudes anteriorly. the supraclaVlCUiaf fossa is deeper.
.and the outline of the sternocleidomastoid and trapezius mus~
c1es is clearer. The acromial end of the clavicle is raised on
the right side. and there is a step between the acromion and
(he head of lhe humerus.
On (he left side. the contours of both the trapezius and
sternocleidornastoideus arc vaguc. The head is not only inclined. but deviates to the right. The transverse diameter of
the .shoulder girdle appears smaller on the right. The head is
rotated to the left, the right ear more visible on the right. The
right ann is slightly flexed and the hand is pronated; the contour of the biceps is more prominent.
Side View (sec diagram in Fig. 7.33c)
The main feature is the forward drawn position. particularly
of the lower extremities and the neck. This posture results in
tension in the triceps smae and the hamstrings. in the muscle
belly of the tensor fasciae latae. and. to the lesser degree. in
Frolll

10

1IIIU!'lt:H'~ MANUAL

the lower iliotibial band. This tension contrasts with the hypotonus in the gluteus maxim us. producing flattening of the
buttocks and lowered gluteal lines. Also noted are lumbosacral hyperlordosis and increased thoracic kyphosis with
some tension (prominence) of the erector spinae and a protruding. flabby contour of the upper pan of the abdomen. The
head ;md neck arc thrust fOf\vard and tension is evident in the
right stcrnocleidomaslOideus and upper trapezius. Lordosis is
prescnt at the craniocervical junction. In Figure 7.33d. the
contour of the acromion is clearly outlined when the arms are
hanging down, and, again. note the step-like prominence of
the acromion in relation to thc head of the humerus. \\'e also
see better the cervicothoracic kyphosis with a raised lower
angle of the shoulder blade. The lower cervical spinous
processes are clearly visible (also a sign of low cervical
kyphosis). The forward thrust position of the head of the
humerus is also obvious. The elbow is nexed and deviates
dorsally. and there is visible tension in the biceps brachii. The
relative flattening of the thorax with a prominent xiphoid
process is also clear.
Back Vie.. (sec diagram in Fig. 7.34c)
The patient stands with his legs apan in the relief position.
Outward rotation of lhe foot is more pronounced on the Icft
and tension is greater at the Achilles tendon on lhe left. On the
left side. prominence of the triceps surae is greater and the dcpression below the knee on the medial surface is dcCIXf.
The popliteal fossa is deeper on the right (with th< knee
flexed) and the patella: is rotateo inward. The lateral outline of
the biceps femoris is more prominent on the right, the contour
of the semimembranosus and semitendinosus is more prominent on the left, and there is a concavily on the medial surface
above the knee. Above this concavity is the prominence of the
short adductors; the gluteal lines arc lowered on both sides.
The pelvis deviates only slightly to the left. but rotation to
the left is apparent. The transverse diameter of the hemipelvis
is therefore greater on the left side, and the outline of the glu~
teus medius can be seen. Abovc the pelvis. tcnsion is increased in the paravertebral muscles on the left; hypertoous.
principally in the latissimus dorsi. is visible in the craniolateral direction. Below the axilla. oo\e the .promiilcnce -of the
tcres major. The convex outline of the infraspinatus belo\\' fhc
spinae scapulae can be secn only on the left side. Here. too.
the upper extremity is adductcd and slightly ncxcd on the left
side. The contour of the left shoulder forms almost an angle,
i.e.. hypotonus of the deltoid muscle is noted. On the right
side. on the other hilI1d. the waist line is deeper. and alxnc it,
tonus of the latissimus dorsi appears diminished. The lower
anglc of the scapula is more prominent on the nght sid~ and
the shoulder is drawn forward. Increased kyphosis in addition
to scoliosis are evident at the cervicothoracic junction. The
he.ad and neck arc inclined and rotated to the left; [h(' car is
clearly visible. There is also some hypenonus at (h(' upper
trapczius on the left side. but the lower fibers of thm muscle
as wcll as the middle trapezius ;lrc flattened .

........- . - - - - - - - - - -

;~

::

1
,

.,

"

.~

#
~

.;

'\

I
"

s;

.~

,,
)

.J

zIa

.....,"'.. ,....UOl" vr-

MU;:)l;ULAH DYSFUNCTION BY INSPECTION

ANALYSIS OF RESULTS

From Ih.: ('hall=:~s in hody sl:lli(:~ and comp'lnson of the p;Jinprovoking and rdid' POSiliollS. it follows that the main and
prillwry disturb~lI1l'c is al th~ pelvis: the parallellincs (sec Fig.
7.:l2b) show maximum divergence toward the left. and pch'ic

dc"imion is signifk.mt. In the relief position. on the olher

hand (sec Fig. 7.34b). less deviation is noted. consistent with
increased lension of the obliquus cx(crnus abdominis on the
right side ;Illd of the qU;ldrmus lumborul1I on till; len side (see
also Fig. 7.20),
The other important change in body statics is the forw;mjdrawn posture wilh lumbar hypcrlordosis. It can be
infcrn.:d thal)hc straight abdominal muscles arc nOI primarily wei.!k. out arc inhibited becausc of the shortcned lum~i.Ir :-;.cclion of the back extensors (including the quadratus lumhorum). Spasm of the external obliquus on the lef,
side is clearly visible. and it is spasm of the abdominal
fllusdcs that is the most frequent cause of the forward-drawn
posture.

141

The numerous asymmetries of muscular tonus described

arc mostly compensatory. In the legs, it involves the biceps
femoris on the right, the adductors on lhe left, and the hamstrings and triceps surae on both sides. In the trunk. it involves the pectoralis on the right and the latissimus with the
(eres major on the left. Othcrs include the slcmocleidom<lstoideus on the right and the upper trapezius on both sides, but
more so on the right. The asymmetric position of the anns
goes along with incrcased tension of the biceps brachii on the
right and adduction on the left. These findings are illustr<1tcd
in Figure 7.35 (sec also Figs. 7.5 and 7.6).
In " similar way, it is possible to eX3mine movement, in
particular gait. as shown in the preceding discussions conccrning disturbed movement pattcrns for each muscle. It is
even possible to infer from typical changcs in body statics
which movement pattcrn will be affected. and from the disturbed movement, which muscle is either shonened or weak.
Visual diagnosis is also useful when checking therapeutic results by comparing findings, such as in photographs,

o
I

~\
I
y

11

r'

12

1./

13

13

-22

,.

15
6
16

-),---

17

20
21

18

!\

-I
19

Fig. 7.34. Back view of Patient K. in the relief position: photograph (a), diagram (b), diagram of dysfunctional muscles (c).

~ ~)

i1~ .....
>

!"~),

,;----------------------------------\,

.{:..

~ ~3

M~nI'\Oll..III'\IIUI'" Ur- I Ht: '=ir'INt:: A

PRACTITIONER'S MANUAL

!,
1

!
.

JiI

,~

Fig. 7.35. Diagrams of patient K: (a) Dysfunctional muscles in the pain-provoking posilion (dotted lines, changed muscle conlours): (b) Dysfunctional muscles in the relief position; (c) Disturbed statics in the relief position, back view (black. changes in ver
tical outlines); (d) Disturbed statics in the painprovoking position, side view (gray, change of horizontal lines; angle a is open in
the direction of body deviation); (e) Disturbed statics in the painprovoking position, shown in the same way; (I) Disturbed statics
from above. (1) head. (2) shoulders. (3) lower thorax aperture. (4) pelvis. (5) knees. (6) feel; (9) level of spinal dyslunclion;
(h) side view.

,.
before and after treatment. Inspection works fast and at a distance. Its results. however. must be checked by using other
methods of clinical cxamination~ in panicular. palpation. testing of aClive and passive mobility-the full range of physical
examination.

6. Janda V: Muscle Function Testing. London. Buttetvlorth, 1993.

7. Koga.n OG. Va~i1yeva LF: Atipichniy lokomotomiy pattern. diagnostik;l i
Iccheniye. (Atypical locomotor patterns. diagnosis and treatment).
No\'okuznelsk. 1990.

Acknowledgments
REFERENCES
I. Lcwit K: Manipulati\'e Ther.Jpy in Rehabiliution of the Locomotor
Systcm. Oxford. Bunerworth. Heineman. 1991. pp 2325.
2. Rash PJ. Burk.e RK: Kine$iology and Applied Anatomy. Philadelphia. Lea
& Febigcr, 1971.
3. Kogan OG, Schmidt JR. Vasilyeva LF: Visualno-palpatomaya dingnostika
patobiomeck.ani$tiehcskick iSll1cneniy posYonochnik.a (Diagnosis of
palhobiomechanical spinal disorders by inspection and palpation).
Manualnaya Medicina 3:10.1991.
4. Janda V: (1990) Differential diagnosis of muscle tone in respect of inhibilOry techniques. In P:Uerson JK. Bum L (cds): Back Pain. an
Intcmation;ll Review. Bostoll. Kluwer Dordrccht. 1990. p 196.
5. Vasilycv:I LF. Kogan 00: Manual diagnosis and manual therapy of atypical motor p;mems. Presented at the IOlh International Congress of the
Federation Intcrnation;lk de Medicine Manuelle (FIMM). Brussels.
September 1992.

I am grateful to my teachers for their contribution to the ideas

of this publication, particularly concerning the role of the musculature. il.. functional anatomy. and biomechanics. i ant gr.t1cful
to Dr. Lewit. who firM opencd the door of m.mual medicine to
Russia. I am indebted greatly to the work of Janet G. Travell and
David G. Simons: to Vladimir Janda for his ide.ts of muscular P;lt
terns: and 10 a.G. Kogan and I.R. Schmidt for their help in analysis
of slatic dysfunction.
I thank Karel Lcwit and I. Lcwitova for their painstaking and
constructive criticism and active editing of the text. Last. but certainly not least. I thank I. Litvinov for the wonderful illustrations in
this chapter.
Ludmila Va... i1)'cva

\ .....:
.~

..

t5

.t;valuatlOn of Lifting
LEONARD N. MATHESON

'

CHIROPRACTIC FUNCTIONAL
CAPACITY EVALUATION
As the chiropractor assists the patient in restoring pre-injury
functional capacity, periodic functional capacity evaluation is
necessary. Functional capacity evaluation (FeE) denotes a
form of work cvalumion consisting of a battery of tests that
focus on selected work tolerance areas. Matheson' defined
work tolcr~nccs as the observed and measured physical capabilities of the cvalucc thilt affect competence to perform the
physical demands of work tasks. The term jUllctional connotes purposeful, meaningful. or useful activity. implying a
definable task that has a beginning and an end with a result
that can be measured. The term capacifY connotes the maxi~
mum ability of the individual. beyond the lcvcl of tolerancc
that is measurcd. Capacity is the cvalucc's potential. The tcrm
el'(l!uar;oll is a systematic approach to monitoring and rcporting performance that requires the evaluator to observc. measure. and interprct the cvaluec's performance in a structured
task. Thc information gathcred in thc FeE is descriptive and,
when standards of performance arc available. normativc.
Descriptive results arc used to compare the cvalucc's ability
with thc physical demands of ',vork or with thc evaluee at a
previous point in time. Normativc rcsults arc used to compare
the evaluee to a reference population.
An FeE requires lhallhe cvaluee put forth maximum voluntary effon for the dcfined- task. The dcfined task may require full strength, full velocity, endurance. a target number of
repetitions. a maximum nUe of responding. or some other
"full effon" performance. When the measurement of function
is less than maximum. the evaluator must bc able to dctermine
to what degree this deficiency is a function of the biochemical. cardiovascular. mctabolic, or psychophysical limits inherent in the cvaluec.
LlI'T CAI'ACITY TESTING
For scveral reasons, the cvaluation of lifting capacity is a key
ingredient of most FeE. Lifting is an important component of
many jobs. because of either the proportion of job activities
that require lifting or the criticality of the lifting task as a
component of the job. Lifting is important because it is a cell
Iral organiz.ing wlr;lIble that provides an excellent estimate of
general work capacity.' Additionally. lilting is an important

variable because lifling tasks appear to be relaled 10 both

increased frequency and increased severity of industrial
injuries. 2- S
LII'TING AND LOWERING
Lifting is defined as the vertical displacement of an object
with mass that is accelerated vertically through the application of force along the direction of the lift. Lifting is generally
considered movement of an object held by onc or bolh hands
in opposition to gravity. Le.. lifting upward.
Some FeE systems consider lifting separately from lowering. Lowering is a distinct task and is dell ned as the controlled movemcnt of an object vertically downward. The force
applied to initiate movement is gravity. The individual's max~
imum lowering ability is taken as his or her ability to resist
this force so that the object remains under control or. at the
least. is controlled at the tcnnination of the vertical move:'
ment. By contrast. vertical movement downward of an object
accelerated by gravity without resistance applkd by the
worker is considercd a "drop" rather than a lowcr.
In practice. when lifting and lowering arc evaluated
jointly, the maximum lifE-lower usually is the individual's Iift~
ing capacity. People gcncr'Jlly arc able (0 lift approximately
20% less than they are able to lower. ahhough this percentage
varies from person to person and depends on the swrting
height, the vertical displacement of the lift or lower. and the
frequency of the task.
LWflNG CAPACITY FACTORS
Several factors inherent in the lifting (ask
imulll load that can be lifted.

innuenc~

the max-

Horizontal Displacement of Load

The distance belween the center of gravity of the load held by
thc hand or hands and the cenler of gravity of the worker is a
crucial dctcrminanl of maximum lifting capacity for ~evcral
reasons:
I. The human biol11cchanical sy:,tem exponcntially mulliplies the effect of the load on the human body :'0 that it
rapidly increases as horizontal displ~lcel11enl inl.:'rcases.
143

~ (j

J'--~""----~--------------------------------------------------

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

144
2. The stability of the worker-load system is maximized
when horizontal displacement is minimized.
3. Risky lifting~lowcring maneuvers arc minimized or
eliminated as horizontal displacement is minimized.
Certain behaviors such as torquing of the spine when
moving an object through a lateral arc of motion can be
eliminated entirely if the horizontal displacement is
sufficiently slllall so ,IS to place the object against the
worker's abdomen or pelvis.

Location of the Hands at the Origin of the Lift

The common reference point for lifting and lowering is the
position of the hands on the object. This positioning is taken
as the point of origin of the force and the center of resultant
force vectors. Lifting is accomplished most easily through intemlediate vertical ranges so that the biomechanical system
can be used most efficiently. At the extremes of the range upward or downward. workers arc less capable of full,muscular
exertion. Different muscle groups arc called into play depending on the starting height of the litt some of which are
more inherently powerful or fatigue-resistant than others. In
addition, secondary limitations occur that depend 011 the starting height of the lift-lower, including cardiovascular demands
and effects of various strategies of trunk stabilization on the
cardiorespiratory system.

Vertical Displacement of the Lift

The vertical range over which an object is lifted or lowered
affects the workers's lifting capacity in the same way and for
the same reasons that the starting height of the lift affects lifting capacity. In addition. however. the vertical displacement
of the lift affccts lifting capacity in tcnns of the amount of
work that is required in the liftMlower. Work is a product of
force applied over distance. Muscles have the capability to
produce power, which is force per unit of time. The biomechanical system is limited in terms of both power and the ability of the system to sustain that power to produce work. The
amount of work performed is directly related to the distance
over which the object is lifted or lowered.

of his or her biomechani("al couplings. A linn stance 011 a stablc surface and a strong and comfortable grip 011 thc object
arc the two most imponant issucs with healthy workers.
\Vhen thc evaluation con("crns an individual who has one or
more impaired biomcchanical components in thc linkage. that
linkage may becomc critic:.:llly limiting. depcnding on the de~
grec to which thc task and/or the posture and mo\"Cnl\.~1l1 of the
worker stress this component. If the task and/or posture and
movcmcnt of the worker do not stress the impaired component, the effect may be negligible. Conversly, if the component is stressed. it may be the primary limiting factor.

Aerobic Capacity
For tasks that arc prolonged at loads that arc signifkantly less
than the worker's maximum lift capacity, the aerobic capacity
of the worker becomes important if the frequenc)' of the task
is sufficiently high. Generally speaking, aerobic capacity becomes important if a light load is lifted once every 2 minutcs
or more often or a heavy load is lifted once every 5 minutes
or morc often. In regard [Q tasks that involve lifts more frcquently than six to eight times per minute, aerobic capacity
may begin to be importam after the second or third minutc of
continuous activity.

Anaerobic Capacity
This capacity of the \vorker is important in high frcquency
tasks involving loads below the worker's maximum single lift
load and in low frequency tasks involving loads ncar thc
worker's maximum load. Anaerobic capacity is a function of
the load of the task relati\"e to the worker's maximum and the
mix of \l>'Ork to recovery time in the task.

Metabolic Capacity
This capacity of the worker is important in repetitive tasks
with a frequency of once every 5 minutes or greater than
are sustained for more than I hour. Tasks perfooned less
frequently or of shorter duration generally are not affected
by the worker's metabolic capacity. unless it is substantially impaired as a comequence of illncss or severe dietary
problems.

Frequency of the Lift-Lower

Because of the inhercnt power and endurance limitations in
the worker's bi0111cchanical system. the number of times a
lift-lower task can be repeated is limited. This limitation is directly related to several factors that interact:
Degree to which the load approximates the individual's
maximum single lift capacity
Duration of thc individual task
Rest period after each individual task
Duration of the task set

Biomechanical Couplings
Both the maximum load and the consistency of the worker's
ability to lift and lower arc directly affected by the adequacy

Test Instructions and Performance Target

The type of instructions provided to the evaluee significantly
affect their subsequent performance. Coaching during the
activity affects thc evaluec's consequent performance. Although few studies ha\'e addressed this topic. the effects
they have reported have been substantial. l As one compo~
nent of the instructions given to the evaluee. the "cogni~
tive target" provided in a maximum strength task is an important component of demonstrated liftMlower capacity. The
difference between "your maximum possible lift.. and "your
maximum dcpendable lift tha! you can replicate sevcral
times per day" is subst<lI1tial. Evaluators must provide a specific cognitive target so the eyaluce docs not select his or
her own.

_..

..__ .... .. '-', ...... ",.\,;;1

145

o lIorizonL:d disph.c.emenl
iii Vcrtic..l displaccmc:nt

El f-rcqucncy of wk

EI Anaerobic/acrobic/melabolic
capacity

E! Instruction5/pcrlorTlU.nee
Gill MusculoskelctAl

strength

tatSCl

Fig. 8.1. Factors that contribute to

maximum performance in a lift capacity t.est.

Musculoskeletal Strength
The worker's strength is the largest single contributing factor
to his or her ability to perfonn a maximum lift. Depooding on
the other factors listed, however. the contribution that museUM
loskclctal strength makes to the ability of the worker to perfonn to a particular level will be limited. In the simplest case.
musculoskeletal strength is limited by the "weakest link" in
the biomechanical chain that cxists between the surface on
which thc cvaluce is standing and the grip that the evalucc
maintains on the joad.'~ This factor, however. presents only a
level of the potential performance that cannot be exceeded.
This ceiling can be approximated in lifting tasks that arc in M
frequent. or that arc performed over a limited vertical range.
involve holding the object close to the body, and with good
biomcchanical couplings and tcst instructions that are perfectly understood by the evaluee. Figure 8.1 is a graphic depiction of the author's estimation of the degree [Q which each
of these factors contributes to the ability of the evaluee to perform a maximum lift in a work setting.
CLASSES OF STRENGTH TESTS

i J
~

Lifting and lowering is a synthesis of the worker's biomcchanical. cardiovascular, metabolic. and psychophysical capacity. The development of tests has been innuenced by
progress in hardware technology. so that the focus in this
early phase of the development of lhe science of lift capacity
testing has been on the biomcchanical system. Anyone of the
four domains. however. may be the most limiting in any single tcst for any given evaluee. Usually. strength tests are limited primarily by the cvaluec's psychophysical capacity.
Psychophysical factors affect the worker's ability to lift in
tenns of the degree to which maximum voluntary effort approximates inherent biomcclwnical, cardiovascular, and
metabolic capacities. Factors such as fear or anxiety about the
task or confidence in his or her ability to perform it directly
innuence the level of effort that the worker is willing to put
furth. Other attitudinal fnctors, such as the relative risk-tOM
reward ratio or work-tavalue ratio as perccived by the

worker also affects the level of effort and. th~reby. the

worker's performance.
Three general classes of strength testing have been identified. They are differentiated in terms of the effect of the test
on muscular contraction, considered in terms of both the mus M
cles' force of contraction and the rate of shonening.

1. Isometric. Under load, the muscle length does not

change. Force is measured in one biomcchanical position.
2. Isokinetic. The muscle lengthens or shortens at a fixed
ratc as a consequence of external control of the velocity of movement of thc biomechanical unit. Force is
measured throughout the range of movement.
3. IsoineniaL The muscle shortens at a variable rate in response to a constant external resistance. As the biomechanicaI trigonometry changes to accomplish movement. changes in muscle length occur at varying
velocities. Constant resistance is inferred from the con- .
stil,ncy of the mass that is moved. Acceleration is assumed to be negligblc.
Various technologies have been developed to assess these
general classes of strength tesL'i and arc identified by namc in
tcrms of the type of function that each iwends to assess. Some
confusion results in that, because of the complexity of the bio M
mechanical system involved in lifting and lowering. the external system .used to tesl the biomechanical system may not
be able to control the tcst at the level of the individual muscle's function so that the intended mode of tcst is actually
achieved. For example, although isokinetic testing intends to
evaluate the strength of the biomcchanical system at a set velocity, accelerative movement occurs carly in the task up to
the point at which the desired velocity is achieved. Even after
thm point. a rebound phenomenon may occur before stabilization at the desired velocity is achieved, As a result. each
of the modes is inexactly sampled by the technolog.ies lhat it
is intended (and advertised) to test.
A lifting task usualiy involves a combination of types of
muscle contractions. depending on the biomcchanical scg-

~O

j-J.L,

~-=-.Ao-_~

140

ment that is considered. These lypeS will change dunng

the task. For example. a "squat lift" from floor (0 knuckle,
whether accomplished in an isokinctic or isoincrtial mode.
usually involves the upper extremities in isometric actiyity if
the worker's style of lift emphasizes IO\\'cr extremity extension. Conversely, with a lifting style such as that used by competitive weight lifters. this same vertical range might be undertaken with the bwcr extremities perfonning isometric
stabilization whik the upper extremities provide :m accelerative force to overcome the inertia imposed on the mass by
gravity as it sits at rest With these ca\'C3ts in mind. the description of each lcst technology is grouped in terms of the
type of function that each is intended to address.

Isometric Testing
This form of testing is the simplest type of technology and
tends to be the most reliable in that. because the body is tcsted
in a static posture. the geometry between the biomechanical
linkages (termed "kinematics") can be controlled and. thus,
replicated.
In terms of safety. however, isometric strength testing has
prompted debate. On the one hand. Garg. Mital. and Asfour,'>
Chaffin,1O and Caldwell. Chaffin. and Dukes-Dobos ll reported
that isometric strength tests are safe. Because it does not
allow acceleration and. thus. the increased inertial loads that
are a consequence of acceleration. isometric testing should
place less stress on the body and inherently be more safe than
other methods that allow acceleration. On the other hand.
Kishino and co-workers. 12 describing their experience with
isometric strength testing of individuals diagnosed as having
spinal soft tissue injuries. found that most reports of muscle
strain or prolonged soreness occurred as a consequence of
isometric testing. They hypothesized that this result was attributable to the longer period of time that peak force must be
maintained in an isometric test (typically 3 to 5 seconds).
whereas the peak force in an isokinetic or isoinertial test is
transitory. Battic et all; and Zeh et all": raised the same issues
after finding problems with prolonged symptomatic responses
and a small incidence of reported back injuries after testing
nominally healthy people in an employment setting.
Three important issues with regard to the safety of isometric testing have not been fully explored on a scientific
basis. The first issue relates to the value of psychophysical
limits in terms of producing safe lifting performance.
Psychophysical limits arc developed throughout the individual's lifetime as he or she is involved with tasks that place demands on the biomechanical. cardiovascular. and metabolic
systems. The learning proceeds through trial and error so that
the individual develops internal controls. termed "work func~
tion themes:' which in essence are rules that the individual
follows to remain free of injury while involved in work tasks.
These rules are applied unconsciously and require input from
the individual's sensorium in terms of the degrce to which a
task places demand on the individuars functional capacity.
This feedback is applied as a consequence of the worr..cr's

RI::HAt::SILlIAIION OF THE SPINE: A

PRACTlTIONER'~

MANUAL

jlt:r(t:pi~'.Ill of the difllcully of the task. Informat ion abollt task

difticuhy is supplied through feedback loops that provide the
indi,"iduJ.1 ,vith inform:nion concerning, initially. the biol1lechanical demand. and socm thereafter, the cardiovascular demand 0f the task. The biomechanical demand depends on sellsors that function best when joints and muscles are in
1ll0\"Cment. Thesc scnsors arc less fUllctional and. thereby.
less useful when the biolllechanical system is static. Thus.
isometric strength testing has proven useful for differentiating
individuals who arc pUlling forth various levels of maximum
voluntary effort because it is difficult for the individual to
gauge the degree to which he or she has put forth ef1'011 and.
thus. maintain consistency with less than a full effort trial. It
is precisely for this reason that isomctric strength testing, unless used carefully, ha.s the potential to place workers who
have inherent defects in the biomechanical system at risk for
stressing the defcctive segment to the point of strain.
A second issue COllcems the unusual nature of the isometric task. Whereas isometric tasks with the fingers and hands
arc relatively common in everyday lifc. isometric whole body
tasks are extremely unusual. Thus. the worker involved in an
isometric "lifting" evaluation is performing a task that has lit
tie familiarity. Although posture is controlled. the psychophysical skill brought to the task in terms of achieving
maximum performance efficiently and with safety is less than
it would be in a task that is more familiar. For example. the
first trial in a particular posture is often wasted because of
problems with balance.
The third issue relates to the care and precision with
which instructions are given. Because the technology is relatively simple. clinicians may tend to use less care in its appli
cation than otherwise would be appropriate, Rather than beginning the lifting task gradually with a "ramp liP" to full
effort. many evaluators allow the evaluee to increase explosively to full effort before the mechanical system's inherent
elasticity has been entirely diminished. This situati011 results
in inertial effects that greatly increase the force within the biomechanical system.
Isometric strcngth testing has been demonstrated to be
highly reliable, with test-retest correlation coefficients exceeding r = .90. 5 Coefficients of variation have been in the
neighborhood of 10 to 13%.15 \Vith regard to validity. one disadvantage of isometric strength testing is that force values arc
mcasured only at a specific segment in the arc of motion.
Selection of the segment to replicate is an important consideration to allow results in an isometric strength test to predict
performance in a dynamic task. Perhaps more importantly. it
may be that the spine responds differently to an isometric task
than to a dynamic task. Marras. King, and Joynt It found that
electromyographic (EMG) activity was highest in the latissimus dorsi muscles during an isometric task, whereas the
erector spinae group produced greater EMG activity during
an isokinetic task.
In spite of concerns about safety and validity. isomctric
tests can be useful because they arc brief and so are the least
costly type of tcst to administer. The ARCON ST is an exal11w

.1

Lo,,,.,...,V"" 'v''! vr

147

Llr 111\ll.:J

Fig. 8.2, ARCON 5T (Advanced

lion Concepts, Irvine. CAl.

Re3.:'~

IilZl-

pk~ Dr thi ... l~-P~ (}r 1l:~1 lhal is llsed widdy. (Fig. X.2l.
Additionally i..olllciric {C~! ICl'hnoll)gy ha~ hl,.'cn in cxistCIKC
for qllit~ some limc and thll:- i" less cxpcl1si\\~ to m;lIHll";:IC[lIl'C
and is widely ;l\ailabk.
l.kl';:HI~C of Ihe way in \\ hidl i:'()IllClril..: II:"', handle inatia. Illl..'y h~IVl' the /JOrnl/ill! III k quill' ,,;Ik, Onr.: mClhod to im
pm\"\,: s~lkly i" 10 provide pafOn1Wlll.:C I"cedh~tl"k so Ihal 11K'
cvalucc is ahk 10 im:rcasc P"~ chophysical input and, lherch~.
<lppropriah:l~ g~lllgC his or 111::1' effor! level. One meI hod 10 il11pron: rcliabililY is 10 pftwiJe I.."ardully c.kn:lppcd :nslnlCliOib
thai ;lre well undcrstood h~ the c\'i1lucl:, Both of Ihese ;:11'pro;ldlcs ha\'c bCl'll lls~d ill lhl.." ERGOS \Vor]..: Simulator Fig.
:(:;l, The ERGOS is a Illultip!c"la:-;k c,,;l!U;ltiOll itlstrulllLllt
thai prcscnh ins[l'lll..,ti()ll~ til the cvalucc ill three ways. supplcnll:lIlt:d hy inpul from ;lll :::\";11\1;11111" who i.. prescIH c.I11rin~
Ihl.: l..\';llu;llillll. Primary in"lful.."tiol\:- art.,' pn..... l.:llIed ;lIIdilori.tll~
lhrllu~h lhl..' lhl' \11':1 :,ynlhl'.. i/l.."d "\"l\kc" in (lllllbinatioll wilh
lext pre~l.:ll1cd {Ill ;l l..'olor \ iLko di~pl;\y Icrminal. Sl.'eOlH.I;Jr~
instruction . . arc prl..'sl..'nll'd pl(torially foll\l\\ ing the II.:X! pn....
scnt;lliol1. u"in~ synlhl..'si/ctl rhOh1~raplls lh~:l c.lepil'[ (he po .,
lun.' III usc \\ ilh thl..' cvalualioll task. Suhscqu~ll(ly. during the
isol11etric lil"]..:", the l..'\,;l!Ul:I.. h pnn-kh.::d "1'L:ill (illll.'" feec.lbal"k
l.:OIKcrning lC11'0,' ~I.'lh:f:lli(Jn thrnu~h Ihe u.. ", 01" a f(m..:c CllJ'\'C
Iha[ l'l\.'SI..'111'" pcrt"lll'lllalll.."l.: on tht.' basis or a ~J cycks per ;.,tc
(Jllll ;dong ,I !og;lrithllllc "'(:llt:. III tile hill1:lI111tll. isomctric.
whole body "'lrcn~lh 1a']..: .... ri~hl hand pl.'rformancc is pn.>
st.'nll.:d sl:paratl.'ly frlllll ldt h'IIH.I\k'rforlllam.:c aeros:-; thc S,IIllC
st.'al.:. usin,g I\H) difli:rclll l:olors f(\f thc furl'\.' l:urvc.

I.'wkinctk Tc.:sting
Thl..' cOllcept of i"oJ..inclit: l.::\l.:n.:isl..'" was lir... 1 inlrodul.."cd hy
Ili:-lllp allli PCrrilll...'1 '1'\\1.; tam is\lkindic fL:fcrs 10 dyn;lInil:

or kl1~thl.'lIillg or a llltl:-dl.: ill cOl1traclioll pCI'''

fllt"llll:d at a 1..'011"(;1111 "d()cit~ rcg:lrdk'ss (If llie fon.::: ~CIlCr;I(l;d

~hllnl.:llillg

Fig. 8,3, ERGOS Work Simulator {Work Recovery

Tucson, AZj.

:3-:. ~;e:ns,

-~----------------

... _._ ... _

. _

......

,~.

"

, I ,'''''--' '"

' ..... '~ .... ' ,..., ,y,""U ....

""L..

Fig. 8.4. LIDO Lilt (Loredan Biomedi-

cal, West Sacramento. CAl.

by the muscle. Accelcration is minimizcd so thatlhc force CX~

crteu is equal to the force necessary to move the object at a
constalH velocity. Because the inertial effects of force application arc controlled. maximum force can be measured
throughout the entire range of elongation or shortening.
Isokinetic testing has been found reliable in several stud~
ics."l - n Isokinctic lifting simulation was shown to be reliable
in studies done by Porterfield and colicagucs. 1J Frykman.
Harman. and VogcL:!~ and Alpen described the reliability of
isokinctic lifting stimulation.:6 The Janer researchers used the

LIDO Lift, presented in Fig. S.4.

Some critical issues have been raised regarding the usc of
isokinctic testing of Iifting.l:!.:~ Although isokinetic testing is
dynamic. it docs not mimic functional activities because work
is not usually performed with a fixed speed. Kishino ct aJl~ rcported that although isokinctk equipment can be ~\ useful tool
in industry and rehabilitation. it had important equipment limitations that limited its ability 10 predict pcrfonnancc in an actual work setting. Til11m~'~ reported that lifting is composed of
various combin<.ltions of isometric. isotonic. ~lOd isokinctic
effort that isokinetic technology may not mimic sufficiently
to be effective as an evaluative or rehabilitative 1001. Mayer
ct nl"'J compared isokinetic lifting on the Cybex Liflask with a
Progressive Isoincrtial Lifting Evalu.llion (PILE). and fOllnd
the correhuions between the two tcsts were low_ They concluded that thc tests do not evaluatc the same pamlllc1cP.' and
~anl1ot be substituted for each other. Alpert e1 al.: tJ however.
found isokinetic testing a valid predictor of subscquent progressive lift capacity testing.

Iso inertial Testing

Isoincrtial dellotC:-i :a dynamic lest of lifting capacity in which
the muscle is cOlltr<lctcd in orda to move a m<lSS imparting

constant resistance ~i1ong a vector. The constam-resistance assumption is violatcd in !i(ting and lowcring because of the accelerative nature of fr.::.\:iEY. Thus. [he force imparted by tilt:
person performing the ~ift is ~Klderativc. As a consequence.
true isoincrtial lift (t"';lng is nOl possible. Various testing
strategics have been de\ doped. howcver. to cOl1sTraillthe opportunity for rhe evalui':c to us~ acceleration. One such strategy involves testing (l\-:r limih:d vertical ranges that com~
spond to lhe range of rr'<Jtion ayail<lblc to (hc cvaluec to usc a
single biomcchanical ,egmcm (c.g.. from Iloor to knuckle
level or from knucki:: level to shoulder Icvd). This quasiisoineni<tl str~llegy he;' been dcveloped because it more
closely replicates the <:~iUal d~l1lands of lifting than do either
the i"omctric or isokin~'\ic stralL'gics.
Isoineniallift cap-=.,:lty typiC~llly is ICs!cd using one of two
similar "lppro"lches. SrFJok ~lIld Irvine.'ll." Garg. Mita!. and
Asfour,'.1 Kahlil anti <:{J,.:.orkcrs:'~ ~Uld Pytel and Kamon1.\ advocate the "psychoph: .,icaJ' approach. which involves thl:'
concept of 111.lximum i.:.cccptabk weight (MA\V). The maximum accepwhlc load h adjusted by the cvaluce by adding or
rcmoving lead shot fr.,m a tote box that is lifted at a particu
lar frequency to determine the acceptability of the load. The
load is adjusted llntillnc cvaluec determines that thc load rt>
fleets his or her MA\'. given th~ frequency. size of the box,
and both Ihe: stOlrting hdght and venical I'~mge over which
{he box is lifted. K<l.r"\\fJ\Vski-'; found this approach was reliable only for low and Illolkrate lifting frequencies (not
grc"Her tl1"111 six Iifb per minute). MiwP:; rt:portcd th<Jt tht:
psychophysica~ IIlcth(,d tCl\(kd 10 ovcrcstimah: the MAW of
lifting.
M,llhcSllll'I', dcsl.:ribcd the WEST Standard [~vaillation
(WSE), a progressive lift~loweril1g tcst proct:durc in which
h.md is il1<:1'casc<.l incrementally while providing the cvaluct:
an opportunity 10 <.h.:crt<.t-\c vl.'ni",."al range as he or she approx-

_ ..

i..
_._----------

14~

I,

illl;IlCs Lll.IXiIllUlll .. 1I1~C

"I'

IlIUliUll 1Illljl.:!"

iUdd.' The \\'SE j,

the most widdy used c(l1l1nh:rci~11 tcst of lifting cap:u.::iIY. \\ illl

approxinwicly IIO() units ill usc in 1991 throughoul Nnnh

1
]

I
!

in
I,
1

()

1
.
.

America and Auslr;t1ia. I'vlathcsOll n reponed Ih;1l Ihis ;11"

proach has good inlrah:st rdiahility wilh l"(lI:fIiciCnls of \;tri
:llioll of k:'\:\ than Yk. Jacobs. Bell. and PopcJ~ lIsL'd a .... illlil;lf
progrcs!'i\"c lifting cap,Kity appro"lch in lhe: Opcr;uional I.ift
Task (OI.TJ. III lhis [CSt. \\\:ight in a craIe is illLTCiLSt.:d illl.:I\,'mentally until the subject is unable to lift thl' load.
Another pmgn.:ssi\"c lil'! c.tpacil)' ;tpproach to isnincni:li
mt:asurcl11cnl or lifting pcrfonn<lncc dc"dopcd by Kroclllcr'"
involves a progressive lifting Glp_lcily prouK:ol in whid} lht:
evnlucc is presented with gradually incre:\sillg loads lIsing iI
weigh[ machine {hm captllrcs the weight :llld maintains a li.xed
tr'ljectory. The stu~y reponed a coefficient of vilfi'llion of ),2
to 3.9% in an overhead lift and 5.2 10 7.Sq.. in il knuckh.'height lift. The smne subjects showed higher v,lriahility wilh
static tests. The coefficielll of vtlriation willt the s[atic lcqs
ranged from II.() 10 15.4<::'t.
Mtlycr ct al JII lllodilicd the progn.:ssi,c lift capacity 'Ipproach to c.k"c1op the Progressive 1s0inCrliai Lift Evaluation
(PILE), which requires four lift-lowers over a standard venical range wilhin a 20-second period before the evalucc is
asked whether the load is cquivulcnt to a MAW acceptable
weight. If noL the load is changed 'incrcmcntally. Different
weight increments arc used bascd on gendcr with IO-pollnd
inCrCI1lCiHS for mcn and 5-pound incrcmcnts for ''''omen. The
PILE ulso involves an age-based hean rOlle limit:'llion and reslricts thc c,a!uce to loads of less than 55 to 60% of ideal
body weight based on gender and height. This approach has
been foun(i reliable in a smull sample. Testrcicsi reliability of
tht: PILE ~howed a corrcl::llion eoeflicielH of r = .M7 for lh~
lift from noor to 76 cm :.md r = .93 for the lift from 76 em to

Il'sls. llw WEST-EPIC;: I. whidl lISI.:S lh\.. ELC pmlOcol. is

11I\S\..'llh:d in Figmc X5. Tht' ELC has ht'(lUllC a "gold sland,tnl" ;1~;lillSt ,dlidl to measure the v;llidity ll( othel" more expl:lIsin: t~ p\..'~ or lil't lest tedmology. Tilt: dl.:\'ell)p~rS (11' the.
EPIC I.ifl Clp:lI..'ily lcst implemenled a lr"ining ,lIId ccnilicaliOll \'1"\1;;1";1111 I'll! lesl II."C!'S that provides l:l:nilk,lIiol\ 01" proli..'ssillll:II, and (11" lcdlllili'lIh. PmlCssion;lls tire ccnificd 10
pcrfo1"ln Iht' \..,,;t!Il:lIiOIl within theil: area or tr:lining and expl;nisl'. Tlll.:y Ill"y ;dsu Stllk'nisc h:dllli\.:'i'llls. Technici;lll:-; arc
cenilil.."d (0 prm'ide lhe CY"lu'llion under the supcrvisiolll,f lhe
ccnilil.."J profl.."ssioual. The primary issuc that distinguishes the
profession'll from the lechnici'lll is the prokssional's lraining.
whidl pro"ides the ahility to make correct judgments COllL'crning Ihe appropriate rcsponse to s)'lllpiolllS that occur as
lhe lesl pmgr~sscs.
In lhl: isoim:flial approach. till.': ohjcL'IS lIsed arc similar to
thosc found in re:t1-world l;lsks. As .1 cunscquence. this 'Ipproach is gellcr,lIly considered 10 have good validity. SOllle
researchcrs. however. havc raised concerns about thc safety of
this ;lpproacb: 1 Others noh: that tllc practicality of lhe tcsl is
limited in that it typically requires 20 10 30 minutcs to dc

137 CIIl.
Matheson ct al JI provided further elaboration of this approach. U~ing the samc four repctitions with ,\ 30-sccond
cycle anti "masked weighls:' which limil the evalucc's
knowledgc of the amount of weight lifted to the .Icwal experience of the lifting task itself. these researchers demonslrated
good reliability on a test-retcst basis: test-retcst reliability of
r = .77 for the lif[ from floor to 76 CI1l and r = ,81 for the lift
from 76 Cl1llO 122 cm with a frequency of four lifts every 30
sCL'onds. This b,l:-;ic protocol hu:-; been revised by other researchers. Alpert cl aPO used il frequency of one repetition per
30-,second cycle and a slaning point of S<Jlit of the subject's
isokinctic maximum; they reported tcst-retest rclinbilil)' of
I' :::;: .91. U~in,g thc ollc-repclition-pcr-cyclc frequcncy over
li,c vcrtical ranges. Goldcn demonstraled good test-retest <lnd
intcr-rater reli:Jbility:n reporting test-retcst reliability that dep~nded on the test and rdnged from r = .62 [0 r = .87.
Subsequent modifications to the PLC protocol have becn
undcrt:'lken by Matheson and colleagucsJ.l.44 in the EPIC: Lift
C<tpacity Test (ELC). Thcse changes include standardi7.ation
01' Ihe load incrcments across gcndcrs, determirmtion of the
vertical liflillg ranges bascd 011 lhe evaluec's height. and deVel(1pmellt l)!" six subtcsts in lile test battery, with later tests
using informatioll from the cvalucc's perfonnal1l:c on e<'lrly

Fig. 8.5. WEST-EPIC Uft Capacily Test (Work Evaluation

Systems Technology, Signal Hill, CA).

MI:t1P.OILil PI IlUN Vr I Nt:: ~!"'INt:: A ~HACTITIONEH'S MANUAL

'vV

Fig. 8.6. Comparison of lill capacity

evaluation technologies using !lle National Institute 01 Occupational Salety
and Heallh test selec!lOn crileria.

I
,,~

~
'~

,I

Factor

Isometric

Isokinctic

Isoincrtial

Safety

Low> High

ModernIC> His:.h

Modcr.:nc

Rclbbilitv

High

Low> High

Low> Modernte

Validity

Low > Modcrmc

Low > Modem!c

HiRh

Cost Eauiomcnt

r-,'lockrJlC

Hi~h

Low

Cost Administration

Low

l\1odcr.llC

High

_.__

tcnnine the MAW for any p'H1icul'lT cOlllbin;:llion of frequency. starting height. and \,(:nic;:,1 displacement. and lhat
both the time \lnd effort expended by the worker is SUbS!imtially more th"l11 is found using an isometric or isokinctic
'lpproach.~h
_
The potential value of isoincrtiJl ~lrcnglh (esting with a
disilblcd population depends on it . . relinbilily .!Od validity.
With lhis nppro'H:h !O testing. bOlh lcsl-retcst aod intcrrater rdiability depend on lhe C'Irl; with which the lest
is COOdUCICd. Within-test "rdiabililY checks" in the ELC
arc available to conflrm the e\'alll~e's performance reliability through a comparison of pal'orm<lnce at different
frequencies or .It diffcrclll ranges of motion. These COI11parisons among individuals are dependable and provide a
reasonable benchmark with which to compare an c\'aluce's
performance to dClcrminc whether or not it represents a best
effort.
The cvalui.uion of lift capacity can be accomplished
in many wayg. Selection of the appropriate test depends
00 several factors. A hierarchy of factors has bcen established by the National lnstitulc of Occupational Safety and
Health.':~ The author has applied this hierarchy to the various types of lechnology thaI arc availabk to cvalualc lift capacity 10 produce a comparison of thcse approaches (Fig. 8.6).
Figure 8.6 depicls a comparison or lif! capacity evaluation systems that can be used to s~lect the technology
that the evaluator \vishcs to purqlC. \Vhen a r<loge of
ratings is listed. the evalu~\tor can improve the ratings
through training and the applic.ltion of diligence ;lOd a high
degree of professional skill and acumen. In most cases. the
range depends on the evaluator's training. experience. and
skill.
The evaluation of lift capacity has developed beyond clinical art to have i.\ firm base in science. aided by well-thoughtout and appropriately designed technology. The intent of this
chapter is 10 present an overview of the technology and applications to .Issisl the clinician in using this technology more
effectively.

A: In\'eslig;uionfo. of the relation between low back pain and occupatiun. III. I)hysical rl.'<)uiremcnls: sitting. standing and weight lifting.
InlluSl Med41:5. 1972.
5. Bigos SJ. Spengler OM. ~fartin NA. Cl al: Back injuries in industry: A
rClTOspcelivc sludy. II. Injury factors. Spille II :252. 1986.
6. ~~atheson L. Moone)' V. C.:liOl1.O V. ct ;II: Effect of instructions on isokin.:tic trunk strength \ariability. i'diability. absolute value. and prcdicti\"e
valid!I). Spine 17:914. 1991.
7. Andersson Gll1, Ch:lffin DB. Pope MH: Occupational biomechanics of
the lumbar spine. In Pope MH. Andersson OBJ. Frymoycr J\V. (cds).
Occupation:11 Low Back Pain: Assessment Treatment and Prevention.
S\. Louis. Mosby Year Book, 1991. pp 20-43.
H. Ch"nin DB. Andersson GBJ: Occup:'Ilionat Biomechanics. New York.
John Wile)' & Sons. 19S4.
'J. Garg A. Mil:l! A. Asfour SS: A comp;lrison of isomelric strength :ll1d dynamic Ii fling cap;lbilil}'. Ergonomics 23:13.1980.
10. Chamn DO: Diomcchanic!< of manual malerial handling and low b"c:k
pJin. In (Xcup:!lional Medicine:: Prindples and Pracl;c31 Applie:'Ilions.
Chicago. Year Book. 1975. pp443--467.
II. Caldwell LS. Chaffm DB. Dukc...Dobos FN. CI al: A proposed st:mdard
procc.:~urc for st:lIic muscle !otrenglll testing. Am lod Hy~ Assoc J 35:201.
1974.
12. Kishino ND. MaycrTG. Galchc1 RJ.'::I al: Quantificmion of lumbar fune
lion. P,I" 4: Isometric and i~okinetic lifting simulution in nonl1a!lIubjccts
and lowh:lek dysfunctional paticnls. Spine 10:921. 1985.
13. Baltic Me. Bigos SJ. Fi!ohcr LO. ct ::II: Isometric lifting strength as:l pre:
diclOr of industrial back pain reports. Spine 14:851. 1989.
1.... Zch J. Hansson T. Bigos S. el al: Isometric strength testing:
Recommendations ba~ed 011 a slali~lical antilysis of procedure. Spilll'
11:43. 1986.
15. Chamn DB. Hemn GO. Keyscrling WM: PrccmplO)'menl slrength lesling. An updated posilion. J (Xcup Med 20:403. 197~.
16. 1'.larras WS. King AI. Joynt RL: Mcasurcmellls of loads on the lumbar
spine under isomelric and i~okinetic conditions. Spin.c 9: 176, 1984.
17. Hislop HJ. Perrine JJ: Thc isokinctic (onccpt of ex.ch.-isc. Ph)'s Tlicr
~. Ma~or.t.

47:114.1967.
IK. Aitkens S. Lord J. Bernauc:r E. ct al:

19.
20.

2 I.

22.
REFERENCES
I. M:uhesOIl LN: Ill1lu~triill Rehabililalion Resource Book. Sanla
Margarita. California: Performance Assc~~lIl(~llI & Capacit}' Testing.
1991.
2. Pheasant S: Grgotlornics. Work and Hcahh. Oailher:<>bur. MD. Aspen.
1991.
J. M,lgOTa A: Illveslig:1110tlS of the rdalion Ix:lweclI low bad: p;lin :md O{'.
cupalion. Indust Med 39:31. 1970.

..

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23.

24.
25.

Analy~i!i

of the \';1\;dity of lhc UlI(l

DigilOlllsokinclie Sptcm fresearch p;1pcr). Da"is. California: Uni\'cr~ity
of Califomia. D'I\i~ School of r.kdidne. 1987.
BurdclI R. V:m Swearingen J: Rdi"bilily of isukinetic muscle em!ur:lllc,:
Ic.~IS. J OCClIp Sports Phy'- TIler R:4S4. 1987.
L:lIlgr:lIla NA. Lee CK. ,\1cxander H. e! al: Quantiwti\'c :lSSCSSIlICllt of
back strcngth using isokinclic testing. Spine 9:287. 1984.
l'.-lcCrory r-,'IA. Ahkcns. SG. A\'ery CM, cl <11: Rcliabilil)' of concClllrk
and el.:(.entric measuremenls of lhc LIDO acli\'c isokinclie rehabilitati<lll
SysiCIll. Mcd Sci SPOn!> Exerc 21(Suppl}:SS2. 1989.
Rose 5. Delitto A, Crandell C: ReliabililY of isokinctic lrunk muscle pcrform;lOce. Phys lller 6S:H24. 1988.
Smilh 55. Mtlyer TG. Gatchel. RJ. el al: Quanliflcation of lumb;lr funclion. Part I: Isometric and multispeed isokinelic trunk strength mcasure:.
in sag,iHal and axial planc~ in normal subjects. Spine 10:757. 1985.
Porterfield JA. MO!'lardi RA. King S. el al: Simul:lled lin te.sling lls;n~
(oll1puterizcd is(lkinelie.\. Spine 12:6:'0. 1987.
FrykTll:l1I PN. 1-l;mn;1O EA. Vogel J: Using a new dynamometer to Ctlll\
rarc Ihree lift stylc... (abstraCt!. Mc~ Sci Spon..<; Exerc 10:87. 1988.

.L

~h.

. ....... ,..... ,,, v'~

:\1(11:11 J. \1.1111":,\111 I.. Beam W, <.'1 al: The r<:liahility and v;!lidily of
l,.h tit' lIl:tXillllllll liflm~ ~';lp;l.... iIY, J O . . ~llp Rehahil 1:13.

tWI> Il~"\

1991.
~7. I{ulh...h.'lll
~S.

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~

Spun:-I'hy .. Tlk'r III:I~(,. 19:-;S.

Tf;. B;t!llc, I). Nidl"l... G. 0.:1 :11: Pro~n:~ ... i\.... i:-I,illcni:ll liC.info
l,";.IU;t,i"I:, II :\ "'\llllpariM'll \\ 1\h i~\lldnclic lifting ill J. di..ahkd ..:hroni..:
It\w.h:u:ll'.lllI indU.'lri:ll [ltlPlll:\li\ln. Spin\.' 1~:99R. 19SR.
.'11. Smluk SII. In 1II1' 01: ~bxil1lum :1":"'Cpt:lhk wcit:hl of lifl. J\.m Intll-lyg
As.,o\: j ::-~ .'~1. 1%7.
31. Snouk Sit: I'.,y..:huphysi"::ll "Imsi~kr;tliuns ill r..:rmissihk '(lads.
ErgIlI\1I111i.. ~S:.l~7. 19S5.
Y!. Kh:llil T~t. \\"aly SM. Gcn:lidy :\\1. 1.'1 :II: Oclenllin:llion of lifting abililies: A cllmrJ!:,1i\'c stully of f'lur lechniques. ATIl Ind lIyg A~soc J

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P::::lcl JL. K:llllon E: Dyna1l1it' .qrenglh lest :IS a prediclor for 1Il:lxjlllal and
al'l.:,:plalll.,: hlling. ErJ;ollolilks 2~:6(,3_ 19&1.
J.1. !\:trWt\w"i..1 \\": \.bxilllll1l\ IO:Jd lifting .:ap:Jcily of rn:Jk~ OInd fCIIHllcs in
le:lIllwu,l. !.\b.,u<t.:Ij. Prnl:ceJing, uf the Hum:1Il FOIclors Socicty.
LOlli,vilk. I\\.'mm:ky: LJl1in'rsil~ of L(luiwilk. 1985, pp 6S0-699.
.j .'. 1\lilal :\: Tlw p'y.:hophysic:11 ;\ppro:tdl in m:lIlu:l! lifting: A verilic:l1iof1
...tlldy. HUlll FaclNs ?5:.1~;;. 19~~.
.\(,. 1\lallle1.111l I..": WEST:! Examincr's Malluill. Work [\.:llu:llion S)'SICIl1S
Ii.. chl\o'(l~~. 19M:!.

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~b~h<'\\' "1"1': Clini.:al u~.::' \,1" i~l,kil\ctic nll::'Tiler (J7: IS.1O, JI)S7.

J\1. LUll!> tH.,

.'lln:lll('rH~, l'hy~

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151

LIl'" 1,.'1'-'

~7.

M:llhcson l.N: Evaluation of lifting & lowering c:Jpacity. Vocational

[ ....:llu:ui(ln :lml Work AdjL"tlltcnt Bulletin, 19: 107. 1986.
3S. J:u;obs I. Bdl DG. Pope J: Comparison of i~okinelic and isoillCnial lifting. tcsts :IS predictors of maxim.:ll lifting c.:lp.:lcit),. Eur J Appl Physiol

57:146,1988.
W. Kn)ClIlcr KilE: ;\.n isoincniallcchniquc to a.<;sess individuallifling capa
hi'it)'. HUIll Facturs 25:493, 1983.
40. Ma)'er TG. Barnes D. Kishino ND. ct al: Progrcssh'e isoincnial lifting
evaluation. I. A standanlizcd prolocol :\IId nonnativc dataha!Oc. Spine
13:993. 1%8.
41. lvblheson L. ~. 1ooncy V. Jarvis G. CI al: Prog.ressi ...c lifling cap:lcily witlt
masked wc,:ighIS: Rdiahi!it)' study (abslract). PAR Rcsc:m;h Found:ltion.
Physical Assessment ;tnd Reactivation Ccnt~r. Irvine Mcdical O:nler.
Irvinc Califomia. Presentcd .It lhc 1"lt'nllltim",1 Society fi)r t"c' Study of
,he: Ul1JllJur 5I'i/l('. Bosloll. MA, June. 1990.
42. Golden NS: An .:lssessment of inlerr:lter reliability .:lnd inlcrtest correl:!
tion of a progressive psychophysical lifting evaluation which me.:lsures
oceasionalliftinf:, cap'lcily (thesis). University of Iowa. Augusl. I99{).
43. Malhe!OOn L: EPIC Lift Capacity EvalU.:ltion Manual. S.:lnta '\03, CA,
Employment POlcntialllllprovemell1 Corporation. 1991.
44. Matheson L. Moonc}' V. Grant J. el.:ll: A test 10 measure lift Cap.:lCil)' of
physically impaired adults. Part I: De... clopllI~nl .1Ild reliability testing. In
press, Spine 1995.
45. N:Jtional Institule for Occupational SafcI~' and Health: Work Pruclices
Guide for ~'bnu.:ll Lifting {Technical Rcpon 81.122]. Cincinnati. OH
Division of Biomedical and l3ehavioml Scicnce. NIOSH. 19S J.

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9 Back School
PAUL D. HOOPER

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NEW PERSPECTIVES IN BACK PAIN EDUCATION

'.--J

Research over the past several decades has provided much

new infonmuion ubout back pain. During this lime, dingnos-

tic procedures have improved considerably (c.g., magnetic

resonance imaging. compulCd tOlllogmphy. electromyography), <IS have methods of (rcalmenl. Likewise. our under
standing of spinal anatomy. mechanics. and pathology has increased. Even so. ccnain aspects show no evidence of change.
The overall prevalence of back pain remains around 80%.
with 'Ill annual incidence of 5%. The number of people disabled by back pain belween 1971 and 1981 incrcnscd by
168% (14 times fasler than the population growth). The annual cost associated with back pain in the United States is estimated to be in excess of S50 billion. I Although the significance of past advancements cannot be ignored. no single
procedure has been shown to alter the long-term outcome for
patients with back pain. Even procedures. such as surgery,
thm positively affect the short-term course show little lasting
benefit. 2
As the problems and costs associated with back pain continue to increase. it is clear that we must approach back pain
with a different altitude. Clinicians providing care for patients
with back pain must accept the responsibility to promote selfreliance and resist the temptation to make patients dependent
on carc. Employers must assist the individual in obtaining
care and make every effort to hasten the injured individuals'
return to work. The thirdparty provider must promote pre
vention programs. in both the work place and the clinic.
Finally. the patient must accept the responsibility for his or
her own recovery. The single 1110st important aspect is the motivation of the p'lIieIH to get beltcr.
The purpose of this chapter is to take a look at the use of
education programs as one factor in reducing the incidence
and severity of back pain. 'In this are'l. education programs
have developed into a formal presentation commonly referred
to as the "back schooL" The specific objectives of the follow
iog discussion arc as follows:

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to describe the general purpose of the buck school and

the role it plays in the prevention of back pain
1O describe the historical development of the back
school
to review the literature regarding the effectiveness of
the back school

II ~ I
I

PURPOSE
The back school is a panicular method of teaching back pain
prevention and self-care. It is a precisely directed presentation
conducted in a setting designed and supplied for the sale purpose of educating the patient This process of education may
take many directions. The programs used by the author are directed at patients with back pain and at workers with back injuries. These programs include the following categories:
Introductory back orientation program (Basic Training).' This type may be used as an introduction to back
safcty for patients and/or for employccs <\s part of an industrial safety program.
Back training and exercise program for all patients and
employees wi"th a history ofb.ack pain-the classic back
school (Put Your Back Problems Behind You!!!)'
Intensive back training and exercise program for pa
tients and employees currently receiving some form of
disability or compensation for b;lck problems-back
school plus specific rehabililation procedures
Back safety and injury response training for management and supervisory personnel. An extended program
designed to acquaint those involved in \Vork~rclatcd injuries with the realities of back pain.
The principal goals of the back school program arc education
and self-responsibility. A necessary step in decreasing Ihe impact of any health problems involves improved understanding
through patient education. In addition. to resolve the problem.
patients must accept responsibilily for their own health.
As a practicing chiropractor. I have treated many patients
with back pain. Most recovered quickly. but as so often OC153

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to describe some of the better known back school programs

to discuss the various formats used in presenting a back
school program
to discuss the physical requircmcnls for presenting a
back school program
to discuss the various applications of the back school in
a private pr.:tctice. as a public service, and in the workplace
to discuss the most common problems and the limitations of the back school

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154
curs, many had rCCllrrcncc~. Like many authors who have ad~
dressed the topic of back pain. Ill)' interest in prevention be
gall after personally experiencing recurring back problems.
As my interest grew. I suc("cssfully applied the principles that
I learned to my own back. Pleased with the changes 111<11 I
experienced. I implemented a back school in my private
practice.
My initial .ittcmpts (0 educate patients in back pain prevention were based on existing programs described in theiitcratufC. Over the pas! decade. I have lllodihcd my ideas COI1-

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

back school.131~ Thousands of back school programs have

since developed; some are fonmil and involve the use of specillc audiovisual aids and materials. whereas others are more
informal and involve readily available props.

STATISTICS

The impact that patient education programs havc on the out~

come of any disease is diftkuIt 10 gauge. Some l\iJcnce illdi~
catcs that certain diseases. such as measles and typhoid. have
been positively impacted by these programs. Objective evicerning the treatment and prevention of back pain. I flnnly
dence regarding the effectiveness of the back school. however,
believe that treatment is \"inually useless withoUl the cooperis mixed. Some studies have shown that the back school
ation of everybody invQI\"t~d. including the patient, the c1ini~
has a positive effect on patients with low back pain.12.IS.17
cian, the employer. and the provider. This cooperation may be
Other studies have shown that the back school makes
attained ani)' through proper education.
Iiule difference when compared to more common and traditional approaches. HI In an extensive review of the literature,
Linton and Kamwendo state support is limited for the
HISTORICAL PERSPECTIVES
idea that a low back school can influence factors such as
Although often described as a disease of modern society. back
sick leave, work status, pain intensity or duration, etc. 19
pain is nO( a new problem. Man has been afflicted with
Berwick et al found no measurable impact in L:umfort or
back pain since ancient limes. Work~related back injuries date
level
of functional status.20 On the other hand. Feldstein
back as far as 2780 BC.~ Likewise. attempts to reduce the in M
et aFI demonstrated that back injury prevention programs
cidence of back pain through educ~ltion programs date back
were successful at changing behavior, at least in the short term.
several centuries.1> In modem times. however. the emphasis on
One study by Brown et alu offers some encouraging supeducation has increased in an ancmpt to minimize the impact
port for the use of back school. The study investigated the
of back pain. This process began largely because of the obcost effectiveness of a 6 M
weck back school and rehabilitation
servations of Fahrni in the late 1950s, who noted a significant
program in terms of decreased lost work time and medical
difference in the incidence of back pain in a "groundcosts as compared to a control group. A key finding in this
dwelling" population when compared to industrialized socistudy was that back school participants had half as many reineties. He anributed this difference in part to postural or
juries as nonparticipants. Data indicated that the back school
lifestyle variations. Fahrni claimed that ground-dwelling
was helpful in reducing the number of reinjuries in these
populations spent more time in a flexed posture, and that deworkers for at least 6 months. The back school group had a
creasing the lumbar lordosis would assist in preventing probsavings in medical costs of $9.743 during the postintcrvention
lems from developing. He was one of the first physicians to
period. The authors concluded that the back school group had
teach therapists in patient education techniques.'
less lost work time. lost time cost, medical cost. and injury
At about the same time. \Villiams developed a series of
during the postintcrvcntion period..!.!
back exercises (\Villiams flexion exercises) in an effort to re~
In contrast to the relatively scarce support for the back
duce the incidence of back pain.1( \Villiams thought that flex M
school in the literature, a number of studies in industry indiion of the lumbar spine would eliminate back pain. and he
cate that back pain prevention programs, including the usc of
urged that every effort be made to reduce the lumbar lordosis.
a back school. have a significant impact on reducing back
McKenzie also thought environmental factors contributed to
pain costs. ~~ Some examples arc as follows:2~
the development of back pain. but he recommended an en~
tirely different approach. one that incorporated extension exAmerican Biltrite saw Workers' Compensation claims
drop from $ ISO,OOO 10 $40,000 annually at the end of a
ercises in an effort to increase the lumbar lordosis. 9
The back school as a formal approach \V<1S first mentioned
back school program.
in the literature ill the early 1970s with the work ofZachrisson~
Southcrn Pacihc Transportation Company saw a 22%
Forsell. What was koO\vn as the Swedish back school was de~
decrease in the incidence of on~lhe~job back injuries
and a 43% reduction in lost work time. They calculated
veloped in an automobile factory in response to an increasing
problem with olHhe-job back injuries. Ill 11 This program was
the savings at $1 million in a single year.
designed for a specific population group and was probably a
Boeing Company participated in a controlled study of
response to the lack of effectiveness of the then current treatthe effectiveness of back education on its workers in
ment r.pproaches. BerquistMUllman and Larson published the
which 3424 workers were provided with a back school
and 3500 were not. Although the overall incidence of
first statistical studies regarding the effectiveness of these cd
lIcation programs in 1977. 12 The next few years saw the develback injuries was not statistically significant between
opment of several other back school programs, including the
the two groups. those in the back school group were
Canadian Back Education Units (CBEU) and the California
demonstrateu tv illlVe lower lost work times.

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When one COllsitkrs tht.: staggering costs of back injuries

011 the work forec. even a small reduction in injury rales or
lost work time hilS a signilk;.lllt impact
One aspect of the back school that appears to be consistellt in the literature is the positive impact of this type
of program on the patient"s attitude. Dutro and Wheeler
cite different slUdics (h'll indicate that most individuals
attending back Sl:hool progrmns found them useful; in addition.
most felt the program hold indeed lowered their level of pain. ~~
UCC,lUSC much evidence points to a variety of psychosocial factors. including motivation and lack of control. as key factors in
the development of chronic back pain and/or disability, this effect on patient attitude. may be the most important role for the
back schooL In fact. I contend that lhe b:lck school is morc uscful in changing an individual's attitude about their back problems than it is in changing the way they lift

(15 10 20 subjccts) and a variety of professionals serve as the

instructors. including an orthopedic surgeon. a psychologist. a
psychiatrist, and a physical thcrapist.
Class I. This session is taught by an orthopedic surgeon
and focuses on anatomy, mechanics. and lhe aging process of
the spine.
Class 2. In this session. a physical therapist leaches proper
body mechanics. First aid methods for obtaining temporary
relief from back pain are also included.
Class 3. ll1is session addresses the psychi:Jtric aspects of
chronic pain and the influence of emotions on back pain. The
instructor is a psychiatrist.
Class 4, The final class is team taught by a physical ther,
apist. who leaches basic back exercises, and a psychologist.
who demonstrates relaxation techniques and discusses stress
management.

PROGnAMS

The California Back School"

Sevenil programs h.lvc been eSlablished as major contribulors

to the evolution of the back school, including the Swedish
Back School. the Canadian Back Education Units, and the
C.alifornia Back School. Although many other programs exist,
including modifications of those listed, it is worthwhile to
.
view the format of these programs.

This program. developed by White Matmiller, includeS three

90-minute ~essions held al weekly intervals. A fourth followup session is scheduled I month later. Class size is small
(4) and most classes are taught hy a physical therapist.
Class 1. The focus of this discussion is on basic anatomy
and aging of the spine. In addition. the natural history of back
pain is outlined. Infonnation on pain relief and activities of
daily living (ADL) is included, Each patient is evaluatcd using an oh<;'f;ldr: cOIln;e and an exercise tolerance tes!.
Class 2. This session concentrates on ADL and'coordination exercises. The obstacle course is used to train pntients in
lifting techniques and other ADL. Participants learn back exercises and onthejob safety procedures.
Class 3. This class includes a quiz on [he information provided. along with a second texl on lhe obstacle course.
Instruction is given on more complex ADL. and individual
problems arc addressed. Patients arc given a stress tcst.
Personal Concerns Inventory (PCI). and instructed on its use.
Class 4. This session focuses primarily on problem sol\'ing. PatieOlS are once again tested on the obstnc1c course. The
PCI is rcviewed and suggestions arc made for reducing stress.
Each of the programs discussed provides participants wilh esseOlinlly lhe same basic information. including anatomy. poslure, body mechanics. first aid, exercise. stress reduction. nutrition. and lifestyle habits. Although the format varies
slightly. each has similar goals. To be dfective. a back school
should be able to adapt to the panicular environmcnt (i.c.. priv<.He practice, industrial, etc.) and to the needs of the participants.

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The Swedish Back School

Developed by Zachrisson-Forsell. this program consists of
four 45-minute sessions conducted over a 2-week interval.
Each session includes a IS-minute sound-slide presentation
followed by a 30-minutc presentation provided by a physical
therapist. Class size is relatively small (six to eight subjects).
Specific goals of the Swedish Back School are to (1) in,
crease pntient self-confidence; (2) understand the role trcatmentplays in the condition. and (3) reduce the costs of carc.
An outline of class content follows.
Class I. The focus of the fir!:t session is on anatomy and
biomechanics of the back. the development of back pain, nnd
lhe types of trealment available. Emphasis is placed on resting positions and some trcnlment advice is given.
Class 2. This session focuses on the stresses imparted on
the back from poor poslure and improper daily activities.
Exercises arc demonstrated for strengthening the abdominal
musculature.
Class 3. In thb more practical session. participants nre
asked to apply infonnution gained during the first two sessions. Various activities of daily living (ADL) are demonstrated and practiced.
Class 4. This session includes a review of lhe first three
classes and patient is provided with a written summary of the
information presemed. Pmicllts arc encouraged to become
physically active.
The Canadian Back Education Units :l'1

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This program. developed by Hnll. consists of four 90-minute

lectures hcld at weekly intervals. Class size is slightly inrger

THE BACK SCHOOL IN A CHInOPRACTIC PRACTICE

Although the back school should not be viewed as the solution to back pain. it is an essential component in the {rearment
and prevention of back pain. It should be an integral part of
any encounter with patients with b~lCk pain. Bccause so many
patients seen in a chiropractic oflicc have a primary complaint
of back pain. the back school should be a standard part of

156

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REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

treatment. Anhur White staled. "Back school is the center of

the fastest moving specially in health care today ... \Vc will
see chiropractors using bO\ck school in all of its forms and it
may change the face of the chiropractic hCJ.lth delivery system. Chiropractors have lraditionally delivered their lrealments .md moved quickly to their next palicnls. They have
nol, in general. spent time 011 cducntion and prevention. If and
when they do so. the public .\Od olher health care professionals will sec them as the I~lrgcsi body of spine care spcciJlists
with the most tools with which to treal spinal disordcrs,"2'1
In addition to reducing the impact of back pain on p:tlicllts. the back school should playa role in preventing back
problems. As costs for health care continues to escalate, the
role of prevention is increasing in importance. As an example,
the National Institute for Occupational Safety and Health
(NIOSH) has SCI, as a priority, a national health objective for
the year 2000 10 implement back injury prevcntion and reha~
bilitation programs in at least 50% of worksitcs. As of 1985,
only 28.6% of worksites with 50 or more employees offered
back care activities.-\{)
A description of (he back school programs used by the au~
th?r follows. Although the focus of attention is on the workrelated back injury, each of the programs is readily adaptable
for a general practice setting.
Introductory Back Safety Orientation for Industry
The purpose of this aspect of the back school program is to
provide all newly hired employees with an orientation course
in back safety, Topics to be addressed should include the folIO\\ling:
Basic back anatomy and biomechanics. This section is
structured to reduce the fear of the unknown. Anatomy
is presented in such a way that those attending back
school have an appreciation for the unique design and
function of the human spine..The role of the muscles.
bones. discs. and nerves is presented. The nature of injuries to each of these tissues and the type of treatment
lIsed for various injuries are discussed.
Cost of injuries. both to industry and to the worker.
Individuals should appreciate the impact of back pain
on everyday life. Most estimates p1:lce the toral costs of
b,lck pain at greater than S50 billion annually. but this
number is unmanageable for most people. More practically, discussion should include the average cost of visits to the dot::tor. the loss of wages that oflen result from
back injuries, and the costs on home and family life.
Overview of how back injuries occur. Too often patients
view the onset of back pain as rapid. In fact, many doc~
lOrs also look at back pain in much the same manner.
For example. when an individual bends to pick up a box
and develops back pain, she or he tends to blame the
box. The patient is often cautioned about picking up
boxes in the fUlure. In contrast. an individual who picks
lip a box and has a heart attack would not consider
blnl11ing the box for their heart problem. The patient un-

derstands that, although the episode may have been

triggered by a particular activity, the activity did not
create the problem. Ii is imponant to understand that
back problems arc like heart disease, they don't just
happen, , , they develop,
Causes of back pain. Back pain has no single cause.
Rather. il is the result of an accumulation of stresses
over a period of time. These factors include ~tress. poor
posture, poor living and working habits. poor body mechanics. loss of flexibility, and an overall decline in
health. To minimize the impact of future episodes of
back pain, each of these areas must be addressed.
First aid for back injuries. One of the most important aspects of any back school program is first aid. Because
many people with back pain arc likely to have future
episodes, it is imperative that they know how to respond
when problems do occur. The response may have a significant impact on Ute severity and duration of the
episode. When a patient sprains an ankle, the.y typically
apply ice. For some reason, however. when a back
sprain occurs, patienls often apply heat, many times at a
doctors advice. In the event of back injury, patients
should be instructed to: (I) stop whatever they are do
ing, (2) relax in a comfortable position, (3) perform
some type ofUfirst aid exercise" (Le., press-up, knee-tochest, or standing back bend), and (4) apply ice.
Self-responsibility. Ultimately. the solution to back pain
lies not in the doctor's hands, but in the patient's.
Consequently, the primary goal of the back school
should be to provide the individual with enough information to allow them to take an active role in their own
back care and to encourage them to accept the responsibility to do so.
This orientation program may he presented in a classroom
style format and should last approximately 30 minutes. It
can be adapted to accommodate small, medium. and large
groups.

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Back Safety Program for Industry

The purpose of this componenl of the back school is to provide all employees with information necessary to avoid serious back injuries. Topics of discussion arc similar to those
covered in the orientation program (sec previous section). The
content is expanded and the fonnat includes active participation on the pan of the employees. It is suggested that two separate sessions be included in this section. Each should be approximately 30 to 45 minutes in length and scheduled within
2 weeks of each other. Class size should be limited to 20 to 25
participants to allow interaction.

Back Training and Exercise Program

Those individuals who have had back pain previously :lfC tit a
high risk for future problems; in fact. a positive hi:-lory of
back pain is one of the most signific<lllt risk factors for future

._ ..._._,.. _._--,._----------------------------~

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0HAt-' II.:H 9 : BACK SCHOOL

problems. J' )! In addition to the increased risk, these individuals typically arc more interested in prevention programs. For
Ihese rc.~asons, this group requires more extcnsive training.
It is suggested thai this group enroll in an extended back
school program consisting of three 45-minute sessions. Class
size should be limited to 10 to 12 individuals to allow individual auention to specific needs and problems.
CI<lss I. Topics discussed include the causes of back pain.
anatomy and biomechanics, first aid for back injuries, and relaxation techniques.
Class 2. Topics include lifting techniques and instruction
in ADL, safety lips, and specific flexibility exercises.
Class 3. Discussion includes the risk factors for back
problems, good health tips, stress management. strengthening
and coordination exercises, costs of back pain to industry and
to the individual, and self-responsibility.
Intensivc Back Training and Excrcisc Program
Those individuals currently receiving care for a back injury or
those currently receiving some form of disability should en
roll in an intensive program to address their condition and
their problems. This type of training consists of three classes
as described in the preceding section plus any follow-up exercise and ADL training as indicated by their condition. It is
important to appreciate that those patients who may be disabled need to be in some form of rehabilitation or exercise
program. In thc case of an injured atliktc, vuc ;:"'oiild nm expect full recovcry without some fann of directed activity. It is
equally unlikely to expect an injured "industrial athletc" to recover unless they arc active.

157
Management issues, how to dcai with the injured
worker (e.g., referral process, liglll duty, company <lttilude, etc.)
Legal considerations
Recent infonnatioll indicatcs that managcment education
and support may be one of the most effective ways of minimi1.ing the costs of back injuries on the job. Fitzlcr and Berger
describe ;]11 industrial progr<lin in which management w;]s
taught to accept low back pain and workers were cncourtlgcd
to report all episodes. Treatment was immediately available
and included worker education. Every effort was made to
keep the worker on the job. \Vorkers compensation costs were
reduced tenfold in a 3-year periodYJ..l In another study, Wood
described the effects of a personnel program designed to min
imize the impact of back problems. The program stressed
early .access to care in addition to changing the attitude of
management. n
Management should make every attempt (0 provide injured employees' with reasonable access to care. Programs
discouraging early return to work should be dis~ontinued.
Employers should explain fully thc employee's rights under
the Workers' Compensation guidelines and work to devclop
an atmosphere of cooperation. Prolonged disability from back
problems is often associated with adversarial situations between the worker and the employcr. litigation, and lack of follow-up .and concem.~ (This topic is discussed in greater detaillatcr in this chapter.) Only through cduc<.ltion, of both the
injured worker and the employer, can we take the necessary
steps to reduce this aspect of the back pain problem.
FORMATS

Back Safety and Injul')' Response Training

Until rccently, the use of education and training programs
reduce the incidence of low back pain has focused on
the injured worker. One of the most significant components
of any back safety or injury prevention program. however, is
the training provided to supervisory staff. The way in
which lhe "compnny" responds to an injured employee
has a great deat to do with the scriousness of the injury.
With this in mind. one must look at a somewhat unique
aspccl of the back school. The purpose of this portion
of the program is to provide the supervisory staff (e.g., management. store managers. union stcwards, etc.) with Ihe
infonnation necessary to deal effectively with the injured
employee when an accidclll occurs. The class is designed
to consist of one full day of 6 hours duration; class size is
limited to 30 to 40 individuals. Topics to cover include the
following:

(0

Risk factors. both occupational .tnd personal

Anatomy and biomechanics
Costs of back injuries, to the individual and to industry
Types of back pain
Causes of back pain
First aid for back injuries on the job

Over the years. I have taught back schools in a variety of formats. including lectures to large groups, small group sessions
with 6 to 10 individuals, and oneon-one instruction. Each
particular fonnat has advantages and disadvantages and the
design of any back school program should be adapted to the
specific audience for which it is intcnded. As stated previously. many industri<ll back safety programs arc bcs.t presented in a lecture fomwt. A program intended for patients recovering from a reccnt back pain episode requires a more
personal appro'lch. such as small group sessions. Some patients with particularly difficult or chronic problems may need
individual instruction.
Before addressing what is necqcd to implement a back
school in private practice, it is important to take into account
the rcquiremenls and demands of your particular situation.
Many well-meaning individuals h.we attempted to establish
some type of on-going patient education program only fo
find that the logistics were complicated and the demands
impractical. As with any patient education program. the
back school will change along with your time. energy. and
experience.
Many different formats for the back school have been attempted. The most successful for p:llicnt care has been a series of three classes, each belween 45 and 60 minUles in

158

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

length. In OUf facility, c1.1sses afC scheduled on Mondays and

Thursdays and participants arc scheduled on three consecutive nights (i.e., Monday, Thursday. Monday or Thursday.
Monday, Thursday). Consequently, the entire series of cl3SSCS
is completed in a period of 8 days. Cla...s size is limited (0 six

to eight individuals to allow individual illlcntion.

Group Versus Individual Training

At times. certain patients may require individual attention. As
a general rule, however. small groups of patients arc more
productive. The advantages of lcaching back school in small
groups include that the friendly environment reduces intimidation; patients learn from each others' mistakes and experiences; the variety of expcriences and questions is greater;
those in the group provide psychological support for each
other; in any state. it is encouraging to realize they arc not
alone; tcaching several individuals at a single session is cost
efficient.

Curriculum
Although the curriculum varies from one location and program to the next. certain basic clements arc found in most
back school programs. The infonnation provided should include the following:

,6
'.II

Anatomy-basics of spinal anatomy. It is imporwnt to

describe the anatomy in tenns that are clear to the palien!. Understanding the parts of the back enables the
paticnt to better appreciate the role each part plays in
their problems and in their recovery. In addition. the
marc an individual understands aOOm the back. the less
fearful Ihey become.
Posture. Many authors have suggesled that poor posture
;Jlays an important role in the develQpmcnt of back pain.
Although not everyone agrees on which posture is most
detrimental or most helpful. it is clear that any posture
[hm is sustained is. at the very least. a contributing factor to back pain. Patients should learn how to recognizc
both healthy and harmful postures. They should be able
to identify positions and movemcnts that allevi.ltc their
symptoms and be trlught to modify their work habits to
improve posture.
Body mechanics. The relationship of acti\'ities of daily
living to the development of back pain is an important
aspect of the back school program. Patients should
be encouraged to use their bodics in safe ways.
which is accomplished by teaching safe lifting tcchniques and by demonstrating and practicing a variety
of everyday movements and activities (c.g.. lifting.
pulling, cle.)
First aid. Thi~ aspect of the back school is one of the
most impol1anl. Even if patients understnnd how to use
their back and establish good back habits. accidents and
injuries slill occur. \Vhen they do. the reaction to the injury has a great deal to do with the seriousness of the

condition. Paticnts should learn to respond to any future

problems by relaxing. assuming appropriate 1l10V~111el1ts
and positions. pcrfonning first aid exercises. and applying ice and suppon.
Exercise. One goal of a back school program should be
10 teach exercises to minimize future back problems.
These exercises will vary with thc background and philosophy of Ihe inslructor. hut they should include rdaxation techniqucs. flexibility and stretching excn.:iscs.
strengthening programs. balancc and coordination procedures. and endurance exercises.
Stress reduction. Many back school progmms have included specific ,mcmpts to reduce stress in back pain
patients. Efforts [Q reduce stress ~nd tension arc a most
productive 1001 for the management of many musculoskeletal problems. including back pain. and should be
a focus of the back school.
Nutrition and lifestyle habits. The relationship bel ween
lifes.lyle and health is described to raise the level of pa~
tient awareness in this area. Topics covered include
good nutritional habils. smoking, alcohol. regular exercise. :lod relaxation.

,
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Needs
To determine the oplimal back school program that is both
effcctive and practical. the following wamlO[ consideration:
(1) patient population, (2) available space, (3) personnel,
(4) availahle time, (5) available equipment, and (6) fees.
PATIENT POPULATION

One of the primary considerations in developing and designing a back school is the nature of tile intended participants and
the demographics of the community in which the program
will function. Those panicipating in a back school may be
current back pain patients. a general patient population. backinjured workers (Workers' Compensation). participants in an
industrial safety program. managemcnt ,md safety personnel.
school-age children. or pregnant patients. As stated pre\'i~
ously. it may be helpful (0 develop sevcral different formats
aimed at rcaching diffcrent groups.

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AVAILABLE SPACE

The back school docs not require a large amount of space

in which to function. It is possible to use separate facililies specifically designed for patient education. or you may
want to "double up" an area that is used for other activities.
If space is a problcm. teaching back school principles to
small groups or evcn one-oil-one is marc practical.
Scheduling back school sessions at a time when the office
is not involvcd in patient treatmcnt activities is another
consideration. A b'1Ck schoolth.1t includes an obstacle course
and an exercise arC'l rcquires an open room with ;approx.imately 200 squarc fCCI of noor sp'll:e. The only rcquircmcnts
are that the room he c<lrpc[cd and clean. If the back school

.,

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159
follows a large lecture fonllat, you may want to consider
renting a small meeting room in a local hotel. at the local
public library. a nearby public school, church. or fitness center. In one instance, I found a nearby dance studio ideal for
our purposes.

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READY. FIIlE. AIM!

One of the most important aspects in developing a b~ll.::k
school is dctermining who will provide the instruction. Some
authoritic:; believe that only experts in lhe field of back pain
have significant success in the back schooL.:n A great deal can
be accomplished with existing office siaff. however, particularly those who have a history of back pain. The next option
is" to look for help in the community. Every community has
people with some health and/or education experience (physical therapists. licensed practical nurses, registered nurses. re~
tired teachers. etc.) who are eager and willing to work a few
hours a day and enjoy interacting with peoplc. An advertisement in a local newspaper should provide a li~t of qualified
pcapic. It is also possible to find the right person from among
your patients. Whoever is selected. she or he needs to be
friendly. uninhibited. and willing to listen and learn. (Note:
This search should not be viewed as an opportunity to recruit
new patients. Being serious about finding the right person for
the job increases the likelihood that the back school will be
successful.)

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AVAILABLE TIME

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The time schedule for back school sessions wilt vary.

Sessions that take place during the nomlal work day while patient care is being administered. necessitate both space and
personnel dedicated solely to this purpose. Scheduling back
school sessions during nonpcak office hours, during evenings.
or on weekends places less of a burden on your facility and
personnel.

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PERSONNEL

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97\OO-therapeutic exercise
97540--ADL and/or job-related activities
97708-ADL evaluation

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AVAILABLE EOUIPMENT

One advantage of a back school is thal no sophisticated or ex-

pensive equipment is required. Most items needed are found

around the house or on the job. such as a vacuum cleaner.
suitcase. floor mop. grocery sacks. etc. It is helpful. however,
to have n slide projector, a cnssctte tape recorder. and/or a
television with a video cassette recorder.
FEES

Perhaps one of the most practical questions concerns how

much to charge and who is to pay. Fees vary from location to
location. but a reasonable fce is the cost of an extended office
visit. Many insurance companies P~\Y for these services and
sometimes the patient's employer is willing to pay. \Vhatever
the cost. and whoever pays the bill. il has been stated that, for
everyone dollar spent Oil education and prevention. nine dollars arc saved!

In planning a back school, consider the options thai arl. llHlst

pmctic'll for your situ<'ltion and BEGIN! Anticipate changes ~tS
yOll gain experience. Many questions will remain llllans\\"en:d
a.nd the chances of success may be uncertain. If you w,lit Ul1~
til all questions arc answered and the best possible f~lcility.
staff, and format arc secured. chances arc you \vill nevCf start.
Certainly. the chances of success arc much better once yOll
begin!

Promoting the Program

To be successful. the back schoollllllst reach the intended au~
dienee. Depending on the type of program developed. this
connection may take place in a variety of ways. If the back
school is intended as a resource for your back pain patients.
they simply need to enroll in back school. If the program is intended as a public service. making the necessary comacts with
local service organizations or groups is required. Any interest
in presenting this information to industry necessitates active
"marketing" of these serviccs. The following information is
provided to assist in the latter endeavor.
Note: The back school will be ,an effective public relations
program for your practice. Most people contacted. and certainly most participants in the back school. will h3\'c a positive feeling about the program and about you. Th~ back
school. however. is not intended to be a marketing tool for
your practice or a way to attract new patients. It is a service to
those individuals wilh back pain and this fact must remain the
primary focus.
Use in industry remains one of the primary functions of
this type of educational program. The chiropractor is widely
recognized as an expert in the area of b;lck pain. and the: back
school allows the professional to positively impact the indus
trial community. To introduce a back school into local indus
tries, the chiropractor must first make contact with the necessary individuals. She or he must establish themselyes as an
expcrt and be able to convincc management that this program
will be lIseful. This relationship bct\\'ccn the chiropractor ,1Ild
industry. often develops gradually over a period of tim~: once
established. however. it should prove to be of bene lit to everybody concerned.
An initial contact is made with a representative from the
company or industry. This first contact will hopefully lead to
a most important step. the interview. which is used to cSl<Iblish what type of services 3re needed.

The Interview
After armnging 3n appointment with the :'Ippropri~ttc company
representative. the real wOik begins. This first mecting is an

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

IOU

opportunity to leave a lasting impression with the company

and that impression should be first class. It is important to

know as much as possible about the company before this

meeting: The following information is helpful.

What is the nature of the company. Le.. manufacturing.

heavy construction. material handling. high-tech. cIC.
How many cmployct::s docs the company have locally
Docs the company have olher facilities or branches
How long has the company been in existence and at this
location
What is the fUlUre market for the products or services of
this company
This infonnation is available through a variety of sources.

to the company. tilt: illl.:atioll ur job description wh~rt: lhe

injuries occurr~d, and th~ manner in which the cbill1s wt:rc
handled.
Once this evaluation is accomplished. it may be helpful to
do an on-silc evaluation or analysis or any problem arc;,s Ihal
arise in lhe records review. or particular iillcrcsi me areas 111at
have holO a high il1<:idt:IK~ of injury, especially back il1.iuri~s,
Other areas of interest induoc slips .ll1d falls. knee injuries.
.1011 and shoulder injuries. and wrist and hand problems.
As with patient care. once problems have been c1ci.lCly
identilied through a thorough case history and exmnin<ttion.
the clinician is in a position to offcr suggestions to address the
problems idcntifled. This advice may include the usc of back
school programs.

The local library has demographic infom13tion on most industries, as docs the local chapler of the Chamber of
Commerce. In addition, a receptionist or some other contact
at the company will often provide a grcm deal of information.
It is useful to vicw this first meeting in much the
S<.1mt: way as we look at an initial pcHicm inh.::rvicw. This
first encounter is the time to identify the primary problems
and to establish if there is a need for prevention services and.
if so, what type of assistance is needed. For example. if

a company has a large number of repetitive stress claims

for wrist and hand injuries but no significaJ1[ problems with
back pain. it may not help them much lO provide a
h<l("k "choot. Another company may have a real problem with
noise pollution or with exposure to toxic chemicals. It is helpful to have a list of individuals in the vicinity who deal
with other work-related problems. If you arc unable to
help directly. perhaps you can refer the company to someone
who can.
In addition to identifying problem areas. it is important to
establish the attitude of the company in health-related areas.
This informalion is crucial in developing a clear understanding of the health-related problems faced by the company and
the role that a prevention program may play.
INDUSTRIAL CASE HISTORY

The Industrial Case History is designed to provide information about the demographics of the company. the nature of injuries and problems Ih31 arc common in their work environment, and the manner in which they view health issues. h is a
most useful resource for this first meeting, It is unlikely that
any company rcprcsemativc will have the answers to all of the
questions on this form: they will need to do some homework
to provide all of the information required. This situation affords an opportunity to schedule a second meeting and also
helps to establish the nrst way in which one can function as a
consuhant 10 the comp:my. Le.. 10 review thcir Workers'
Compensation claims.
One of the first steps in developing a prevention program
\vith <I company is evaluating their p,ast on~the-job injuries,
Rt:vicw of the workers compensation claims for the past
2 ycars provides informalion on the type of injuries common

NEW PERSPECTIVES

The significance of past advancements cannot be ignored. yel

no single procedure has been shown to alter the long-term
outcome for patients \Vilh back pain, As stated previously,
even procedures such as surgery. show little lasting bcnent..\~
Similarly, the back school has not been shown to provide any
long-term changes in persons suffering with back paill:1'I,JII
Consequenlly. our approach to the back pain problem needs to
change,
One of the newest arC<lS of back pain prevention programs
is education of management <lnd supervisory staff. This type
of program involves addressing methods of prevention and
worker training and. perhaps more importantly. developing
appropriate management skills for supporting the injured employee. The emphasis of most industrial back s;'lfety progr.lIns
is on preventing injuries. Hcre. the emphasis is on minimizing the impact of the injury on the injured worker and on preventing drawn out litigated cases th.lt often end in disability.
Several studies have shown that the manner in which a supervisor, company doctor. or employer responds to the injured workers has ~I significant impact on the seriousness of
the injury.JI.J~ Chronic back pain .lOd disability arc not solely
a result of physical injury, but arc ;,lssociatcd with a complex
interaction of factors, including psychosocial issues.
Management and the clinician must make every effort to understand the impact of injury on the individual.
Industry can facilitate worker recovery by providing c<lrly
return-to-work policies. maintaining contact with the injured
worker, and accepting his or her injury as real. Efforts should
be made to reduce the likelihood of liligation. Onc study by
Ihe California Workers' Compensation Institute showed that
lhe most crilical element in reducing litigation was inform<ltion. Most injured workers went to an attorney because they
felt they did not properly understand the Workers'
Compensation systcm.JJ Other studies clearly demonstratc
that the presence of an attorney delays the "hculing" tirnc.""I,J;'i
With these factors in mind, an innovative educational program was established that was designed to teach the manage
mcnt team how to deal effectively wilh Ihe injured worker.
Topics covered include the following:

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Costs of back injurics-to industry and to thc Individuai

ClUSCS of back pain/types of back pain
Risk factors. both occupational and personal
Anatol11Y and biomcchanics of the back
f-irst aid for back injurics on thc job
Management issucs-how to deal with the injured
worker (e.g., rcfcrr'll process, light dut)'. company ;luitude. etc.)
Legal considcrations

THE "10%" FACTOR

One of the predominant statistics in the litcntturc pertaining to
back pain is that approximately 10% of workers account for

80% of the coslsY' To gain control of the back pain problem

in industry, we must take a close look at this small group of
individuals to try to dctermine why their situations arc so different.

The Injured Worker

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' .... I V , ...." V l ' uvnVUL

To understand bettcr the back-injured workcr who becomes

chronically disabled, we must take a look at the situation from
a ncw and different perspective. No longer is it adequate to
equate the impact of the injury with the "seriousness" of the
physical ailment. We must inslead differentiate between the
disease of low back pain and the illlless associated with low
back pain.-I7
The process of disease is defined solely as a biologic dis
turbance. The illness is the subjective experience of the dis
case by the person in his or her environment. As such, understanding the behavior of an individual with a disease or a
disorder in the context of that environment becomes crucial.
Two individuals with similar disease.\ often respond lotally
different ways, One patient may be (O[ally disabled. whereas
the other may be merely inconvenienced. In spite of the nurn
hers provided previously. there is some thought that the ,U...
ease of low b.lck pain has not incrc.lsed in incidence during
the past several dec.ldes. whereas thm of the illness has increased dramatically.
Part of our efforts in preventing. or managing industrial
back p"in should be directed at identifying individuals al
risk ..l,~

Sinlrt h.llflh or time Oil

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Lm:k nf .h';' satisf;\ction/p<lll[' supcrvisnry ralin~<> <.:

Hig.h str~ .." levels at work"
Poor g~Ilc:r:.I1 hC;llth~l/smoking\1
RISK FOR DEV"_OPING CHRONIC BACK PAIN

Other raL'lor.. ,hml1icily JJ1"('clic:/ol's) lIlay 11:1\"1': rc!l:v.ll1ce

ill c\'aluating .: ~rollP of patients with aculC low hack p:lin
to <.lclincate Ilh',e :; or I ()tIc who will (h.:vclop a chronic
problcm:
Clinil:al rrt:>,clltation of a palicm ovcr the initial weeks
after injury Illay be a valuable guide in determining
chrollicit~. Fal:wrs indudc:
-Leg pain. particularly the.: presence or root tCI1SLOIl
signs~' ;.
-Nonorpnic signs. whkh may he assOl:iated with
symptom magniticoltion syndromc. hypochondriasis.
and/or malingcringl l
-Pain self-report. A pain complaint thal docs not conform to known physiologic patterns. particularly
when coupled with om abnormal pain drawing"l
-Nonspecific diagnosis. The lack of a specific
pathoanatomic diagnosis is associatcd with a le~s f;jvorable outcomc('!
Age. Indi\iduals younger llwn :lge 25 years ;m: at
greater ri5-k of injury but usually l'elUrn to work sooner,'"
Those injured workers betwcen the age.: of 30 and 55
tcnd to h<:.\c higher incidences of chronicilY and disabiliti-":'
Sex. Eighty percent of back injury cOlllpens~Hioll
claims ar~ tiled by I1)cn."\ although an occupatiOll~l\ly
injured \\oman is more likely to remain disablcd.~"l
Educmion. An inverse relationship exists between educational le\"d and tow back pain and disability. with the
most pronounced incidence in the least cducatcd.~"~
Context of the injury. An ;lcute cvcnt related to lifting-.
bcnding. or (wisting or an accidclH such .IS'I slip or fall.
has a predictive \"alue for chronicity.-IInconsi!'h~ncy of medical carc(~1
Lack of <.1\ailability of interim light duty workJ,~
RISK FOR BECOMING DISABLED

RISK FOR INJURY

In the gcneral uninjured population. certain factors (injury

(JfediclOrs) may serve to differentiate the group at risk for a
back injury:
History of back pain is the single most important pre
dietor l '!
Trunk strength deficits. The probability of injury
is [hree limes greater when the job lifting require
mcnts approach or exceed the individuals' functional
co\ll<lcity!ol1
Individuals involved in heavy manual labor, vibration
and driving. heavy lifting. and prolonged siHing l

In addition to the factors just mentioned. 'l1lother set of pre

dictors (chronic' olltcolJle predictors) might be helpful in idcn
tifying those individuals for whom trcaUllL'11l or intervention
is likely to fail. It is this poHienl who 1110st contributes 10 thc
"high cost" of industrial back problems. Thesc racwf:O: in
elude:
Compcmation and Iitigation 111
LIS time. The longer it takes for an injurcd Wllrkcr to
receive care. the longer it takes for a referral to a specialist lO occur. and the longer she or he must wail for
procedure, such as surgery. A chronic outcomt: i:- nK,rt:
likely in this situalion.

REHAl:.illll A lION OF THE SPINE: A PRACTITIONER'S MANUAL

100:::::

\Vhcn surgcry is suggestcd but not pcrlorlllcd

Lack of availablc work upon rcturn~"

11

Total Management of the Back-Injured \Vorker

Success in this task includes an unders!:.mding. of the following:
The injured worker-whal Iype of worker is injured
The injury-hO\\' docs the injul)' occur. \\-'hal types of
activities arc associalcd with hack injuries
Thc response to injury-what happells .lIlhe time of injury, to whom docs she or he report. who docs. she or he
see, what help docs the company offer
Return-to-work factors-what is the company policy.
what is the employee. attitude and expcrience. Illodillcd
work program. who arc the slake holders
Wlmt makes an injury serious

SUMMARY
Patients must lake a morc activc role in their n:covcry.
Clinicians are being asked to abandon passive treatment in favor of mcthods that encourage patient activity and participation. After three decodes of interest. however. controvcrsy
surrounds the effcctiveness of the back school as a means of
combatting back pain. The back school is treated by somc as
an important part of the solution to the growing problcm of
back pain. By othcrs. it is considered unnecessary and unproductive.
After 17 years of active involvement in back school
programs, I havc ~een interest in this topic increase and decrease. The substantial commitment of timc, effort. and
energy needed to establish and continue a successful b'lck
school program in a chiropractic pr<lcticc or any other
clinic may account for the current decline. It is clear, howevcr, that efforts to decrease the incidence and impact of back
poin have failcd. and J am convinced that the back school
is a vital and necessary step toward recovcry for all patients
with back pain.
Appropriate management of back injuries, particularly
those sustained on (he job. must includc a cooperative effort
ilwolving the injured worker, the company. the clinician. and
the insurer. This coo~ration is achic\'cd only through proper
education. Thc individual who providcs this information is in
a uniquc position in the industrial arena and in (he treatment
of back pain.
REFEHENCES
I. Haldeman 5: Prcsidcmi:d addrcss. Nonh Amcrican Spine SociCly:
Elilurc of Ihc pmhology modcllo prcdict back p<lin. Spinc 15:718. 1990.
2. Wcber H: Lumbar dj~ hcnlialion: A cOnlrollcd prospeclivc !>Iudy wilh
len year:;. (If oh~cr"aloin. Spine 8: 131. 1983.
3. Hooper PD: Ba."ic Training. Di:uuonu Bar. CA. Injury Pr.:;\'cmiun
Tcchnologies. 1992.
~. Hooper PD: Put Your Back Prol:tkm." Behind You!~!. Diamond Bar. Ct\.
Injury Prevcntion Technologics. 1992.
5. Br:mdt-Rauf PW. RrandlF;'IufSI: History of occupation,,1 medicine: Rele\';\1\(e of Jmholcpand Edwin Smilh papyrus. Or J Jnd Med 44:68.1987.

6. I'dtlcr t: Til,' l>:ld ...:hl,,,1 ,'I Iklpcd\ ill ~I0111pdicr. elin Onhllp 179:4.
1<):\.'.
I. F:lhrni \VII: B;td,;;t<.:hl ;t1ld I'rilll:lll'tlsllm,::. V;l\Icou,cr. ~hNlucallll'uh..
1.1.1. 197{1.
s Willblll~ PC: 1.0\\- Il:Id;, ;111\1 S......k Pain: CI\ISCS <Ind COllscr.... alin,::
Tr ;lll1'...I11. Sl'rlll~lidd. C!l;lrh:, C'I"""Has. 1974.
'J. ~1 ",lI/k It: \11... l.umh.l! Spin,: i'..lcch:mical LJia~l1l1:-.i:-. ,mil 11\1,::rap~.
Wcllinghlli. 1':C\\ h'lbn,!. Spl1l:lll'lIhlic;ltinns. 11)8;'\.
Ill. Z.dIrlS'-llll ~1: fh 1. '\\ Ibd. S...h,KII. 1):lIIdc~d.Swedeli. 1):llllkryt!'"
iI'hpil;tl SI'"l1d Ih ,Iill... phl;:!';lIll. 1'J7~.
II. Zadlri':-'''n-Fllr,cll ~I: Thc SWt:di.,h B;tt:k. l'ehool. Phy:-.iotherapy 66.
April. 19Stl.
I~. Ikrqui:o.IUllm;lll ~l. l.;INm U: :\CIIIC' low back pain in i1H.luslly. :\cla
Onh.l Sl';mtl (Supp1J:170. IlJ77.
1.\. Hall II: The C;lll;ldiall 11;11.;1\ EJII~'ali(1ll Units. Physiolher;Jpy (l(l: 11 S.
ItJXlI.
l~. ~1:11111ilh:r AW:Thc C:llifurIli;1 Hack school. Physiother;lpy 6l1:115.
IIJXI I.
15. lIali II. kctOIl JA: Ibck sc!lo(,ll: An overview wilh spc...ilic rcferclIce In
Ihc l'an:l{Ji;lII n:lek blucallUll Units. l'lin Orthop 179: 10. 19S.'\.
1(,. "Ial\t:r~-hll"fell JA. Chasc S:\-l. Portek J. CI al: A C(lntmlkd perspcctin'ludy lu cvaluatc the cffeclivclles" (If a l't;u.:k school in the relief Il(
chrunk low h:lCk ~in, Spine II: 120. 1986.
17. ~l;lll1lilkr ;\\\': The California !lad; school. Physiolhempy 66: 115. I()SO.
IS. K\'icn TK. Nilsen H. Vik P: EcluC:llion and sclf-care ofpaliellls with low
b;tck p;lin. SCilnu J Rheum<ltol 10:320. 1981.
19. Linton SJ. Kamwcndo K: Luw hOlCk schools::\ critic:ll rc\icw. Phys
Ther 67:1.375. 1987.
20. Berwick OM. Rudman S. Feldslein M: No dinkal dfecl (,I' b;lck sdlQols
in an HMO: A r::lndomi"lcd pro~p<.'Clivc trial. Spine 14:.'38. 19R9.
21. Fclclslein A. Ualanis B. Vollmcr W el ;11: lllC Back Inju~' Prevt:lllitlll
Projcct Pilol Sludy. 1 Ckcup Mccl 35: 114. 19<13.
22. Brown KC. Sirles AT. Hil)'cr JC. el al: CosH:ffeclivcne:-.s of a back
school intervention for lllunidpal employees. Spinc 17: 1224. 1992.
23, I'looper PD: Prcvcnting Low B;u.:k Pain. Ballilllml. Williams &. Wilkins.
1992.
24. DUlro CL, Wheeler L: B;H.:k ~Ch~IOI and chiropraclic proH.:tke.
~'lal1ipulati\'e Physiol Ther 9:209. I n6.
25. DUlro Ct. Whccler L: B;ld sdmnl anti chin'l1r;lt.:tk pr:....lk"e.
~lanipu1:ltive Physi{ll 'nler 1):209. 19~6.
26. Zachris...on-Forscll M: 'nle Ibd school. Spinc 6:1t).J. 1981.
27. lfaUII: The Canadian Back Edul;;tliull Unils. Phy~iolh"r;IPY ()(d IS.
1980.
2H. While AH: B:lck School and Olhcr Cuns.cr\,;,tive Approaches III L{lw
Back Pain, 51. Louis. c.\'. i\!oshy. 1%3.
29. While A: The Baek st.:holllt,f lhc FUlllfc. In While L (cd): Bad Sclu.\.!.
Phil;lddphia. Hanley antI Bclfu<;. 1992.
30. J)cpanlllellt of Hcahh and lIuman Rcsourccs: Dr.lfI Obj... cli\'cs f(lr Ihc
YC:lr 2000. W3!ihinglon. DC. U.S. I'uhlic Health Service. 1989.
31. Pederscn PA: Prognoslic indicators in low back pain. 1 R Coli Gell Pr:ICt
5:99.198l.
32. Lloyd DeEF. Troup 1DCi: \{cClIrrclll hack pain and il:-. prcdictivlI. J SlX'
(kCllp Met! :'3:66, 1910
B. Fit~.Icr SL. Bcrger RA: The Chelsca back program: One )'ear latcr.
Occup He:llth Saf 7:52. Il)1\2,
34. Filzkr Sl.. Berger Rt\: Alliludillal I.:hange: The Chclsc;l h~lck pw~r;\I1l,
OCl.:l1p Health S;lf 3:20.1. ]\)l:O.
3;. Wont.! DJ: Design and cvaluation of a h:ld injury prc\'cllliiJn pro~r;ltl\
wilhin a geriatric hospilal. Spine 12:77. 1910.
36. Nordin M. Crilcs-Batlie M. "opt.: MIL el ;11: Edul-;llion and Irainin.;!. In
l'opt.: ~lH. Andersson GnJ. Fryllloycr JW. CI :11 (cds) OcCU[hllioll:t1 Luw
Hack. Pain: Assessmcnt. Trc;IIIllClll al',J t'rcvclIIiull. $1. Louis. Musby
Year Buok. 1991.
:17. S;lUndcrs !-If). Iscrnh;lgcn SJ: Back Schools. In lsernhagcn SJ (cd): Wwk
Injury. RllCkvillc. MD.A:-,pcll. 19HH, [l '17.
38. Weber H: Lumbar disc hcrniatiulI: A commllcd prtlspccli\'l; SIUtly with
len YC:lrs of obsen.'alioll. Spinc 1'\: I J I. 19M3.

...,

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163

..... HAI-' II:H 9 : BACK SCHOOL

!,

1
,N. Il.llIll. k ..' l.lll JA. 1I.\~k ,dl,I,,1: Au ,\\,:n:..' \\ with sl)\,'dli.. rd..'r..'n.:.: til
Ih..- C:lI1;tdi;1I1 kl':].., \',!II,;\li"JI unih, Clin (lnlll'l' 17'): Ill, 19X3
.10 t\l.lb..' r:-'llllh'lI J:\. Cll.\,< S~l. I'nnd. HS. ,'I ;11: :\ "'Illlll'llikd. 1'('''1>('..
!I\ ..' ,Iudy It...'\"aIU;ll.. th.. ...fk.:ti\"(.'n.....' ,,1.1 h:Kl.. ,duM.1 in th.. rd,dl.r
.-l1(,'lIi..- Ihl'. Spill'" II' J ~(l. I"X(.
.11. B.lrn..':- D. Smith I). (;:lld,..:! R.l.'l ;\1: 1'.. ~ ..I"h.r.:inl:l:"n"ll1i.: ph'IIKbJ"

1
~

"r

Ir-::IIIll<:llI \lll:,:..-, .tf.ldml ill ..:1U"I1I'

t",\b:td.. pail!

I'ali"'lll-, Spill~

1.j:.l~7. JlJ~i'J.

.12. Fr~lIluyl'f J. (':,hB.llll \\-: I'r..'di..'ltlr, ,.1 tn\\ h.ld. tlisahility. ('lin Orlh,."
~2U\').

.,1.__

r.. hh

II/Xi.

11\ \\"ulka:-' Cllllll'.:n',tlJ<>ll. I'J\'so:nl~t1 at lh~' St:ll..:

... C"l1I!,":Ih.lli"n :\d\ i_'"r~ C"lllllliH~'\', S:lll Di\.~". CA.
Cklllhcr. J 97.t.
B1o,:k AR, t\1''':Ill'':l' E. Gaylor \1: Ikha\i,'r;d lfl.'atlll\l1l Ill' ... hrpili, paill
\ari:ll:oks afli:.:tin;: (r'::lllllelll cfli..a.:y. I':tlll S:Je.7. 19SII,
Whilc !\\\'M: l.ow h:ll:k p:lin illlllell l'..''':",I\ Ill;: workl1'cns ..nmp..n':llioll.
em ~kd :\~~(lC J 9~:;\(J. 1966.
Frymlly....l' JW. Pop..: ~IlL I{oscn 1. ":1_,<1: [rid.. . lllioillgi'" slllllie, of low
h:li.:k rain. Spin.. . 5:-119, 19HO,
'",:nl\l11 H: Chifl>pr:l(tic A modd til' lll... oq....'r:ltillg the illll.... s~ hch:l\'ior
m\...kl in Ih..: 1":Ul:I;:Cll,..:llI III' low h:\\'I., r:.l;n Ilali . . 1l1s. J ~l:mipul:tli\"\:
Ph~ ...itllllll:r 1-1:Ji ). 1991.
'
1'01:l1il1 I'll: I'r..'diclHr... III' low h:1d. p:un disahililY. In Whit..: AI-I.
Amkfsoll R kd"!: Clllh.. . rv:llivc Cll'\.' (11' Low Back Pain. B;lllirnorc,
Williallls..'\: Wilkin.... 1'1'11.
Uigo~ 5J . ..:1 :11: A pro...p..:cliv.... ":\';llu:llilJn uf ,,:olllfllunly used pr..:-cmployrncnt s.:rr:cning trio!... fIll' anile intlu"'lrial hack pain. Spine 17:922.

:\: l.ili';::lll\'ll

\\"rlltl~u

.\-1.
-1~.

-1(,.

-17.

.IX.

JIJ.

199~.

50. Chaffin DB, Park KS: A longitudinal sludy of low-hack pain :I~<'()ci;llcd
wilh occup:lIional weight lifting f:lCl\lr<" .-\tn Inti I-lyg A"slx- J ,1~:51~.
1973.
51. B'~I\' 5J. 51'..:ngkr ()~1. .\-laflin r\A. Cl ;IL B:I,,;I.: injuries in indu'lry: ..\
rclrlhpc(ti,.... ~Iudy. III. [mpllly,,'erd:lt..:d fa~h)f:'. Spine II :252. 1986.
52. --"trand NE: ~1cdical. p'ydwlvgil.:;tl. 'Illd ... ~~ial f:lCtors :lssociall:d with
hack abnorillalilic~ ;IIlU sclf-n:porlcd hack p.lin. Hr J Inc! ~'1cd J-1:J27.
1987.
5:;. ~1:tgora A: Ilwcstig:tlion of Ihe rd:lliull,hip between 1(lw hack pain alld
occup:lIioll. Scand J Rehah l\kd 5:191. I<JB.
5~. Wc<;lrill C. H1rs..:h C. Lindcgard B: 11le flI.'"NJnality of Ihe I:o:t;:k p:.ti":lll.
Clin Orlhop S7:20{,j. 1972.

~-_._-----------_.

~-

..

5:'. SI~'uKryk S. Jenkins CD. Rosc RM. Cl al: Thc prospectivc impact of pSyw
dlt"l'....i;ll vari'lhh:... on r.1l....s of illness and injury in profession:,icmploy_
c, _J O":l.:Up t-.'kd 29:(H\ 1987.
56. Sr n~kr m.,1. niglls SJ. M:lrtin MA. C( al: Oack injuries in induslry:
..\ rL'lrn",pcl.:li\"e sludy. I. Overvicw and cost Oln:llysis. Spine II :241.
1'J:'h.
:'i. Fr~mnyer JW. PIll"'" .\IIi, Clemcnls JH. et al: Risk f.,Clor." in low back
p:lil1_ J BOlh: Jninl Sllf~ I t\1lI I 65: 184. 1983.
5S. Iham~.S"r":Il~1I F: A I'h"'pe..:li".... study of low ha..:k p:lin in :l gCIl":w!
!"rul:l1il'l\. Sl':ll1d J Rd1:lh f\kd 1):81. 1(8).
:"). Tr...up J1)G: Slr.lifill-Icgr:lising tSLRI :Illd the qualifyint;. tcsts for illrr~"hed rUllt tCllsiun: Thcir predi,,li\'!.: value afler back :lml s~iadc pain.
Spill\' 6:526. 19S I.
hO. W.I..l\kll G. M..:Cul1ou~h JA. KUlllmd EO. CI OIl: Nonorg:lnic physic:ll
"'l~n... in lllw h:Kk pOlin. Spine 3: 117. 1980.
(d. KirkaldyWillis WH: Thc dinicOII picturc-introduction. IN KirkOlldyWilli~ WH (cd): M:m:.ging Low Back POlin. 2nd Ed. Ncw York.
ChurchillLivingstonc, 198R.
62. F~mo)'cl' JW, C:lIs-Baril W: Prediclors of low hack pain disahility, Clin
Onhop 221:89, 1987.
63. Bigos $1. Spengler D~1. ~'larlin NA, Cl :II: Back injuries in industry:
:\ rclrospcctivc study. 111. Employee-related (;tctors. Spine 11:252,
198b.
M. F~'moyer JW: Back p:tin and sci mica. N Engl J Mcd 318:291,1988.
65. Klein BP, Jensen RC. Sanderson LM: Assessment of workers' compensalion claims for back !'ilrain.slsprains. J Occur Mcd 26:-143. 1984.
66. Dzioba RH. Doxey NC: :\ prospectivc investigation imo lhe orlhopcdic
:lnd pS)'chological prediclors of outcome of first lumbar surgery foUoww
ing industiral injuiry. Spine 9:614. 1984.
67. Dcyo RA. TsuiWu Y: Descriplive epidcmiology (11' low h:ICk p:\in :\nd its
rdatcd medical C:lre in Ihc U.S. Spinc 12:264. 1987.
68. A"lr;lnd NE: Medical. p...ychologic:ll. and soci:!l factors OIs.~ocjatcd with
back abnurmalilks and ,e1f-reporled hack pain. Dr J Ind r-,.Ied 44:32"1_
I%i.
69, \\'ci~d SW. Ferfer HL. Rothman RH: Indll.~lrial low b'ICk pain-:!
pro'pceti\'c c\'illualion of a sl:l1ltlarizcd di;)~nosli..: and tr..:atmelll prolocol. Spine 9: 199. 198-1.
70. Robertson LS. Kc....vc JP: Worker injuries: The dfccts of workers'
compcns;ltion .1Ild OSHA inspections, J He:lhh Polie Polk)' L-lw R:~81.
1<J10.

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IU

YatIent

~ducation

CRAIG LlEBENSON and JEFF OSLANCE

Pmicnt CdUC.l1ioll is as csscmiallO successful rehahilitation as

afC exercise or other trc~HmClll stri.Hc:gics. Sometimes education. advice. :.lnd training arc all that a person lh:cds. Im-

proving a pmiclll's sining posture or recomlllending J llcadset

for prolonged ll.:lcphonc work arc jUq two cXi.unplcs. Patient
cducmioll is prdcm.:d over cxcrcisL' bee use once a person

,I

lc;mls how to rcdll<..' c strain. that Klwwll'dgc is with them forever. whcrc<ls exercises must be performed over and over
again.
Traditional subjects for patient education include spinal
imtltomy. pain sources, fir~;( ;Iid for acute recurrences. body

mechanics. and preventive exercises. We place the most important areas to cover into four c;.uegorics. First. reassurance
that the natural history of most pain syndromes is toward a
speedy resolution. Second. body mechanic!' lhat arc univcrsally applicable (i.c.. workstation ergonomics. lifting advice).
Third. the importance of focusing on function in addition to
pain relicf as a goal of care for the subacutc. chronic. and high
risk patient Finally. explaining the dilTerencc between hurt
and harm so the patient is less likely 10 immobilize themselves and become deconditioned in their attcmpt 10 <lchicvc
pain relief.
NATURAL HISTORY

Close to 90% of back pain episodes resolve within 6 wccks: liI

This excellent prog.nosis should not. however. lead to a negligent approach to managing this problem. A review of 1989
\Vorkcrs' Compensation low back pain claims revealed that.
"cases that go on to have prolonged disability arc the primary
contributors {O the cxpense of low back pain.'''' It was deter
mined thnt "25% of low back pain cases accounted for 96%
of the costs'" Persons who are still suffering ..,ftcr 6 weeks arc
at considerably higher risk for 1;lsting disability and chronic.
pain. According to Nordin. " ... there is a very small window
of time in low back pain care: we must .Icl quickly within
46 weeks to bring paticIHs into an active reconditioning pro
gram if we expect to return them to productive lives and prevent recurrence."11 With recurrence rates around SO(k and the
high costs associated with chronic disabling pai-n, aggressive
conservative C.lre focusing 011 restoration of function and pa
tienl education should be the standard of carc.
Unfortunately. because of the excellent prognosis for
most patients. many health care providers arc misled into be

lic\ing. that c;'lrly aggressive conservntive care is not neces. ~sary for patients with low back pain. Experts and emerging
consensus-based guidelines disagree vehemently with this
lfodilional approach. sloling lhal the lypical managemenl approach of bed rest with medication is responsiblc for fostcring disability in those prone to it. Troup. an esteemed British
orthopedic surgeon. stated that, "The first attack is the ideal
time for active and perhaps aggressive treatment but if it is
tacitly assumed that the vast majority of patients recover-from
back pain whether or not they are treated then the opportunity
may be missed."lO It is essemial to pursue rapid resolution of
symptoms aggressively to minimize the likelihood of recurrent symptoms as well as the development of a chronic. disabling pain syndrome. The Quebec Task Force on low back
pnin disorders said. "Management strategies should be directed at maximizing the number of workers returning to
\.. ork before I month and minimizing thc number whose
spinal disorders keeps them idle for longer than 6 months."t'>
Prolonged disability or pain will lead to both physical and
psychologic dcconditioning. which we should 'strive to prevent through appropriate care of acute episodes.
In the early managemcnt of back pain episodes. manipulation is the single most effective treatment strategy. I:
Rehabilitation with exercise 1m!' also been shown 10 hasten return III work tInct reduce the rate of recurrenccsYl.1 Radicular
syndromes arc associated with a less favorable outcom~.
Nonetheless. ovcr 90% of individuals with pain below the
knee and nerve root tension signs recover without surgical il1tcrvenlion.. ~wrhe length of time prescribed for bed rest may
be longer (up to I week), the value of manipulation less certain, and the overall length of time required to achieve symptom resolution more than 6 weeks, but the prognosis for recovery is still good.
Thc prognosis is poora for chronic pain syndromes.
Patients may henefit from a trial of manipul;Hivc therapy. but
11 biopsychosocial approach is detinitcly indicatcd. Exercise.
education, and encouragement arc the mainstays of successful carc. Psychologic intervention may be needed as well.
Focusing on function and reducing the patient's fear about
movemenl arc critical to succcss. Carefully explaining that
hurt docs not equal h;lrm and that wc do not follow a "no
pain~no gain" philosophy is an important prelude to rehabilitation. Functional goa.ls must be clearly cst;lblished and objective outcomes used to monitor and demonstrate progress.
165

........

.~,---,'W::..'_
~

__

166
in cnronic pam m.uwgcI1lCIiI. il

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

j,

\.'sscnti;111O t'\)(US I.Ul control

nnd nol cure ;,md to place )'(lur:-df in tilt: role of hdpcr rather
lhan healer. n
Rarely is back pain 11ll: prl'''l'luing symptom llf .1 serious
disease. A thorough history and clinical cXillllin;l\i\l\1 should
be obtained. howc"cr. to ruk oul inrcclions. 1ll1l10rs. and other
serious disease=, (Iwt t;tIl mill1ifcs( with spin'll pain.
Reassuring p:nicllts lhal their prohlem is IlIcl...'hanic:'l1 .llld not
.1 sign of inlcflwl disCilSC is an important step in p;Uicnt edu-

catioll.

Standard of Care and Identification of

High Risk Patients
Over 80% of the population will cxpcriclltc hack puin Juring

their Iifelime. Only:; to ISCJ( of these individuals. however.

will become chronic suffers. lkcause of thr: disproportionately high cost associated with chronic C:ISCS. much altention
has been placed on linding bellcr treatment ~lnd prevention
strategies for this minority. The :IlHhors of a large re"iew of
worker's compensation low back claims concluded that. "the
primary goal of low back pain management should be the prcvention or reduction of prolonged disability"'"
A question posed by guidelines panels is. How many
treatments 3re appropriate and for how long? The Mercy
Guidelines concluded that 6 weeks of carc is usually sufrlciem for "uncomplicated" cases.-' Three to Ihe sessions per
week for 1 to 2 weeks is appropriate. followed by "Progressively declining frequency is expected to discharge of the patient ..."$ Spinal manipulalive therapy has been shown to
lead to a 34% better rmc of recovery (at the 3-week mark)
when compared to other traditional forms of Iherapy.l"
Between I and 19 sessions with manipulation have been
proven effectivc over a 2-month period.'~ Shekellc said. "an
appropriate trial of therapy is 12 manipul<ltions lasting up to a
month."I~

Risk Factors
The various factors lhm may lead [0 a slo\l/cr course of recovery arc presented in Table 10.1. The factors associaled
predictively with chronic or recurrent episodes arc listed in
Table 10.2.
According to the British Guidelines. low educational
attainmcnt and heavy physical occupation arc lesser risk
factors. but will interfere significantly \vilh successful rehabilitation. s

Table 10.1. Factors That May Predict a Longer Recovery

Past hislory of >4 episodes
> 1 week of symploms before presenling 10 doclor
Severe pain intensily
Pre-existing structural pathology or skeletal anomaly (i.e .. spondy~
lolisthesis) directly related to new injury or condition
(From Haldeman S. ChapmilnSmilh D. Pelersen OM: Frequency and dura
tion 01 caro. In Guidolines lor Chiropractic Quality Assurance and Practice
Parameters. Gailhcfsburg. Aspen. 1993. pp 115. 130.)

Table 10.2. Risk Factors for Chronicity (British Management

Guidelines lor Back Pain)

Previous history 01 10\'1 back pain

Total work loss (because of low back pain) in pasl 12 months
Radiating leg pain
Reduced straight leg raising
Signs 01 nerve rool involvement
Reduced trunk strength and endurance
Poor physical fllness
Sellrated health poor
Heavy smoking
Psychologic dislress and depressive symptoms
Disproportionate illness behavior
Low job satislaction
Personal problems-alcohol. marital. financial
AdversarLal medicolegal proceedings

(From Waddell G: The Low Back Pain Guidelines (British). Clinical

$lnndards Advisory Group: Back Pain. London, HMSO, 1994.)

1I011Y MECHANICS

Reducing strain is essential to preventing recurrences.

Tcaching office workers to take frequent "microbreaks" every
20 to 30 minutes can help immeasurably. Studies havc shown
th<.ll tissue creep occurs after just 15 minutes. IX Also. if just
4% overload is encountered. a negative metabolic state is eswblished. I".~O Propcr chairs and workstations arc a must for
patients with low back and neck polin as well as those .suffering from upper extremity repetitive strain disorders (i.e..
carpal tunnel syndrome).
Work station ergonomics is a practical place to get started
when looking for sources of mechanical overstrain. Go
through the workstation checklist with your p<.lticnts (sec
Appendix 10.1).

Lifting Technique
Lining technique is often debated; typically. squatting.is recommended over stooping. Unrortunatcly. Illost workers fail to
follow this advice if repctitivc lifts arc required. Garg and
Hcrrin lloted the increascd encrgy expenditure associ:ucd
with squalling versus stoopin.~1 What appears to be an attaintlble goal is maintolining the lordosis. independent of thigh
and trunk angles.~~ Adams and Hutton reported thm less
compressive load on ..I fully flexed lumbar disk (i.e., stooped
posture) is needed to cause posterior herniation of nuclear
materi'll than would cause end plate fracture in the uprighl
positipnY According to McGill. "Because ligaments arc not
rccruilt;d when lordosis is preserved. nor is lhe disk bent, it
appears that the annulus is at low risk f"r failure.":: This
statement was supported by thc work of Hickey and Hukins. ~~
Lifting while maintaining lordosis allows the further benefit
of activming the musculature and thus prov.iding for neuro~
muscular control to protect ligamcntous tissues.
Lifting technique is important, but when you lift may be
evcn more significant. As a result of the increased fluid contcnt in the disk after lying down al night, disk bending stresses
arc increased by 300% and Slrcss (0 ligaments is increased by

J
.,
.}

.0

L
',Y

.........

, ... n

I U . n.,l I l:. 1'1 I

t:.UUCATION

Thus. th",' ri~k of injury during. forw..ml

inl:rcascd in thc early morning..
Prol\H1~eu n".':\il\ll. SllC.::h as in sining. can rcnder the back
'ulner'lole 10 liftin~. ~-1cGill ,lUll Brown (ound lhat after jwa
3 minutes of full tk.xion. slIhjecls lost half lheir stilfncss.: h
AJall1.'i anti Hutton nclievc thaI prolonged full flcxion nwy
l';\USC ligalllclHoll.. neep and fender lhe spine sllsceptiblc to
lkxioll ()\'crlo~~d dming liflil1g.:~ According to McGill. a brief
I..'\lUrs~ of CXh:lbion exercises hcforc lining may prc\Icnt
injury. ~.:
XO'./r in thl;

t1Hlrnin~.:'

klldill~ ;\~{i\itil.'''' ;~

CO-""olllr,K'tion of thc lumbar erector spin;lc muscles during lifting app;;;lr... 10 redistribulc compressivc forces 011 the
spine by adding guide }\'ires In a nexible rod. like rigging on
a ship's masl.:: The i;lCrcasc in compressive loading on the
spine is slI,!"lstmnial if even a small :Jmoullt of IOrsion is required during lirting. 22 To prc\'~nt injury. objects should nOl
he lifted if they \\'ere awkw"lrdly placed. To reduce the extensor J1l0Il\elH. the load should he held as close as possible and
lifted smoothly.:: :\ jerk lift is only appropriate for highly
trained illdividu;ll~ who must lift light. awkwardly placed objects. The purpose of this lift is to avoid loading the spine in
flexion for any longer tl};;lll is abs.olutcly nccessary.~~ Table
10.3 !'llllllllarizes current advice about lifting.
Ergonomi<:: Factors
One of the JllO~t delelerious activities people engage in is sit(ing. Erect sitting ill\'olves disk pressures significantly higher
than th.it of normal standing, Sitting slumped forward (ante
riar sitting) increases disk pressure cven morc. and the greatest increase in pressure is associated with slumping backwards (posterior sitting),:!"~s Using a lumbar support or back
rest reduces disk prcssurcs.~l A scat-backrest angle of 95105 reduces both erector spinae EMG activit)' and disk
prcssure.~'u"

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The chair ~C<tt ~hould provide a stable base and yet not be
constraining. 'I The height of the chair is imponant. A scat
height that is lOa low places too much slrain on the ischi:JI
tuberosities, Too high a sc..ll increases pressure on the thighs,
Chairs lacking variable height adjustments m.lY necd to be
complen1t::nted by <L footrest. The scat edge should not touch
the popliteal fossa: this situation leads to too rigid a sitting
posture. A slighl dcpression for the buttocks is beneficial for
slability. A concave seat increases weight bearing through the
greater trochamcrs <lnd intcrnally rotates the femur. again restricting movement of the legs. Seal angle is controvcrsial. nlthough it is apparc'llt th,H a forward sloping scat increases
lumbar lordosis during sitting and maintains the erect siuing
position.

!Oo

Table 10.3. McGill's Rules for Lifting'12

Ma[ntah normal lordosis

00 nollill immediately alter prolonged flexion or rising from bed
Lightly cocontract the back and abdominal muscles before and
during lilting
Keep Ihe load as close as possible as long as lordosis is maintained
Avoid twisting

167
Thc proper dcsk hcight is normally about 27 to 30 em
above the seaL"~ The shoulders' should be able to relax with
the elbows bent 90 and the hands relaxed on the desk sur-

f.cc. A slantcd dcsk (10 to 20) may also be hclpful for rcducing neck str'lin.

FOCUSING ON FUNCTION
Functional restoration gels to the heart of a recurrent disorder
more effectivcly than searching for the technique to "fix." the
problem. Pain relief is enough of a goal for many first-time.
pain patients. When pain is recurrent or chronic, however. or
lhe individual is at high risk for a chronic. disabling condi
tion. enabling the patient to focus on function becomcs a high
priority for the Ireating physician. \Vc should help the pmient
to understand that a more fit back is less likely to become injured; whatever the cause of their pain (disk, facet. myofascial, etc.). they will be marc stable if function is restored. In
fact, 80% of the time. an exact cause cannot be identified. but
clusters of functional changes can .,ddrcs~ their symptoms.))
A deconditioned individual has lWO options for achieving
lasting pain relief. First. they can avoid all strenuous activities. Second. they can increase their functional capacity (Fig.
10.l). These options arc really the only means available to
prevent spinal problems. Either the load is reduced or the capacily to handle that load is increased. Convincing a patient
to reduce external strain is optimal, because once they change
their workstation or learn better biomechanics. they have that
knowledge forever. If. however. only limited reductions in external strain arc possible. improving their intrinsic functional
capacity or performance is the only remaining option.
Exercise is always more difficult (0 accomplish than educ:Jtion because of problems associatcd with motivation and
compliance.

PATIENT MOTIVATION
Achieving compliance in patients asked lo shure rcsponsibility for management of their pain rests on convincing them
that body mechanics and functional improvement arc essential for longtenn success, No amount of persuasion is adequate. however. unless their fears and anxicties arc also addressed. Most chronic patients fear that aClivity will cause
them more pain. Explaining the difference between hun and
harnl will help considerably (sec Chaptcr 2).
Exercises that stretch stiff, shonencd tissues may in fact
cause pain or discomfon but are not injurious, In facl. patients will learn how to stretch safely and to feel a comfortable "good hurt." Also, strengthening exercises arc best
performed in a pain-less range, with pain only felt (he following day (sec Chapter 14). This postexercise soreness
should involve only the lrained muscles and not be felt
in any symptomatic spinal or postural arcas, Occasion>tlly.
"McKenzie" exercises CJ:lllse some discomfort, but this pain
should be local. These exercises arc avoided if any radiating
pain is perceived, Learning that they can control their symp-

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

168

"c

'"E
"n'";

Injury

~x

Non-injury

Functional capacity
Fig. 10.1.

Relationship between external demand and functional

capacity.

graph for c1inici:lIls. Repon of the Quebec Task Force on Spinal

Disorde~. Spine 12(suppl 7):$1. 1987.
7. Bigos S, Bnwyer 0, 81"3en G. et 31: Acute Low Ba....k Problem$ in Adults.
Clinic:tl Pr:Ktice Guideline. Quie\: Reference Guidc Number 14.
Rockville MD. U.S. Dcpanmclll ofUc:llth and Human Scrvicc.", Publish
H..:alth S..:nice. Agency for Ikallh Carc Policy :md Research Pub. No.
95-0643. D...ccmr.cr 1994.
S. Clinical Standards Advisory Group (CSAG): Back Pain. London.
HMSQ,1994.
9. Webs!cr ns, Snook SH: 111c COSI of 1989 Workers' COlll(lCnsation low
hac\: p;,in claim!'. Spine 19: 1111. 199t
10. Troup JOG: The perception of Olu~uloskclctill pain and incapacity for
work: Prc\'cntion and carly IrC:Il111ent. Physiother.lpy 74:435,.1988.
II. Nordin M: Early findings of NIOSH-CDC model back clinic reveal surprising observations on work-rel:tled low back pain predietol11o. Spine
Leu 1:4.5, 199..t
12. Shekelle PG: Spine update spinal manipulation. Spine 19:858. 1994.
13. Linton SJ, Hellsing AL, Andersson 0: A controlled study of thc effccts
of an carly inlcn'ention on aCUle musculoskeletal pain problems. Pain

54:353. 1993.
1-1. Lindsaom A. Ohlund C. Eck C. et 31: The effcci of gl"3ded activity on palientlO with subacule low back pain.. Phys Ther 72:279, 1992.
15. Saal JA, Saal JS: Nonoperative trcatment of lumbar herniated disc with
I"3diculopalhy. Spine 14:431, 1989.
16. Bush K, Cowan N. Katz DE, el al: The natural hislOry of sciatica associatt.-d wilh disc pathology: A prospccth'e study with clinical and indepcndc-nl radiologic follow-up. Spine 17:1205. 1992.
17. Fordyce WE: Pain history musings. APS J 3: t40, 1994.
18. Oogduk N_ Twomney LT: Clinical Anatomy of
Lumbar Spine. 2nd
Ed. r-,ldboumc. Churchill Li\ingslonc. 1991.
19. Andersson G8J: Occupational biomechanics. In Wienstein IN.
Wiescl SW (cds): the Lumbar Spine: the Intcmation.3! Socict)' for
the Study of the Lumbar Spine. Philadelphia. WB Saund.:,:;. ! ')90,

me

toms becomes a liberating experience for 1110st patients. As

slated previously, the rehabilitation specialist should teach patients how to control their symptoms and not promise to
"cure" or "fix" the problem.
Patients need to know the exact goals of exercise. For instance, a goal might be to strengthen the "big muscles" (i.e.,
abdominals. glulcals. and quadriceps) to take strain orf the
lumbar spine. \Vhen proper goal setting is aCl:omplishcd and
those goals are mutually acceptable. patient adherence and
compliance 3fC easier to achieve. If excessive fear and anxiety persist. then referral to a pain psychologist may be
needed. A psychologist may be able to teach better coping
strategic!' or relaxation techniques and can uncover hidden
obstacles, such as drug or ~llcohol dependency. job dissalisf"ellan. or family stress,

REFERENCES
I. Aenn RT. W('I('Id PH: Pain in the back: An aucmpt to eSlim;l\e the ~izc of
the problem. Rhl:umalol Kclwbil 14: 121. 1975.
2. Horal J: The clinical appc:ar'Lncc of tow back p;lin disordcrs in the city of
GOIhcnourg. SWc...d cn. Acta Onhop Scand Suppl 18: I, 1969.
3. Ruwc ML: Low back pain in industry. J Occup Mcd II: 161. 1969.
4. Bcrqui!'t-Ullman M. L..l rsson U: Acute low hack pOlin in industf). Acta
Orthop Scand Suppl ; 70: I, 1977.
S. Haldcman S, Chapman Smith D, Petersen 01\1: Frequency and uurOltion
of care. In Guidelincs for Chiropractic Quality Assurance and Practicc
Parameters. Gaithcrsbag, Aspen. 1993, pp 115. 130.
6. SpilT.cr WO, Lc Blanc roE, Dupuis M. et al: Scientific approach to the as~!'i!'men{ .ll1d 1lI0lnagement of activity-related spinal di~orde",: A lllono-

p213.
20. Sato H. Ohashi J. Owanga K. et

m: Endurance time and f.3tiguc in st<llic

contractions.. J Hum Ergol (Tokyo) 3:147.1984.
21. G<lrg A. Herrin G: Stoop or sqU:lt: A biomcchanical and metabolic e"nlualion. Am lost Indus Eng Trans II :293, 1979.
22. McGill SM, Norman RW: Low back biomechanics in industry: The
prevention of injury through Nlfer Iifting_ In Grabiner M (cd): Cur
rent Issues in Biomechanics. Ch..mpaigll. IL. Human Kinelics.
1993.
23.. Adams MA. Hutton We: Mechanics of the inter...enebral disc. In P
Ghosh (cd): The Biology of lhe Intervertehral Disc. Boca R.3lon, FL.
eRe Press, 1988. pp 39-71.
24. Hickey OS, Hukins OWL: ~c1aljon belween the structure of lhe annulus
fibrosis and the function and failure of the inte","ertebral disc:. Spine
5: 106. 1980.
25. Adams MA. Dolan P. I-Iutton we: Dirum<tl \';Iriations in the stresses on
the lumbar spine. Spine 12:130. 1987.
26. McGill SM, Brown S: Creep response of the lumbar spine to prolonged
fiexi()n. C1in Biomech 7:43. 1992.
27. Amkrsson GB. Murphy RW. Onengren R. el al: 111c inllucm(. of
hack rest inclination and lumbar support on lumbar lordosis. Spine -1:52,
!979.
28. Andersson GS, Jonssoll B, Onengren R: Myoelectric activity in individIlal lumbar ereclor spinae muscles in silting. A study Wilh surface and
wire electrodes. Scand J Rehabil Mcd J(suppl):19, 1974.
29. SChuldl K, Ekhnlm J, Hanus.Ringdahl K. el al: Effects of ch:lnge~ in Silo
ling work poslure on static neck and shoulder muscle aClivity.
Ergonomics 29:1 525. 1986.
30. Andersson GS, Onengrcll R. Nachemson AL. c.( al: The sitting poslUrc:
An clcctrornyographic :lnd discomelric swdy. Dnhop Clin Nonh Am

"J

i'

)
~

.~

;
..)

.'

6:105.1975.
31. Oniz D, Smilh R: Ergonomic Considerations. In Basmajian JV, "'yb...-rg
R (cds): Rational Manu"j TIlempies. B;I\timore, Williams & Wilkins.
1993, pp 441-450.

".-

...... n1\1'"'

I!:::H 10: PATIENT EDUCATION

169

.\2. Gr;tnJj\.:lll E: Filling. th~ Task to Ihe Man. 41h Ed. London. Taylor and
Fr:m..:i..:, 1988.
;\.\. Moffroid r-,rr, I-laugh LO. Benr)' SM. ct al: Dislingui~h:lblc groups or
l1lu"..:uloskclclal low ll:lck p'lill (XI(icll1~ and .asymptomatic <,ontrol su\)..
j..-Ch o3scd on physl\.'al lllcasur~~ of Ihe NIOSI-I low b.., d; al[::l.'i. Spine

19:1.':'O.199t

APPENDIX 10.1. How to Care For Your Back

and Neck: A Section Addressed to the Patient
Wllo is or Risk?
Evcl)one. BUI, those who silo bend. or twist a lot arc nt higher risk.
Not liking one's job or having problems .It home also places one al
higher risk. Finally. not being in good sha~.~~ciall}'jn your back
and abdominall~-is an'~ddi(i;~al fa~tor.

---_._--_._-_._----

Whlll Call Br: DOlle?

Surgery is necessary for back pain less lhan I % of thc time. Most
b.nck or neck pain is what we call "mechanical" pain. One of
the great myths is that arthritis and disk syndromcs are responsible
for mosl peoplc's pain. In fact. one third of all people without
back p~in h~ve herniated disks. h is now frequently considered a
coincidental finding. Most spinal disorders can be trcated with simple conservative care involving m:lOipul~tion. self-t;:~c;_ advice. and
exercise.
If you are in acute pain, the initial goal is to stabilizc lhe painful
~We want to protect your back or neck by teaching you ~ow to
find relief positions that take stmin off the painful.area. For insla~ce.
you will be advised 10 avoid certain strenuous positions or movements. such as sitting or bending and twisling. This advice typically
consists of prescribing limited activities and the usc of pain-relicving methods (i, hCal. uh~d. electrical muse;..:: stimulation. manipulation. massage. tmction. etc.). A support may be given and bed
rest recommended. but this regimen is used fOf the minimwn time
possible to decrease the danger of dcconditioning (becoming execssivel)' weak or stifn.
Perhaps most important is the reassuranc:;c thal you will receive
that ),our condition has been evaluated thoroughly and that you do
11m h<lvc ally scriolls medic'll conditions. If you do havc a disk SYI\-

Fig. 10A.1. Spinal column (side view). (From Basmajian JV:

Primary Anatomy. 8th Ed. Baltimore, Williams & Wilkins. 1982.)

drome. which is resulting in pressure on a nerve. a diagnosis will be

madc and appropriale treatment will be initiatcd.
Thc sccond goal of care is to get yOll aClive agilin. This process is
called rcmobiliz.ation. which is accomplished by reli.lxing tense 1ll1lS
C$S ',ocl loosening stiff joints. Gmdllillly and safely. you will be in:
creasing the activitics you perform with Icss and less fear of reinjury.
Stretching and light cardiovascul:lr exercises. along with nmniplll:l-

Table 10A.1. Stages of Care

SliJgcS:
Goals:

Treatment
Strategies:

Stabilization
Pain RcliCJ. Reassurance. Proteclion

Remobilization
Acslore

Mobilily

Find relief positions

Manipulation

Limited bed rest

Supportslbraces
Physical agents (ice. heat, ultrasound,
electrical muscle stimulation. etc.)

Stretching
Ergonomic advice (i.e . how to sit)

Manual therapy (manipulation. massage. traction)

Analgesics or anti-inflammatories

Cardiovascular exercise

Reconditioning

Improve Strenglh and FleKibility

Strengthen ~big muscles" (abds. buttocks.
thighs)

Stretch postural areas (calves, back)

Biomechanical advice (i.e .. how to tift)

170

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

lion. ;trc the primary mode:, of care in this siage. Fewer physicallhcr
~py techniques an~ u!'cd and you will receive ndvice about how tu

prevent or reduce strain in daily 'LClivitics. e.g .. how ~o sit withollt

causing slf:Jin.
(he third and fin,,' goal

or c;m.~

is to achic\'~ reconditioning of

vour "weak link," Typic~lIly. after a painful episode. movements arc

~~~(I;l-~l~~~akncss dc\'ch1p....
prcdisposc~ yOll

Unless

addrcs~cd, this condition

\1

)~

--- ~~. ~. '"",=---

to future rccllm::nccs. You willlc.arn a combination

Ii

of stretching and sln.:lIgI11l:nillg exercises dc'sigm':d 10 impwvc lhe

function of your b;ICk or nCI:k. AI this time. ;,IOVICC about lifting :lOd
bending usually is given.
The stages of C,Ire arc shO\\ n ill Table 10A.I.

Nucleus
pulposus

WIIlII.DO('J tll(' Spine L(/ok Like?

The spine is one of the most r<:m:trkable organs of lhc body. It's job
is to protect the spinal cord and serve ;.ts ;a mQbile rod for bending the
trunk. tllU~ allowing us great mobility. These two opposing functions
of stability anulllobility arc both accomplished by this single ;'lmaz
ing slrllCllln.,:.

The spillal columll has three curves when viewed from the
side (Fig. lOA. I). E<.:tch n!nebm fomls a number of joints wilh

its neighborin,g vcn~bral segmenls (abovc and below) (Fig. IOA.2).

One of the most imponant spinal struclures is the disk. It is a
cartilagil\ou~ ~mUCIurc

each vertebrae. It has

thai serves as a shock absorber betwecn

<.I

lough criss-crossing network of liga-

ments (;.mnulus fibrosis) famling a prolective ring around its

gel~

Fig. 10A.3. The disk. (From Basmajian JV: Primary Anatomy.

8th Ed. Baltimore, Williams & Wilkins, 1982.)

like fluid interior (nucleus pulposus) (Fig. IOA.3). Viewed from

above. you can see the spinal canal, which houses the spinal

cord. and thus the relationship between the disk and nerve roots
(Fig. IOAA).
Wilen' Call the Puill COllie From?
Nearly all the struclUrcs of Ihe back and neck can cause pain. Most
commonly. muscles, (cndons.ligaments. or joints become sources of
pain when Ihc)' arc irritated or overloaded. Sciatic (leg) pain comes
from irritated nerve rOOls.

. Certain movcments arc particularly likely to cause problems.

Bending over to IiI"! something places tremendous strain all our
backs. The combination of bending and twisting can cause damage

II

Th1! lUMBAR SPINE

~
~,
,

:~j!
l

Thl'

t
~

Fig. 10A.2. Lumbar vertebral joints. (From Basmajian JV:

Primary Anatomy. 8th Ed. Ballimore, Williams & Wilkins, 1982.)

NERVES

Fig. 10A.4. Relationship 01 the disk and spinal nerve roots.

(From KirkaldyWiliis WH: Managemenl of Low Back Pain. 3rd
Ed. New York, Churchill Livingstone, 1994.)

I"l
.~

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.--,

.L

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,
)

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even if we <Jon't Iirt anything in that position (Fig. IOA.5).

Prolonged sitting. even in a Stiod chair. places a great deal of stmin
011 Ihe muscles :lIId disk~ of the ~ack. Being on the telephone or
working at a compuler for long periods of time can strain the neck.
upper bad. shoulders. elbows. or wrists.
It is common for joints or muscles 10 be the source of pain referred
to the low back. butlocks. thighs. between Ihe shoulder blades. neck.
hc:.d. face. or arms. Figures IOA.6 to IOA.13 show c!,\ssic rcprcscnlatiuns of pain referred from certain key muscles.
Joints and lig;,unclIls arc also able to cause local and refcrrcd
(somc distance from its origin) pain. Figures IOA.14 and IOA.15
show typical refcrred pain pauems from irritated vertebral facct
joint!' in the ccrvical and lumbar spines, respectively.
The most famou!' culprit of severe pain is the "herniated disk"
which can pinch on a nerve rool. sending pain or numbness .down the
Icg~ even [0 the foot (Fig. IOA.16). If strained too much, the disk can
bulge or ~ssibly [car, causing gel (nucleus pulposus) to herniale inlo
lhe area containing lhe spinal ncrycs (Fig. IDA. I?), A bulge is comIllon ,md oftcn does not cause pain. Hcmiatio~s Ciln pinch on nerves
or irritatc thcm. causing "sciatica" (leg pain). The fascinating thing
is th:1t disk disorders occur in one lhi~d of all people who have no
symptoms; thus. sllch a finding in a patient .may be coincidenta~. A
thorough e~amina(ioll is necessary to dctennine if a disk problem is
actually causing your symptom,s.
Another structuml problem occurs when arthritic spurs (dcgener
,Hive joint disease) jut out from lhe. vertebral. joints and either pinch
nerves (stenosis) or restrict our normal mobility. Here too. it is con ' man for degener.ttive joint changes to occur in the spine and be painless. In f:lct, arthritis increases with age. as docs graying of the hilir
,md wrinkling or'thc s~in. yet back pain peaks between ages 28 ilod
50 years.
A

.,~

171

eDUCATION

<)!

I,

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..~ ~

:1:

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Fig,10A.5.

>,

Dangerous bending and twisting position.

TP,

Fig. 10A.6. Referred pain from the upper trapezius muscle.

(From Travel! JG. Simons DG: Myofascial Pain and Dysfunction:
The Trigger Point Manual. Vol. 1. Baltimore. Williams & Wilkins.
1983,)
Whor COli I Da?

Back and neck p,lin are interwoven into our lives, They arc normal
yet unpleasant experiences that. if mismanaged. can become chronically disabling. In the past. docto~ believed bed rest. pain relievers.
and perhaps somc physicallherapy (hC'l1. ultrasound. etc.) were all
that was needed to lide someone over until the problem receded.
Most of lhe time, such an approach succeeded in alleviating the pain.
But. <llltoo often (up to 20% of the time), it failed. According to recent independent. gO\'ernlllent studies from Canadil. lhe United
Slates. and Great Britain concerning the back pain problem, eonsen~
sus has emerged that this poor rcpon card is largely rcl~lled to the
ovcrprcscription of bcd rest and medical ion ,lI1d l~lilur~ to focus care
on quickly restoring funcliOlwl integrity to your muscles and joints.
What is the solution? Today. we know that manipulation (i.e .. chiropractic adjustments) is the most effective trCillmcnt for quick pain
relief. TIle Rand Corporation. British Low Baek Pain Guidelines.
~llId the U.S. Agellcy for He,llth Care Policy and Rcse,lrch have concluded that Illilnipulation is olle of till..: Illost cffective (onns of early
intervention for back pain. Milnipuhuion in combination with ~~r~
cisc :md simple educ<llion have proven to be far superior to tmditional prcscripliOl\s of prolong~c;..d_U:ji1Jlm!.I!Lc..illillion.
When you are in pain. the first rule of pain relief is 10 avoid :Idditiona I strain. Figures IOA.IS .1Ild IOA.19. show the different
arnOUfllS of muscular effort required to slabilize different postures.
You should minimize assuming strenuous postures all the time, bu[
they should be avoided completely when you are suffering an acute
cpisode.
If we <lrc involved in high risk 'lctivitics. such as repetitive lifting
or prolonged .~itling. it is impnrl:liit tn learn how 10 modify 0111'

I,-=::.J
~

rI-

,-

~j

'

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

172

Fig. 1OA.7. Referred pain from the levatal sl,;i:tlJuiae muscle. (From Travell JG, Simons DG: Myofascial Pain and Dysfunction: The
Trigger Point Manual. Vol. 1. Baltimore. Williams & Wilkins, 1983.)

~rt~t
",

/:'"

Fig. i0A.a. Referred pain from the scalene muscles. (From Travell JG, Simons DG: Myofascial Pain and Dysfunction. The Trigger
Point Manual, Vol. 1. Baltimore, Williams & Wilkins, 1983.)

..........

.'.....

'LoI'

IV. rMllt:I't'

173

CUUL;AIIUN

,:

00:";'
Fig.l0A.9. Referred pain from the sternocleidomastoid muscle. (From Travel! JG, Simons DG: Myofascial Pain and Oysfunclion~ The
Trigger Point Manual. Vol. 1. Baltimore. Williams & Wilkins, 1983.)

-,

"---.J

.~)

J l
v
v
v

"v

oj
Deep

Deep '---'.,."

Fig.10A.10. Referred pain from the quadratus lumborum muscle. (From Travell JG, Simons OG: Myofascial Pain and Dysfunction:
The Trigger Point Manual. Vol. 2. Baltimore. Williams & Wilkins. 1992.)

f'

I
,~

ell
~~---;,

'tj

IJv
~._'-.: ~: __--,
&

i t,J
~

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

174

Fig.10A.11. Referred pain from the piriformis muscle. (From Travel! JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger
Point Manual. Vol. 2. Ballimore, Williams & Wilkins, 1992.)

r
~I
Fig.10A.12.

Referred pain from the iliopsoas muscle. (Travel! JG, Simons OG: Myofascial Paln and Dysfunction: The Trigger Point

tv1:::l.nual. Vol. 2. Baltimore, Williams & Wilkins, 1992.)

175

/~\

.t

.,

II

1 (')

",
.....,

..

\, "J

I
I

,"~

Ii n

,~

,f,, ""

,j

1;

,)

,,
~

Fig. 10A.13. Referred pain from the gluteus minimu5 muscle.

(From Travel! JG. Simons DG: Myofascial Pain and Dysfunction:
The Trigger Point Manual. Vol. 2. Battimore, Williams & Wilkins,
1992.)

")

~ (}

Fig.l0A.14. Referred pain from the cervical spine joints. (From

Dwyer A. April C. Bogduk N: Cervical zygapophyseal joint pain
patterns: A study in normal volunteers. Spine 15:453, 1990.)

I,

':)

.~

I ()

~
<

"'2"

v
v
v

"

"v
"
"

-",
v
v
u
u
0-

),
!

"

Fig. 1GA.1S. Referred pain from the lumbar spine joints. (From McCaIlIW. Park WM. O'Brien JP: Induced pain referral from posterior
lumbar elements in normal subiects. Spine 4:441.1979.)

j:~!

~'-.':.

~V_

ij

-----------------------------~-

" ......

",~,_.""

.............. ,

, .... "", ......... " , r. ..... '

"'o.JU"'"

,v,r.,vvr.,-

.Kli\ill<::- ,,(I we tJ~Jx:_B.~~ICI,:han.i~_~I!~U~~~~~tJ.r~.It III")' ;IIS(I hc

nec.:I..""an ((. paform "If:..',,::;..:,, durin!.! hn::lks In ;:IlIo\\' lllusc.:k~ ;lIld
li~;\llll'l\;:- thai h;~~:~ i~l~:::~~~~~~~i;; .til~;r--~lr-engt1J. 1:[;''111)'.
SlrCl\~lh":lIilll! cxcn:i~('"

f,-'; .)llr ;lbLlullICIl. olluocks. Ic!.!s. ;L1ll! b,KK

may IIC Ih::Clklllnhdr. t1 ... .;.\,:il~f;Jtiguc ill (lll";~~ck ;lllJi~l\n::r ll;ick.
Acll'"i~;;;;ilCd p~;g;;;1111~::::.~~~)\I1ati{-:;~~;~ci~~:;_'d CdlK,,{i7;'ii" \\ill
he d('\"j":..'d 10 llIee! your ;,::.. -1 ....

Normal "pinal pOSIIIl"e h~l~ . . r..:duce potelllial strain. Ul1f~)rh11lald)'.

uur moocrn lircstylc~. in c,'nI.'Cf1 Wilh the forces of !;r;l\'iIY. conspire

tu min our he;llthy upright ~)sturc. The eldcrly arc oftcn slmnpcd

iI

~e"use of bad postur\," ~lr somcliml.:s from osteoporosis (Fi'r.,.

101\.201. 1l1;S habit of .~lu:i..ping begins in childhood whenwe sit'ill
I"rOlI1 of telcvisions. :-it in <non!. sit in ems. ele. Siair!E and imlCli\'-

I
j

Jf I

.~

i
i

I
I
1

~
~
i

Fig. 10A.16. Referred pain from an irritated or "pinched~ sciatic

nerve root. (From Cox JM: Low Back Pain: Mechanism.
Diagnosis, and Treatment. 5th Ed. Baltimore. Williams & Wilkins,
1990_)

Fig. 10A.17. Herniated disk. (From Kirkaldy-Willis WH:

Management of Low Back Pain. 2nd Ed. Edinburgh. Churchill
Livingstone, 1992.)

!
ij

~jJ;

I;
i

"I;i

200 Ibs. Pressure

150 Ibs. Pressure

100 Ibs. Pressure

..J

~
~

55 Ibs. Pressure

i~
t

11

iI

1
~

200 Ibs, Pressure

;;;
~'

Fig. 10A.18, Effects of posture on lumbar disk pressure. (Adapted from Dutro S and Wheeler L: Pregnancy and exercise. In White A,
Anderson R (eds): Conservative Management of Low Back Pain. Baltimore, Williams & Wilkins. 1991.)

~
,1-------------------------.",

25 Ibs. Pressure
100 lbs. Pressure

_________~L~

. . . .

~.,

177

.., . ,..,.,,-,,,. CVUI",M.llVN

m.:.; tlpri1;ht puslur..... The n:sulting forward drawn or slumped poslur~' b rr.:inf(\(().:d hy gr;lvily. which makes it even harder to maintain
:l lhlnn;l! uprig.llt posturc. The signs or poor poslurc include the
f"!1,\\\in1; (Fig.ur.... IOA.20l:
-\\r.:ighl mw thl: h;llIs of our feCi
- ..\\;IY hOl!.::k
-inI.:Tcascd Hllllldlll.:ss of lIlid.uppr.:r b'Kk
- ..hOlildr.:fS roumkd forward
-hc'ld forward
-..:hin pokr.:d

)
Til ~'orTcct poor pmilllrr.:. it is hdpful (0 .ttlClllpl the "military posi-

,,

-~

lilm.' which willmo\"y-you hack in the right direclion. A good rule

(\1 thumb is 10 assumc thc '"military position" and Ihen back off about
10(;. tFig.JOA.21). It is a good idea 10 move in Ihis direclion about

1)(

()
()

C\-r.:~

2)(

20 milltlles as a way of "fine tuning" our posture until it il11-

pro\'6 :Iulomalic;l,lIy. Aftcr just a few months. our new posture

3X

wilt

bccol1l......I habit. The military repositioning involves:

Fig. 10A.19. Effecls of posture on neck muscle aClivity. For

every inch that the head moves IOlWard of its normal posture, the
compressive forces on the lower neck increase by the additional
weight of the entire head. (From CurIO: Head Pain. Baltimore.
Williams and Wilkins, 1994.)

-----_._

-llallcning your low back against a chair or wall

..
-rolling your shoulders back and down-
-tucking your chin in whilc ),ou glidc your head backward

111... ~iuillg poslure IS fatiguing because of the pressure it places

on Ihe disks of our low back and thc amount of muscular effort
r....quircd In keep both our b'lck and neck upright. The most import'-tnt thing to remember about sitting is to keep the low back str..light
or '-lightly <Irched. This po~hro'llTili~vTir'prc~ci;lustrom siurnping.thus preventing both lower back .md neck slr.lin (Fig. IOA.22).
Drh j'ng or sitting in :I car is onc of the situations cncounter~lmost
fr~qu~ntly. The best way to sit in :1 C,I( i.s witl12.~~.~~~.,!~~_cll
wpponcd and lhe seal back Slightly reclincd. The seat should be
at ;I height such that your hi;~';-r~levcr\vith or slightl)~ highcr

lh::n your. knees (Fig.. IOA.23). It is imporlantto have the scat far

Fig.l0A.21.
Fig. 10A.20.

~MilitaryM

Slumped poslure.

correclion.

it}' autom,lIicaJl)' invite poor poslUrc. thus o\'-crstraining our spinal

mllscle~. Iig;llUl.:nts. and joint:'.

The SlumpetJ or Forw=trtJ Dr.IWIl Posture

We arc born in the fetal position with our spines rounded forw<lrd. As
we grow. our spinc extends ill both our lower back ,uld neck. which
allows us to look stmight ahc:ad. walk upright. :ll1d usc our hands.
Unfortunately. modem occup'\lions and lifestyles. by overusing the
sitting position in C;Jrs. while C:;\ling. w;Jtching tclevision. :lnd working al desks and computer workslations. have imbalanced ollr nor

Fig. 10A.22.

Poor driving posture.

lfti

Hl::HI-\CIL.1 1.... 1 IUI"l VI"" I Nt:

~/""lt'H::

.... t-'HAI,j 1IIIUI'H:H :::> M ..... I... UAL

that Ihl.' had is higher lh:1II Ihe frollt (or usc a fO;IOl wedge) (sec
Fi~. IO.\.~.'\).

A d... ,k Ih;ll is

IOI}

1(1\\ \\ill prmnnlc a !".lull1ped posture. AllY rC:ld-

in,g or writin,g. eHn on:! J~:d.: nf proper height. may C~l\lSC neck and
sl1l1ukkr Il\"l.:rslrain (Fi~. It).\.})}. III stich cases. studclIIs and desk
wnrkcr, will h.... ndil fr\\m a \\Tiling wl'dgc or b()(}k sllppun (Fig.
1OA.~61.

,,
-,,

""\
j

Fig.10A.23.

Heallhy driving posture.

Fig. 10A.25.

Typical slumped posture during writing.

.)

-,

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.,
.j

-)
- -'

Fig. 10A.24.

Good sitting posture with arm rests.

enough fOlv,'ard So you do nO! have \0 deville (shrug) your shoulders

to reach the steering wheel. You should not feci lhe need to slump

forward.
When sitting in a chair. lhe same bOlSic rules "pply. Milke sure your
feet rest comfortably on the floor and usc armreSls if they arc rt\'ail
able (Fig. 101\.24). When you perform work al a desk or computer.
you may want to experiment with the lilt of your scat. It is oftell
more comfortilbk for yOUf back and neck if the sea! is tilted so

Fig.10A.26.

Use of a writing wedge to improve posture.

.~

----_._-------

._----

'."

,I

179

\,.,M1'\1"" I t:.H lU : t"Allt:N I t:UUCATION

1,

,,

:<,

l
L

l
B

A
Fig. 1OA.27.
strain (b).

Improper sitting posture (a) and proper silting posture for reducing finger, wrist. elbow, shoulder, neck, and back

checklist of the important point!' to review with reg'lrd to your work

st:uiolls.
\Vhen you sit or stand, it is imE.Qrtant t.h_~.t~_sho~ldcr~~
laxcd back and down. This pnsitioning will help prevent the slumped
po$ture and, with it. the head forward posture. Slumping eventually
IC:ld~ to a pcnnancnt rounding of the upper back (dowager's hump)
(Fig. IOA.28). Additionally. with the head in a forward position. the
muscles in the back of the neck and between the shoulder blades are
c<l~ily fmigllcd and IxCOIllC strained. M:Il'y hc,Jdaches, neck. shl)ulder. arm, and shoulder blade pains result from this posture. A simple

Table 10A.2. WorR"station Ergonomic Checklist

Fig. 10A.28. Proper head/neck posture (a) and slumping and

Ihe dowager's hump (b).

When typing or imputing Oll'a computer keyhoard. your hands

should rest on the keyboard without your wrists bent, your elbows
should be bent ~ll a right ang.le (90"). and your shoulders should be
completely relaxed (not shmgged) O\g. IOA.27), Table IOA.2 is a

Chair ~-seat height adjustable

Feet should be on floor and knees no
higher lhan hips
Arm rests
Good lumbar support
Seal back should be able to recline (95 10 105)
TIllable seal pan
TIlt seat 10IWard for desk work
TIlt seallylckv/_ard for reclining work
Computer ~Center of monitor nose level
No glare on monitor
Keyboard height so that wrists are not bent,
elbows at a 90~ angle, and shoulders
relaxed (not shrugged)
Other ~
"""DOCument holder
Head set

YIN

180

H~n""OlL.. 1 ,

,'U,'1 u r I n..:; v, IU'-. '"' , , '

"

I ."-',~

,_

!
j

,~
i

!!
~

'~

II
I

I
"
"

'\

Fig. 10A.29.

(
Postural exercise lor round shoulders and head forward posture.

exercise can be performed frequefHly throughout the day for just 2()
lO 30 seconds C"lCh time {(l pre\'cl\I Ihese ill effects of the ~
pmaurc. As shown in r:i,gUfl.' 10.-\.29. you can roll your shoulders
~~k Jnd down (by squeal"!! \"Our shoulder blades together), rotale
your hands outward, and 1\lck your chin. This same exercise can also
be perfonncd at home while lying on your abdomen. Hand weights
can even be added for u greater strengthening effect. If ~. . cr
b~~karchcs too much. you call try placing a pillow under your

you will need n larger pillow than someone with narrower shoulder.s.
Finally. it is important to placc your pillow betwcen your neck and
shoulder. not under your shoulder.
Lifting is probably Ihe area of greatest concern for all back doclars. The mOSI import,mt rule is 10 "keep your back straighl."

abdomen.

Your posture for sleeping is abo impoftanl. The ideal sleep posture is one in which nil the norm.1I spinnl curves arc maintained with
mi[limum strai;-Th~~ fetal position achieves this 20111 (Fig. IOA.3e.
Our lumbar spine and pch'is should not twist too much and a pillow
between thc knees or thighs rna\' be :311 that is required to .wold the
c~~oii-ha_lf lunlnly/half fetal ~Iecp posi.tion (Fig. IO--;\.31)~\Vhen
slccpi;lg'on 'our b'ICh. ~I riflo\\" u~idc~-ii~c 'knees will keep the low
back relaxed to that it docs nOl o\'crarch (Fig. 101"\.32).
Sleeping is orrell il uifficult advclllllrc for individuals with neck
pain. Finding just Ihe right pillow can be Ol "nightmare." TIle ideal
pillow will cradic and suppon your neck without distorting its nor
mal ~t1ignrnent (Fig. 10'\.33al. If your pillow is not supponing you
properly. you might wind up with recurrent "stiff necks:' headaches.

or~\''cu.referrc~.J~~.(~~~__~t~~9!"~_~~ll\. or ha.'.W~.!!Jil!~;ort~lnt't()
~\'oi~.~i_~.~_ t~. li.t_tle or 110 pillow. w!lich pl_;)..~1::~ __~he_ un.supported
n~k under strain all night long (Fig. IOA.33b). It is equally unwise
to .u~_W-!!!'!..nJ:"p'illow~~.or.[ 00 finn_oL4LP_~.~.hk~y,')hcsthe

Ilt::,c;k_.lm.~-,~d.p.hl!!'::~_l!~~j,?~l~!~l~)gcthCJ. tEig. J Q!\:J:?l_!Y!1ther ~u

lie on your side or your back. your pilluw must be soft enough to
mold !Ct.YEur head and yet still fill in dte space between your bed and
your neck. Re~;;mber: your head is bigger Ihan your neck. so accommodating both wilhout distoning Ihe position of your neck is the
key. Sometimes. a bohlcr or spcci<ll onhopedic pillow is helpful to
fill in this space. If you ;lH: a side sleeper and have broad shoulders.

Fig.10A.30.

Fetal position.

CHAPTER 10: PATIENT EDUCATION

181

Fig. 10A.31.
the knees.

Sleeping with a pillow between

Fig. 10A.32.
the knees.

Sleeping with

pillow under

()

C)
A

\
c

Fig. 10A.33. a, healthy neck/pillow relationship; b, too small of a

pillow; c. too large of a pillow.

Second, .\Void twisting when you lift. The combination of bending

and twisting I!> the death knell for yOllr lumbar disks. It is also imporlant to try 10 lift objects as dose to your chest as possible; the farther the object is from you. tile greater is its "mass," Another reccnt
disto\,cl)' documents Ihal the back is especially vulnerable immcdi
ately after sitting for a prolonged period (just 15 minutes will do it)
or .1her;'1 night's sleep. Remember 10 usc good lifting habits. especially irnlllcdi,ltc]y ,Iftel' gcning up fH)'lll a chair or afler a night~s
slcl.':p__ Whenever possible. try to avoid lifting from the floor; ph.lce
things .It knee. waist. or chest height. Lifting children can be especially difficult bec::Iusc they obviously do not sit still like boxes do.
Nonetheless. because we will do lots of bending and lifting if we
have kids. the sooner we learn to do it rig.ll1. the less likely we arc
to have recurrences of disabling back pain. Pigure IOA.34 shows

Fig.10A.34.

Proper lifting technique from the ground.

the proper technique for lifting an object 011 the ground. Pigurc
IOA.35 shO\vs poor technique in lifting ",ilh the back. bcnt instea(l
of straight Table lOA.:; slllllrnarizes the key components of proper
lifting lechnique.
Reaching for things above shoulder h:vd is another strenuous activity for your back. Usc of a fOOL stool is an excellent w.IY tl) rl.'ducc
the strain (Fig. IOA.361. If a stool is un;l\"ailablc. then a trid;. is to
tighten your abdominal and buttocks llluscks so you flath.'ll your
hack (Fig. lOA.}?). This maneuver will pr~vellt the tcndency \() :-tiek
out your buttocks and ovcnlreb your back.
Carrying suitcases. groceries. or a baby ;lrc all chalJ~n~C':, for a
person with a bad back.. When p;'lcking. for ;1 vacation. it is Ixttcr to

Table 10A.3. Proper Lifting Technique

lift with your back straight
Never bend and twist while lilting
Keep lhe object as close to your chest as possible
KJ:>J:>["Ithings that need to be moved at waist level whenever possible

---------------------._----------_.

182

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

,,

Fig. 10A.35. Improper lifting

technique from the ground.

.,,

..f

I
B

L
Fig. 10A.36.

Use of a stool for overhead activities.

.J

Fig.10A.37. a, Incorrect overhead reaching with back hyperextended; b, Correct overhead reaching with back flal.

j
pack (wo smaller suitcase!' Ihan one oversized one; you can thell
h;llancc the loads and .\Void straining your back (Fig.. IOA.38).
Avuid carrying a bahy or any other object with outstretched ;arms.
By holding the \\'cighl close 10 your chest. you greatly reduce
the pnlenlial sIr-lin (Fig. IOA.39). This :'Idvicc is particularly
impOJ1ilnt when pUlling a baby in a car scat. By holding the

baby

c~c (0

you, you arc less likely

10

injure your

b:'lck

(Fig.

IOA.40).

Pushing and pulling can be yet ,mother source of lumbar str'lin.

Given a choice between the (wn. pu:,hin!; is preferred bcc;ltIsc lhe
legs can be used more effectively (Fig. IOA.4I). When huying. a
carriage lor your baby, try 10 find one that is lilted 10 your heigh!.

183

CHAPTER 10 : PATIENT EDUCATION

Heat is generally avoided in the acute stage because it can <lclUally

im:rease swellinr: or infl,unm:uion in the back. Anti-inflanlJ11illorics
may be helpful for the first few days to reduce the swelling quickly.
Your chiropractor or other specialist may fit you for .1 lumbar br.lcc
;lnd give you sp.:cilic therapeutic exercises to try. Some of the safest
exercises arc simple strctches or lumbar extension excrcisc~ (Figs..
lOA.47 t() IOA.50). Walking l1l<Jy also be suggested. Gcntle lreatments may bc applied thai will also speed the process ;tlong. As soon
as your ",cute pain bcgins to case. morc aggressivc conscf\,;lIi\,c
treatmcnts will follow Ihat will gct your back functioning again as:
quickly as possible.
In order for your back to cillm down. you must Ie am ways to perform normal activities without placing any unduc strain on the back.
Sitting should be minimizcd and sometimes ;Ivoided altogether. The

()

()

Fig. 10A.38. a, Too heavy a suitcase; b, Balanced carrying.

0'

If you arc rull. the carriage will need longer amlS (Fig. IOA.42). In
any case. try 10 keep your back straight and avoid slumping when
yOll stroll a baby. The same is gcner..tl1y true when selecling a
vacuum cleaner-a laller unit will help you to keep your back
~[raight.

{)

Changing your bahy is another opportunity fOf back slrain. The

rule is (0 have a changing s!alion of appropriate height so that you
do not have to bend too far fON'ard (Fig. IOA.43). Sometimes. a foot
stool can be used to reduce back strain.
The foot 5tool is a h.,ndy aid fOf much counter top work. (runing.
cUHing vcgetables. folding laundry. and brushing your lccth arc just
a few examples of situ;lIiOllS in which a low counter top can cause
overstrain (Fig. IOA.44). If a foot stool is not available. it is sometimes possible to bend your knees <md lean them against the cupbOilrd (Fig. IOA.45).

Pi nil aiel for

CJ

(lll (lell/c'

('pisoc/(' of bad pain

One of those acute. disabling e~odcs of back pain Cim easily provoke anxiety and even anger. ~nunatcly. such episodes typically
arc tml1Sielll and usually begin to c~ll11 down after just 2 to 3 davs of
rcs~ up 10 I week if they arc accompanied b}' pain./numbness
bclo:........ _~~.J;ne:V Proper C:lfe of the acute episode leads to dramatic
improvcmcnrquiekly.
Much C~1Il and should be done to ensure that an acute episode docs
not mushroom imo a severe. disabling episode. Try to reduce ,lilY
source of c~tcmal sWlin on your back. Assuming proper rest posi.
tions is of vital importance. L}'ing~ your b,!S=k wi_tiLy.ou(.kQe_e~bnt
js...one...oL1h~clief" p2.ili.i.ons for the spine (Fig. IOA.46) in thaI

it r@ces pressure on the di~~~.'.l.l1d r~t;!'~~lUh_~~~i;~tNii~iyTng

ie~__ ~2 minutes four to six times per day normally is a~"i~;lb'::J

Fig. 10A.39.

a, Incorrect carrying of

a baby with outstretched arms: b,

Incorrect carrying of an object with
outstretched arms; b. Incorrect carry
ing 01 an objecl wilh outstre.tched
arms; C, Corre!;t carrying of.. an object
held close to the chest.

---------------_._-_ ... -

0;"';;

<C-

184

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

danger comes when leaning forward over the sink. In this situation. it is pruden! 10 bend your knees or usc a foot stool so that

I
II

when you bend forward. all the pressure docs not go into your

b3ck (sec Fig. IOAAS). Getting in and out of Ihe car is :.mother

...."

chalh:ngc. Avoid pivOling at your waist; instead. keep your

torso rigid as ),ou tum your clHirc bod}' 10 gel in nnd out uf
the car.
Until your back "goes OliL" you do nnl reali7.l~ jusl how many ac
tivities place strain on your back. Just pUlling on p.mts. sock.s. sluck
ings. ctc. usually entails stressful bending. Two -o'piio~s exist f{l~
aVOlclilig'tllis stress. TI)' either dressing on your back or standing
against a wall (Fig. lOA. 52). Getting up OUI of a chair is another simple activity lhul seems like "murder" when your back is "out." If yOlI
~lre in a chair, scoot to the edge of the chair before rising and usc mill
rests if available to push yourself up (Fig. IOA.53). Avoid bending

."1

forward if possible. Lovemaking. is another activity that can seem

daunting if you have a bad back. It may be casier if you arc on your
back with your knees bellt. Another possibility is making love while
lying on your side. It is import...nt that a bad back not interfere with
family life. if you can help it.

Fig.l0AAO.

Placing a baby in a car.

Exercise
A sedentary lifestyle is a recipe for back and neck pain. Exercise

C~1r1y

morning is always J critical lime. Not only arc we usually

stiffest then. but

also~r

disks arc swollen from not bcine com-

pr~scd

by gr.1\'ilY. Getting Out of bed safely by avoiding doing a

sit-up is absolutely crucial. It is best to get up on our side and try

to avoid twisting or bending at the waist (Fig. lOA.5I). The next

nourishes all the tissues of the spine and increases Oc:x.ibility <Hld
strength. When recovering from an acute episode of pain. exercises
actually h~lp the tissues to heal faster. Unfortunately Do! all exer.
cises arc appropria,,' (or lb.- bjlck jlD.(tw:d>...s.nm.Ul\CJsi:i,~.sJh~ actually..caD.....CMus.c.llaffil are as follows:

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Fig. 10A.41. a, Unsafe

pulling; b, Safe pushing.

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,-,nl"\'" I t:H lV: t-'AllcN I EDUCATION

185

4- Lat

Pull Downs. A great exercise. but not the way it is commonly pcrfoml~d. You should nO( have to crane your head forward to avoid the weight stack nor should you hypcrc.xlcnd
the low back (Fig. IOA.57). Have )'ou;b;ct--'I~lhC-~iC
,1I1d plac~oOl far enough forward so 111:11 the weight can
be lowe.red withOlI1 h:lVing 10 move your head oul of" the

weights way. Also

~rform :t

slight posterior pelv;c lilt by con-

tracting hoth yourabdciimnals and iiui~~iisw"i)i~icrt'y(;urT(:;wcr

bolek.

-.-.- - . _...-.- .. ". -_.

@ncc y.0~!" pain i~~t~~~li~cd and your back and neck is ocginning
to ....10Cl~~._L!p~.flgain. itjs imponam t<? f~cus on improving the func-

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Fig. 10A.42.

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Stroller arms of proper height: b, Slumping be-

cause stroller arms are too low.

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\ Toe touches. TIley stretch the back and hamstrings simultaneously.

which is too dangerous (Fig. IOA.~4).
2 Sit-ups. Never come up alllhc way because the disk pressure is (00
high. Also. they can be bad for the neck if you pullan your neck
or. poke your chin rorwar~ you come up (Fig. IOA.55).
3 Hamstring curls. The tendcncy is 10 o\'erarc:h (hypcrextcnd) the lumbar spine during this excrcisc (Fig". IOA.56)."

as

tion 0f.y<?urJ>a.c1. Reconditioning involving stretching and strengthening is CVC!)' bil as important as learning how to sit or lift. Beforc
you go out and join a gym or gCI back into that \vorkout routine.
however. you should be "awarc of somc of the morc dangcrou~ .:xercises commonly performed today. 11,e four mas! l.:(}n~tnon errors made in the gym are hypcrcxtcnding the low back slumping
at the waiSl,fking the chin forwar . an CXC~SSI\'C s l!"U~<.!il! of
the shoulders. The exercises in which improper fonn is seen most
commonly include the foilowing:

t. Hypcrcxlcnding the

low back
-sitting leg extensions
-hamstring curls
-Iat puB downs
-supine f1ys
-()vcrhcad press

-lunges
-squats
-trunk curls on an incline board*
-sit-up)
-Roman Chair

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Fig. 10A.43. a, Changing stalion height

too low: b, Correct changing station
height.

186

REHABILITATION OF THE ::;I-'INt:: A PRACTITIUNt:.H"::; MANUAL

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Fig. 10A.44. a, Typical ironing posilion; b, Use of a footslool to
reduce a low back strain.

Fig.l0A.45. a. Brushing teeth with both knees bent; b, Use of a

footstool to reduce low back strain.
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Fig. 10A.47.

cise.

Back relief positions.

Back extension "sphinx exer

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eM IV: t'J\IICN I t:.UU\,;AI"ION

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-stiff-legged di:,ld lift*'

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-bent forward rowing*

3. I-Ic;ld forward po~aurc' with chin puked fon.. .md
-sit-ups

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Fig. 10A.50.

Prayer stretch.

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bicycle

-hmmtrillg :-;tn.:tchcs (toe touch or on floor)

-exercise bicyck
-l:It pull downs
-pllsh-ups

-st;lirclimbcr
-push~u\ls

2. Slumping at the w"isl

~sitling leg extellsiolls
-sitling chest press
-stairdimbcr

4. '-liking or shnlgging of lhe shoulders

-rowing m;lchinc
-hem o\'er rows
-latcf.11 arm raises

-overhead press
-pushups

nc;n"'Oll.II""IIUN ut- IHt: ~"'INE:

-.

A PRACTITIONER'S MANUAL

.,
B

Fig. 10A.51. Technique for gelling out or in

bed with a bad back,

A
Fig. 10A.52.

Sale back options for putting on pants, socks. elC.

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chair.

Safe technique for rising from a

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Dangerous toe touches.

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spin.: .,~ainsl maintaining. a rdax!:d shoulder POSllW:. Desks Dr

wm!\sl.lti\ln:- 11I:.ll arc ton high or poorly placed (or absent) arm
l"L'stS l."lllltrihuIL

10

elevalion of the shoulders. Again. proper pos-

lllrL' alld fnnn Juring exercise is I\eccss~lry to prevent mlding furtha flld ((1 Ihi.. lin:. A ~uud rule of thumb is that the shoulders
!'ohllUhl hl' rcla:l.Ld

ha~k

anu dnwn. It is ncvcr a gooJ ide;t during.

;lIll:l.cl"t.:i:o;c hi L'itha rollihe :-hnullll'r.> furw<.lrd t)r hike them lip tnw;lnllh...: L;lt...
SI/IIIIII/IIY

[f you

h,IV\'

louffcre<J

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scvere episooe of bilck or ncck pain

t1r yuu I.:xp.:ri::IlL1' chronic p"in in these arc;\s. thcre is ,I proven

way

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C('lllrol these

:O;ylllpIOIll:'.

learning h'lw to rcum:..: strain

The long-term solution

lIlld

yuu rel."..:i\"t._ from your rch,.bilitation

Fig.10A.55.

ill Ihis handuut b llcsigncd

Improper sil-Up.

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These ftlUr cardinal error.>

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illvol\'e~

improve poswn.::. Tht: advice

spcei~llist

help you

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and that is indudc:d

hdp yOllrself. Back

Fig. 10A.56. Harmful hamstring (back 01 thigh) exercise.

(lft;:n be l'urr~'tcd by p'lying: aHcntioll

to proper jloSlUrC and form. Th... lumbar ~pilll.: ~hould Hormally bl.:
kept in a "mid-range" p()~itioll. oflcn c;llI...d Ihe "nelllr,,1 positioll" or
"functional raogc." This position \';lrics for everybody. Some people

arc most vulner'-lblc whcn Ihey ~11l11lp. (llhers when they hypcn:xtcn~_ A g~nllc cQcontr.Klillll of ~ (lUI' abdolllin:tl!'o <llld your hUltocb.
is usu~llly sufficicllI to is(lIlH:-irtc:illy hold your spIne 111 a st~ll;lc posi'--:-----------------_._-----------_.-

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tloopr !~!~_o-,h~!!~l}-'l!:,Y.~lf 1.'-~XQ<;.i2.!:'~.i!~_I11Cnlioncdc all hc pc!::

fortl!c_~_~a.rf:I)~:ccnail1 cxc'rciscs I ~ L hO\~'ever,-~'I~'~~ hI.: dil~i

~d C:()lllpl~tcly rr~)lli;:j'l~~ri}lltlii~-;:_l'Our'back spcci\llist'\~sllOW

you.aJtc-rnative!'.

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When your hC<ld is forw<.lrd of y{IUr tor:o;o. it is vulnerable 10 injury. Thi:;: position fatigul.:s your neck Illllscies and place:- the eer-

,)

vical spine under gr... ;1\ strain. P()kill~ your chin further irritalC\
the joill! between thc back of your head (\lc;ciput) ;lIld the lir:o;t vertebrae \11' tbc fled (<l11;Is). It .d~v creatcs a "~lIillotinc"-likc effect
between the tr;lll~ili{lll or the 10\\1.:1" p;trt (If your neck and the upper pan of )'uur thoradc spine. By silllply making slife YllU <Ire
not slumping ;tt your w,li:-t and kl.:epiu!; yuur shouldcr~ hack t{l
prevcllt them from rolling forward. your head POSilicllI will oftell correct itself.
Excessive shoulder :o;hrugl;illg

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COIIUlHll1

probkm. EJtHltinnal

tension kads to shoulder ;lIld neck tension. which results ill "having-;I;'~ -~\~igi;l_oLthc-wodc..!~;;~i_y~).ur--:o;I~llul~JcQo.r requCllt sighing
is a tip off

[0

Ihis OCC\lfrel1CC ..\bl).-ll-i;;~t ~j~sks alld (hairs

COll-

Fig.10A.57.

Improper form during "lat pull-down"

exerci::,;~.

191
\11' fwd,

p;till ;Iri:-l':-

frlHIl l'XPO~\ll\" In mCCh:lllic;ll slr.lin Ihal

~r;tdtl;dl~ :tl..:tlllllll;lll...

yuur lifetimc. If you karn

ttl ~il. li(l, hend. l"n~. :llld :-kep ~lll;lficr. tile likdihlll1d Ilf di~
,:tHl1(WI ;llld ri:'l~ uf ,\'.injll1')' is fl..'duccd. If yOIl 1l;ln.' d.:couditi,llll:J :I' ;\ I"o::-ult ,If kadil\;; :l "'l:,kllwry lift::~ayk Ilf frlllll fe
:-It'il'lill~ ~t'llr :ll"tl,iti\.', ;1:- ;, cOllsequence of pain. thell ynll

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Ihrl1u;;holll

I\lay abll lIc.:lI to sian a lhcrapclltic stretching and strenglheniftg program. Learning how 10 perform typical .t\.:tivitics of
d;lil~ life without incn.:asing strain, and also training musck~ In

he

lll11n:

fit. will enable

yOll 10

control your symp-

hllllS ;1IIt! pre\'ellt the likelihood of lIlore seriolls problems in the

fUlUro.: .

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IV
FUNCTIONAL RESTORATION

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11 Role of Manipulation in Spinal Rehabilitation

.KAREL LEWIT

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Rchabilit.nion is dcfined :.IS the restoration of function in thc

motor systcm. This definition implics rec..:upt::ration of Jctivc
voluntary motion. To place emphasis on activc exercisc
is therefore justified (0 achieve normal active control of
movement. Structures that move passivcly, howevcr, such as
joims. li,g.llllcnts. fasciac. and tcndons. frequently playa key
rolc in this recovery. and passive tn:a(mcnt of these struCturcs
C,IIl be effective. c\en for severe muscle spasm. In fact. the
usc of pnssivc manipulative therapy by a qualiflcd individual
may enable <:1 patient to c..:arry out .lctive motion. whereas
omitting thesc methods would result in frustrmion and loss
of time.
Manipulative treatment is an important factor in the
restoration of passi\c motion. particularly now thal up-to-date
techniques affect not only joillls but <llso the soft tissues. in
p.t:nieular fasciae. <I~ wei; as muscles in spasm and with trigg,er points (TrP). Many of these techniques also make lISC of
thc paticnt's muscles and therefore may be considered scmi
acthc. Such methods are perhaps a link between passive and
active trealll1cnt. I - J
Evcn more important is the diagnostic v'llue of thc tcchniques dcscribed by professionals who use manipulmion for
Ihe assessment of changes or lesions in [he tis!'lues and .,tructures that constitute the locomotor syqcm. These 'Isscssment
techniques are useful not only for joints. but ,llso for soft tissues. including muscles <HId fasciac. No less important is the
contribution of these professionals to the diagnosis or dislUrbances in spinal stalics (e.g.. short leg. poor posture)...:,r

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CHANGES IN FUNCTION
The condition affecting the motor system that most often requires treatment. including rchabiliwtion. is not the obviolls
loss of 1110tor (;ontrol or motor function. bUI poil/. also termed
lIIyofa.\'Ci(/f /W;// (i\'1 p). Use of (his descriptive term seems justified in so far as thi!'l pain. whatever its tlll~ origin, is expressed or felt mainly in Illuscles and their attachment points.
Despite its enormous incidence, this 'lfIlictioll is poorly understood: flO pathologic structur<ll changes have so far been
conlirmed as relevant. and it is the secret hope of many
r~searchcrs thal discovery of such changes i~ just round the
corner.
One of the features of mallipulation ~lI1d other techniqucs
u.....:d to treat MP is that they :lct inullcdi'ltdy. This feature is

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also true of othcr methods o!" what may be called "relk.\ therapy:' e.g.. acupuncture or local anesthcsi~l. Sudl iUHI".cdiate
effects would hardly be possible if the underlying !.;;.I\lSI,;" Wl;rc
a pathologic change of structure that requires hc..:alill~ and
could not be reversed immediately. This concept is casily UIlderstood. however. if the existence or real it)' of c..:hant!.es in
function is recognized. For stnlclUre ill the living org<:ln~slll ill
general. and in the locomotor system in particular. b no mort:
real than is function:'musclcs in spasm (with TrP). incapabk
of lengthening; restricted joints (perhaps because of lllcniscoid entrapment and/or spasm): and short muscles or r;'lsciac
rcquiring stretching (shifting):-iC'
An examplc of an even l1lor~ elementary situation is'tension ano muscle pain thai Jccompanics an uncomfortable pnsilion: discomfon improves imlllediately with a change of position..l-;\s observcd by Brugger. if ,I person sitting in a
round-shouldered position is examincd. the l1luscles of the
shouloer !!.irdk.. 'Irms. and even of thc IC2s arc tcnse an.d~n
der on p;ipationY'fhe moment lhe person changes into an
/
erecl (lordotic) relief position (Fig. J 1.1 l. the s.une muscles
arc soft and painless. Nothing hilS ch;'lIlgcd except body sUllics. but relicf has been obwincd.
A slrong reluctance rcmains. ho\Vcver. within the mcdic;1!
profession to accept altered funl..:tion as ;'111 imponant cause of
disease and suffering. In fae!. lhe term "functional" is widely
used as <:1 cuphcmbm for psydl(llo~ic or even imaginary problem'. In il1lcnml medicine. some changes in function ;'lpp:lr~
ently arc accepted. e.g.. cardia(; arrhythmia or ~ndocrine dysw
function. but such acceptancc remains an inSUrtllOUllWblc
obst<tclc in the motor system. where funclion is p"ramount.
Anatomic verification at <:IlHOpsy has become the obsession.
as though physiology was or little import'IIKc. it being, indeed. unvcriliable post mortclll. I therefore like to lise a simple example from engineering.
If an ,1lJ(olllobilc stops fUllLtioning. the L'H1Se ITwy be a
broken cylinder or b..tllbcaring. Alternatively. the problem
lllay result from maladjusted combustion or ignition. In the
lirst case. therc is ~ross pathology. BCGllI!'lc a machine cannot
heal. we must repl'lce the damaged p'lrt. In [he SC(;OIH.I case.
the ~tructure is intact. we have only 10 adjust the ignition or
c..:ombustion (i.c .. jlmerioll) and the m;H.:hine pt.~rforms again,
An importall\ warning is appropriate ill this point: just as
it lllOly take l:qual effor( to adjust" complicated engine as to
eh.mgc SOIllC sparc pans. trcaltllclH of changes in locol1\otor

.J

...

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

196

Ihis selling is all the 1110re imponant in thallhc Illotor system

carries oul volunlary movcmcnt and thus has no othcr mcans
to protect itself against our whims. Pain rcceptors, therefore.
are found precisely where tcnsion is most prominent in the
motor system. i.c.. in muscles with their attachment points.
joint capsuks. ligamcnls. meningeal sheaths. and lhe out::r
laycrs of the annulus libmslIs.ll.l:
From wlml h;IS hccn said, it C;llI well he 1IlH,lt;rslOod that
MP is the Illost frequent Iype of pain experienced by Ihe
human urg:.misl11. As dislurhed function plays the main role in
causing this type of compl~lint. it is nccessary to cxpl'lin some
basic approaches in dcaling Wilh it. The question is where and
how to apply treatment. If we have a painful structumllesion.
e.g.. inflammation. wc know where to apply trealment.
Function. on the other hand, implies correlation and interplay
of many structures. Therefore, "he who applies trC;llment to
the sitc of pain is usually losl." This fundamental change in
approach threatens the c1inici'l1l with the loss of firm ground:
in fnee Ill.my who .In: involved in treating dysfunction tend 10
;lpply these methods (e.g .. manipulation) mainly to the
painful area and not In the.: re.:al source of dysfunction.

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function is sometimc!' quite involved. Unfortunately, physiology is no less complicmcd than anatomy. As, however,
changes of function arc by definition reversible. treating functional pathology of the locomotor system is a rewarding chal~
Icngc.
.The ra~[ that some changes ill function are imm~d.iatcly
revcrsible provides a rational explanation for some "miraclc
cures" after treatmCnl by manipulation and other "rencx ther
apy" methods. Unl.<munately. locomotor dysfunction has
rCllmincd a medic",1 no man's hmd.lost belwccn such specialties as rheumatology. onhopedics. ncurology. and rehabilitation medicine. In \'icw of its importance. a clear distinction
bctween structural and functional" pathology (dysfunction)
is fundamcnral. for di~gnosis and managemellt as well as for
c1assificalion. It can be compared only {() the distinction be~
tween Iwrdwarc and ~oftwarc.
If we accept c1wngcs in function as relcvant in MP, then
we should be able to explain why and how dysfunction can
truly cause it. This explanation seems relatively easy: whatever the type of dysfunction we trcat-a muscular TrP, a rc~
strictcd joint. a change in soft tissucs, or altered body statics
or movement patterns. we invariably meet increased tension.
In fact, impaired function of the motor systel~l is associated
less with inability to movc than with pain resulting from in~
crcased tension. If we movc in the direction of a restrictcd
joint, overstr.lin. assume unfavorable positions. or perform
strenuous work, the common JCl1omin:uor is increased tension (strain).
The link between strain and pain should be rCi.ldily under~
stand able. Pain is. in lhe first place, a warning sign of im~
pending danger and. in the locomotor systcm. is an indicator
of the need 10 proH.:ct 'lgainst overstrain. The role of pain in

Chain Reaction in Functional Pathology

Experience has shown lhal changes in function follow' cert<lin
pmtcms; <lS .1 rule. if we lind one change. there is <lnulher
connected wilh it, i.e .. we ubservc CCr1:.1in chain r('([c:films.
At first, this observation \V.IS purely the outcome uf clinical
expcrience. On closer scrutiny. however. it W.IS possible to
show that these chain reactions fo\l(w/ certain rulcs that
correspond to the ba.,ic funclions of lhe locomotor sys~
tem:"\ (I) gait. invoh'ing mainly the lower eXlrClllities and
the pelvis with the lumhar spine: (2) body stalics. involving
ll1<1inly the trunk :.md neck: (3) respiration. involving mainly
(11(' thof<lx; (4) prchen ...ion. involving In<linly Ihe upper ex~
tremitics. the shoulder girdle. :.md Ihc neck: and (5) food in~
take, involving mainly the nrofacial system and Ihe ncck. Th.:llrst of these l:hains i... presenled with a detailed cOlllmcntary.
thc rest in Tables 11.1 10 11.,'l Ihat the rcader \\fill undersland
by analogy.
These ch:lins not only illustmte a different :lppro.1Ch in
the dhlgnosis of Wh'lt we l'all function;]1 pathology of tilt:'
motor system. hut .t1"o :Lrc important in therapy. The point i~
to determine the mo\,( r('{('l'Oll! link in the t:hain and (0
choosc the most approprhlte mcthod of trealmcnt. When successful, treating the key link should improvc Ihe l:hain as a
whole.
The cau:-;c of di:-.turbed futll'tioll is frequelltly in the motor
systcm itself: it may. howcver. lic outside. in parti<.:ular ill the
viscera. triggering charactcristic patterns or ch;lins.
The chains prcscllled in Ihe tables do not c1ailllto be eom~
plele, constant. or lixcd. In Olddition. renex ch~lI1gcs in the skin
and (if chronic) changes in !",\sciac and pcrioslcal p'lin POillh
must be considered. but their indusion in the tahles would
make them too invoh'cd to he USci'll!' It is W0l1h nOling. ho\\'~
e\fer. that these chuin... ;\fl.~ char.lc(eristic;t1ly formed on one
sidc of thc body.

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197

..... nl"\,... I en II : NULt: ut" MANIPULATION IN SPINAL REHABILITATION

Table 11.1. Galt: Stance Phase and Swing Phase-

Table 11.4. Upper Extremity tJrehension

Stance Phase

Extension
1. Increased tension:

1. Increased tension:

2. Tender attachment
points (referred pain):

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3. Joint dysfunction
(blockage):

Swing PhaselIexion and internal rotation

1. Increased tension:
Extensors of the loes and foot, tibialis

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2. Tender attachment
points (referred
pain):

3. Joint dysfunction
(blockage):

anterior, hip flexors, adductors, recti

abdominous. Ihoracolumbar erector
spinae (upper extensors)
Pes anserinus (adductors), patellae
(rectus femoris, tensor fasciae
lata e), minor trochanter, symphysis
(upper and lateral aspect), xiphoid
Knee, hip. sacroiliac joint, upper lum
bar spine and thoracolumbar junction, (atlantooccipilat joint)

Chain rcactions arc related to the stance phase of gait concerning lirstlhe
physiologic extensors and external rotators of the lower limb. Group 1 lists the
functional sequence 01 muscles to become involved. Group 2 lists attachment
points (or relerred pain) olthc above muscles that are likely to become tender
if the mUSCles are hyperactive or tensed. Group 3 lists joints likely to develop
dysfunction (bIOCj{~~f!~ in 'hi:<; (:h~;ro r"!~r.lion. Joints ;:He not related 10 single
muscles. their dysfunction is lhe result of changed static and dynamic lunction
as a result of (mainly) muscular dysfunclion.

Table 11.2,

Ii

2. Tender attachment
points (points 01
referred ~<l;i:l}:

3. Joint dysfunction
(blockage):

Flexion
1. Increased tension:

2. Tender atlachment
points (points 01
referred pain):
3. Joint dyslunction
(blockage):

1. Increased tension:

points (points 01
referred pain):

8~S

Tension in muscle parts

Sternocleidomastoid: short craniocervical extensors
Scaleni and deep neck lIexors: levator scapulae. upper trapezius
Iliopsoas and recti abdominous: erector spinae and quadratus
lumborum
Tender attachment points (points 01 referred pain)
Posterior atlas arch. transverse process of atlas, spinous process
of C2. linea nuchae, medial aspect of collar bone, upper and
vertebral margin of scapula, xiphoid. symphysis, lowest ribs.
ilia~ crests
. .
Joint dysfunction (blockage)
Cranioc:ervical.junction, cervicothoracic junction, upper ribs, thora
columbar junction. !umb.osacraJ anp sacroiliac: junction

Finger and wrist extensors. thenar.

supinators and biceps, deltoideus,
supra and infraspinalus. upper lixators 01 shoulder blade. interscapular
muscles
Proc. styloideus radii and latera! epi
condyle. attachment points 01 supraand infraspinatus, attachment poinls
01 levalor scapulae. and spinolls
process of C2 (referred pain)
Elbow, acromioclavicular joint, midcervical spine, cervicothoracic junclion. upper ribs

Finger and wrist flexors, pronators

,subscapularis and pectoralis. slernocleidomastoids scaleni
Medial epicondyle. medial end of clavicle. sternocostal junction, Erb's
point. transverse process 01 alias
Carpal bones (carpaUunnel syndrome). elbow, glenohumeral joint,
cervicothoracic and cralliocervical
junctions

Table 11.5. Head and Neck: Food Intake, Mastication,

and Speech

2. Tender attachment

()

Toe and plantar llexors. triceps surae.

glutei, piriformis. levator ani. ereclor
spinae
Calcaneus (plantar aponeurosis and
Achilles tendon), fibular head (bi
ceps femoris). ischial tuberosity
(hamstrings). coccyx (gluteus max
lmus. le....ator a;;:), mnc crest (glu
teus medius. lumbar erecior
spinae), greater trochanter (gluteus
medius, piriformis), and spinous
processes L4S1 (erector spinae).
Midloot joints. ankle. tibiolibular join!,
sacroiliac joint, low lumbar spine

3. Joint dysfunction
(blockage):

Masticatory muscles. digastricus. sternocleidomastoids. short extensors of

craniocervical junction. trapezius and
levator scapulae, deep neck flexors,
pectorales
Hyoid. posterior atlas arch and transverse processes. spinous process
of C2. linea nuchae, medial end of collar bone. upper margin of scapula.
and angle 01 upper ribs
Temporomandibular joint, craniocervical
junction. cervicothoracic junction,
upper ribs

Structural Versus Functional Pathology

A short survey of the main chamctcristics of dysfunction as
cOl11rastcd with structurill pathology may bc useful to demonstrate (he fundamclltal differencc in approach.

I. The

step is to decide whether the probkm de

by Ihe patient results I1winly from dy~rul1t'
lion or from structural puthology.
2. A strucwrallesion frequcntly c<lusesdysfunction (hat
then produces the clinical manifestations; on the
other hand. dysfunction by itself Ill;',y cause clinical
first

scrib.cd

Table 11.3. Lifting the Thorax at Respiration (Typical

Respiratory Oysfunclion)

1. Increased tension:

2. Tender allachment
point (referred pain):

3. Joint dyslunclion
(blockage):

Upper section of abdominal muscles.

pectorales. scaleni, sternocleidomas
toids, short extensors of craniocervical junction. levator and Irapezius
Posterior atlas arch and transverse pro
cess, spinous process of C2, linea
nuchae, medial end of clavicle. upper
margin 01 scapula. sternocostal june
lion (referred from scaleni) and upper
ribs
Craniocervical junction. cervicolhoracic
junction. upper ribs, thoracic spine

manifestations.

3. The reversibility of dysfunction makes immcdiate

cure a possibility. whereas structural pathologic
change requires hcaiing.
4. The aim of structural diagnosis is to IOC:'lliz~ :.mtl dc~
termine th(: nature of the lesion: in dysfunclion. it is
csscmial to illvcstig;'l!c correlations and interplay. i.c.,
the chain n::''1l:tiollS.

diagnosi~ aims at the organ at fault, functional diagnosis at tht.~..J.).rgi1!Jj~ a whole.

6. In cases of Jysfunc!ion. structural diagnosis gives
ncgalivc results. whereas with functional diagnosis.
we typically lind lllMe than we expcct from the pati~nt's history.
7. Tile aim of therapy of pathologic change involving a
structure is hcaling or excision; in dysfunction. it is 10
treat the rclcvant link of the chain'.
S. In slructural pathology. modern technology plays an
evcr-increasing role. whereas in functional pathology,
clinical methods rcmair} unchallenged.
9.. 1n structural pathology. the relationship betwccn
. cause and effect is unambiguous. whereas in dysfunction. cause and effect arc frequently interchange-

S. Structural

ity of soft tissue structures one against the other: skin against
muscle, musck:s and fasciae against bone, not forgetting the
important task of movcment palpation in joints and mobile
segments of the spinal column. In this effort. we use not only
our sense of touch but also proprioception.
One of the most degam methods of diagnosing superficial
hyperalgesic zones (HAZ) is skin drag: we move ovcr thc
skin, and in areas with more moisture (s\vcat). resistance
(dr::~) is in~rcascd. Most ~nlethods have-(}Jlc thing in
common: during palpation, we move our fingcrs or hands.
The diagnosis of a TrP. which is discussed in anothcr
section. has another important feature, which is more pronounced in this case yet common to other methods of palpation: provoking a twitch response, i.c.. we establish illteractioll with the patient. In this way. a most important feed M

able.

back rclationship betwecn doctor and patient is established,

In. Methods and techniqucs of "altermnivc" or "complementary" medic inc arc relcvant mainly in disturbance
of function.
DIAGNOSTIC UTILITY OF PALPATION AND
THE BARRIER PHENOMENON
As statcd previously. dysfunction causes increased tension in
various structures (tisslles) of thc motor system. and this ten
sion relatcs to pain. The main tool in the diagnosis of changes
in tension is palpation. Palpation is an art that was once impOl1ant in medicin_e. T02ether-,-,viih--inspection-'andauscultalion.
wa-slhcbasis of clinical medicinc; regrettab-Iy. it is
nmv Iargcly neglected. For this rcason. it is necessary to gjve
a concise analysis of palpation in relation to manipulation. 1-t-1I

Palpation
The flrst step is to apply our fingers to the body surface and to
conccntrate 011 what we want to investigate: resistance to
prcssure. temperature. moisture. smoothness or roughness of
skin. and tissue mobility. If we intcnd to proceed from one tissuc layer to the next. we never simply increase the pressurc.
but shifl our attention and apply small movements, i.e., we
ch<!ngt;Jl 9_th intensity and dircct,i~n ?.r_prcssu~e, u_sing dis,crecl,
il!otion (Fig, 11.2). We may want to palpate' the 'sll~ipc '01' a
struciurc:-thc transition of muscle to tendon. or where the ten~
dOll is allachcd. Thcn. we want to palpate the relative mobil~

providing a we?lth of information and at the same ti~lC ProM

viding the basis for effective therapy. This relatiomhip devel M
ops when_ applying all typ~s of massage, and the good therapist. whether consciously or not, profits by this feedback,
sensing the refjction o(the patient's tissues and correcting his
or her moves accordingly.

Barrier Phenomenon
To make both palpatory diagnosis and treatment more etIeetive and better understood. we must be <l\l,'are of the barrier
phenomenon. It seems to be common to most ~trllctures and
tissues of the motor system, and thus plays a key rolc in manipulative therapy. It was first described by ostcopaths in
joints. but it is relevant wherever manipulation is applied. Il'
Moving a joint from a neutral position involvcs flrst a
range of motionin\~hic,hresistanc~i~, ~ll,ifor!~~ar~(,Lt.lt;gljgU5le.
As \ve ~lP~p~.ro;lch the
'(j(t-ilc-r:i;lge-. hO\~'~\'cr. we mcct rcsistanc~. which gradually incrcases. The moment rcsistance
starts to increase~ i.c., whcn wc meet the slightcst resistance.
we have reached the barrier. In other \I,-'o[(.\s: thc sooner we
sense the barrier. for diagnosis as \vcll as for therapy. the better our sense of palp~ltion and our techniquc. It follows that
the normal barrier is soft and resilient and can be easily
sprung. On the other band, a palhologic or rcstrictive barrier
is one that is n~et too soon and feels abrupt (Fig., 11.3). In the
diagram in Figure 11.3, we sce that the anatomic barricr is
nevcr rcached under normal conditions: thc ptlYsiologic barricr corrcsponds to the normal rangc of movcment. The patho
logic barrier signifles movement restriction. The neulral point
(N) may shift to the normal side (N I ). if there is such a patho-

-end

Barrier
A

Ph

Path

N~

N,

Ph

CI?~~~r-~-'--------,.
Fig. 11.2. Palpation.

Fig. 11.3. Barrier phenomenon: anatomic, physiologic, and pathologic barriers.

;",

CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION

199

Fig. 11.4. Palpatory changes preand posHrealment.

logic barrier. Barriers arc found not only in joints. hut also in
tissues that call be stretched or shifted against each other.
However useful the barrier phenomenon may be for di .. g~
nosis and trcallncnt. it also has an important protective function. This role is Illost obvious in joints: resistance increases
before full range is reached; however fast we may stretch our
"rm: the antagonist SlOpS the movement in lime to prc\'cnt
damage. Other protective mechanisms come into rlay \.. . hcn
we stretch connective tissue or cause shifting between diffcrem tissue layers. e.g., fascia against bone. The stretch renex is
part of this protective mechanism.
To usc the barrier phenomenon for diagnosis and tremment of pain and dysfunction. take the following steps. By engaging the barrier (taking up the slack). wc determine the
range of movement (shift or stretch) and recognize the location and quality of the barrier. After engaging the (pathologic)
barrier. we wait: after a few seconds, the barrier "gives" and
myofascial releasc is obtaincd. Release may last from a few
seconds to half a minute (or even more); this release must be
sensed. making sure we havc normalized the barrier. i.e.. normalized tcnsion and thereby obtained relief of pain. As shown
subsequently in discussion of specific techniques. this release
is as true for joint mobilization or muscle rclax~tlion as for
skin stretch or shifting fasciae or subperiosteal tissues. using
the bmTier phcnomenon as common denominator.
The clinical importance of release lies in the relief of pain
originming in the structures treated. Palpation thus provides
an invalu;'lble criterion of painful lesions without slructur.i1
pathology, Le.. in cases of dysfunction. In fact, if we have obwined release. we know that the structure treated will be less
p,.inful.
Unfortunately. the ,evidence for these statcments is only
clinical, based (Jll p.i1p'.Jtion, .lI1d the charge of subjectivity
cannoL be ruh:d out. As the palpating finger (hand) is COI1siantly moving, changing both intensity and direction. meaningful measurements are difhculL to conceive. This situation
is complicated further by the feedback relationship bctween
therapist .ll1d patient.
The problem of palpatory diagnosis has been further un
dcrlined by the discovery of palpi.llory illusion. On palpation
of the pubic symphysis. and even more so of the ischial
tuberosities in the recumbent patient, shifts as greaL as 2 em
c;:ln be noted. After simple "reposition maneuvers" or using

_.'-'.-_._-_ ..----

soft ti~:,ut: techniques. symllletry is readily reswrcd. :llld yet

r'ldiographic cX<llllination shows 11(,1 chang.e has ul."~lIrred. If.
howc\'t:r. the radiographic image includes the palpming lin
gers. it i:, clear Ihat the position of the lingcr~ ha~ changed
(rig. IIA). Hence, lhe chunge lli.~s occurred in the ~ort tissucs
or "media" through which the bony landmarks wl,,'r(' palp;:llcd.
This obs.ervation provides evidence that Illost 'adjustments"
noted by chiropr'lctors or osteopaths after manipulation to restore ':-ymmctl)':' as indeed they sen~e. me in the :,oft li~sucs.
because joint renligllmcnt is not cvidelll radiogr<.lphicall)'.''
rvkaningful research in palpation hns rarely been underwkcn. in PLirt because of the complexily or Ihe task.
Interpersonal reliability studies have so far been frustrating.
because no one person knows exactly whnt the olher i~ doing.
Ncverthdess. palpation yields invaluable inform~\tion that is
essential for diagnosis and thcr;'lpy. in the same W~l~ the blind
rely on the inform'llion gained from p;.dpation all through life
(Figs. 11.5 and 11.6VI'.~'"

DlAG:\OSIS AND TREATMENT OF

SOH TISSUE LESIONS

In a simple outline of the IllOst useful techniques. lhc bmricr

phenomenon offers the most useful basis. The
with \\ hich to stan invol\'es the soft tissues,
the skin.

simpk~{ model
lk'~il111il1g

with

...
'-<'====""=,-=-===.======
':'

\
Fig. 11.5.

...

~Lowtech"

---------

medicine.

200

REHABILITATION OF THE SPINE: A

PRACTIT10Nt:.H~

MANUAL

in the same dircction); no springing thard "cnd f~d") is 1l001.:d

on engaging the barrier. If we hold on after engaging the barrier without increasing stretch. the barrier gives after a hllcncy
period of a few s('.conds and release takes place. Relcasc may
last from :'1bout 10 seconds to half a minute. We then lind a
nonnal barricr (like on the normal side) and skin drag is restored to nom1al. This reaction is found regularly: if there is
an underlying cause of the HAZ. it soon recurs.

I,
~

Connective Tissue (Fig. 11.8)

Fig. 11.6. "High-tech" medicine.

..--..

,\

The most useful diagnostic technique is to create a fold and to

stretch it (never squeeze!). Again. when creating a fold. we
reach a barrier where resistance is first sensed. a resistance
that differs from normal if there is a restrictive lesion. After
engaging the barricr and holding it, release takes place after a
fcw seconds and continues up to a half a minute. until the barrier is nonnalizcd.
Such connective tissue is found most charactcristically in
hypcrsensithc scars with tender spots wherc tissue tension is
increased and pain is ea5ily elicited. Such scars arc usually
surrounded by a HAZ with increased skin drag. They arc a
source of increased nociceptive input, comparable in some
ways to a diseased, painful visceral organ or joint. Release
can be obtained by stretching the skin overlying such a scar
:'Ilong with the deeper connective tissues. 2627
Shortness of the connective tissue is most chamcteristic
for short (taut) muscles. usually in overactivc muscles.
Producing a tissue fold and stretching it is the most cffective
way to obtain lengthening because the stretch reflex can be
avoided. Such a fold is useful wherever it can be produced: in
the m. trapezius, pectoralis. the quadratus lurnborum. the stcr-) nnclej~jd.ai1dm'OSi' of the muscles of thc cxtrellllties.
This mcthod is not suitable for muscles with TrP: in such
cases. p.Qstisol1lctric relaxation should first be used.

)
i)

.}
)

Fig. 11.7. Palpation of skin drag.

~'

Skin (Fig. 11.7)

Hyperalgesic skin zones (HAZ) arc found most convcnicmly
by using skin drag. which consists of moving the cushions of
the finger tips ove.r the surface of the skin. sensing resistance
or drag. Drag is incrcllscd in HAZ owing to increased mois~
lure (hyperactivity of sweat glands). In the same areas, the
skin fold is thicker. and if we stretch the skin in this region.
we meet resisl'IlI~t: sooner than on the nannal side (stretching

..

Fig. 11.6. Palpation 01 connective tissue changes.

1
I

'_,';

CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION

201

Fig. 11.10. Stretching (shifting) the gluteal fascia.

()

o
{)
Fig. 11.9. Pressing deep soft tissue.

,
l

Pressure (Fig. 11.9)

Even if pressure is used. it is most important (0

eng~lgc

the

barrier with a minimum of force: after waiting for a few seconds. the finger will sponwncously sink deeper into the tissue.
This method is most effective in muscles with superficial TrP.
where it can replace postisomctric rel~xatiC?1! (PIR). \Vllen the
-will'-reach the nonnal barrier
finger sinks into
after approximately 10 to 30 seconds. but if the direction of
pressure is slightly changed. funher release may be obtained.
Such change in direction is important in large muscles. e.g..
the gluteus maximus.

Fig. 11.11. Stretching (shilling) the dorsal fascia over the shoulder blade.

Sitc:s of restricted fascial mobility also occur on the chest

(charactc:rislically in mastodynia): on the buuocks. frequently
in a cranial direction: in the groin: around the elbow and knee;
and around the ankles .lIld wrists. In addition. some structures
bcha\c like fascia: the scalp should move easily in all directions in rdation to the skull. Restriction in any direction is frequcnlly linked with headache, and treatment mcthods that follow the same principles <:IS for fas.cia can be most rewarding.
Shifting and Stretching Fascia (Fig. 11.10-11.12)"""
(fllercfore. examination of scalp mobility is warranted for paWhen using this import<1nt technique. the most chamcteristic
tients with headache and/or vcrtigo. Another such structure is
the SOfl tissue pad at lhe heel. which should shift easily in all
finding is thaLmusc!cs (or all the soft tissues) on one side do
directions on the calcaneal bone. Rcstriclion is characteristic
not ~.Jlli.S_asily on th~ underlying bone ~s those on the
other...si9c if moved in the same direction, i.e. the barrier is
of a painful c.l!c,mcal spur and should be treated.
rC~led sooner on one ~ici~-;rni~ol'SPri~-:Iti~Tmpor.
The rnetatarSi.l1 and metacarpal bones can be shifted each
tant to note that the restricted side is not necessarily the
against its neighbor: they are connected only by soft tissue.
and resistance to this shift is characteristically incr~ased in
painful sidc. A "tight and loose complex," i.e.. one sidc is rc
stricted and the other side is hypotonic. is frequently noted.
nerve root syndromes radiating to the toes (fingers). Not only
Shifting is examined and treated in a craniocaudal or cauis exacllocalization of the involved root possible. but ,1Iso. by
docranial direction on the back. but it should be assessed and
engaging the barrier and obtaining release (in a dorsoplantar
treated in a circular manner around (he axis of the neck and
or palmar dircclion). we can obtain striking Ihernpeutic rethe extremities (sec Figs. 11.10-11.12).
sults. This restriction is usually linked with a HAZ of the
Because the fibers of most fascia arc intertwined with
skin fold between the toes (fingers) in the corresponding segment. This fmding. too. can be di<1gnostic and can be treated
muscle fibers. frce mobility of f'lscia is essential for norm<ll
muscle and joint function. It is in chronic pain patients that
with skin stretch accordingly.
mobility of fascia is frequently impaired; in such cases. joint
(spinal) mobility is as a rule restored by moving the fascia. It
Shifting Periosteal Tissue
also follows that unless we restore normal mobility of the fascia. muscle and joint dysfunction wiII recur. This principle is
Restrictive barricrs arc also found at painful pcriosteal points.
particularly important in fasciae that arc cornman ta a great
By palpating such Icnder points. we can shift the s.urrounding
number of Illuscles. like the lumbodorsal.
tissues close to the bone and compare mobility with 'hat of

th"cnluscle:"it

202

H
Fig. 11.12. Stretching (shiiting) the cervical fascia,

CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION

203

the Il\:rhl~h.. al I'lIilll 011 Ihl.' llofillal sidl.'. \\"111..'1'1.' we lilld n::aril.'lit\l1. lI~\l:d[y ill :llatl~I,.Jl[ial directioll \{l (l11..' p:lin point. WI,.'
lake up lhe :--Iack lir~a for di:l~nu ... i:-> and Iht"1\ hI ohtain rck;I~l.
Unlike pcri\l~[l..'alll1assa~1.'or "deep fr;ltion: Ill!,.',\,.' sofllis.'lh.'

1
1

~,

".--">.

IcdUliqul.'s arc gentle: pressure is lIot dircdld 10 the p;lin

point. but l"allll'l' t<lllgl.'ntially Ill\WCS thL' pl.ri\l"ll'allissllL' ;I\\';l~
from (he p\lilll of pOlin. P;linful SpillOll.'" pnH:l':'o'''''S ill tile hUllhal' spill\'" off\-'" a ,good cx;nnpk. They an: palpah:d ill lIIidlinl..':
lltlwevcr, il" 1hL' palpating lingL'r l11tl\"L'S sidc\\;l~ S. \\'1..' lind Ihal
only one sid\..' of the spinolls prnl.:css is n.ally lender. 011 Ih:1t
side. We l11eel resistallce if we try to eXert del'fl pressure par;llIcl to Ihe spinous proceSS. AI this poinl. Ihe sl:u..:k is takcn up
and release follows. pnxlucillg relic!'.

Soft Tissue Syndromes

\)

()

(J

or

ti~suc syndromes" arc

grcat practic<l1 impor[;.mcc. The lirst goes h;md ill hand with;1I1 ;.lpp<.lrCll( shin :11 the
pubic symphysis ,Iud the ischial tuberosity. caused by incrcascd tension (TrP) of the straight abdomin.i1 muscles and
their .1It:1chmcnl at the symphysis. and in the lute;'11 muscles.
causing restriction of (he cranial shift of the buttocks on one
or both sides. Typic'llly_ the most prominent sign is a forw:.trddrawn poslllrc. which may be noted at lhe pcl\"is in rdation !O
the feet. at the shoulder girdle in relation to the pelvis. <lnd
with the head thrust forw<lrd when looking at an object al eye
levcl. We then also lind increascd tension in the back museulatun.~ with the patient sumding. as well as in the neck lIlU:-des. Tension in the neck (and b:'lck) muscles .,ubsides. ho\\"evcr. when thc patient is sC:'lted. If we engage lhe b;:uTicr by
shifting (he bUllocks (111. glutei maxi mil in a crani<ll direction
nnd then obwin rclc:.lsc. or if we usc pressure \\"hcn~ we sen~\.'
hypcrtollus in the buttocks and obtain release. we normalize
mobility at the bUllocks ;'IS well as lcnsion in lhe abdomin;tl
muscles and at the ..utachmcnt points :'It the symphysis. and
symmetry is restored. The luberosities then appear symmetric
on palpation. The forward-drawn position also disappear"
and. therefore. tension in the neck and back muscles reverts (0
normal. However striking this effect Ill'l)' be. the condition
tends to recur if tlK~ abdomilliJl and gluteal muscles arc wcak
(Fig. 11.13) (sec Chapter 14)."\1.1
The second soft tissue syndrome. dcscribed by
Silverstolpe and Helsing.'\I.\~ can be detected because ofa tender TrP in the midthor;:lCic region. more frequently on the left
side. On mechanical stimulation. this TrP causes a twitch response in Iht.: low lumbar arC;'1 of the spinal ereclor ,md may
even cause contraction of the hamstrings. producing sharp
dorsillcxion. Typical findings include a lender point III the lat
eral gluteill arca at the height of the upper end of the inlergluteal fold and all c"cn morc tcnder point at the s<lcrotllhcrous ligament. When the indcx linger reaches this puint
(slighlly vcntral and craniao on the latcral edge of the tip of
thc sm;rllrn). rcsi~tancc is mcl. After taking up the shick. we
oblain rc1c<lsc after a latency of scvcral seconds. Both the Trl'
in the thor:'H':ic spinal erector spinilc and lhe lateral gluteal tender point (TcP) arc gone.

Two "soft

Fig. 11.13. ForNarddrawn posture (left); after soft tissue treat-

ment (right).

Both these :;.yndromcs affcct most of thc postural musculature. and lherefore symptoms may arise in any pan of thc
motor system. including headache with restriction in the craniocervic;.11 junction. and even tension in the masticatory IlllISdes. back<lche. and p:.Iin in lhe arc" of lhe coccyx. Sacroiliac
involvemcnt I~ pica II)' is not part of these syndromes. but it
may occur. The pathologic barrier al the sacrotuberous ligamcnt is probiJbly attributablc to a TrP in the Ill. coccygeus.

I'OSTISO~IETRIC RELAXATION

(I'IR) IN THE TREAT",iENT OF MCSCLE SI'ASM (TRi'J'-'-''-"

Postisolllctric relaxation produces rclc:.Jse in Illuscles in
spasm. the moq frequent type of spasm in myofascial pain
(MP) being the Irigger point (TrP). This technique w~s introduced by Mitchell for joint mobilization. and it is in its
essence a type of son tissue rnanipul<Hion. Just as in the techniques described prcviously. the lirst step of PIR is to cng:.lgc
the barrier by lengthening the muscle to the point at which the
first. slight rC3iswnce is met. After this point. however. the paticnt is wId to exert slight resistance in the opposite dir('ction.

~U4

holding it isometrically for about 10 seconds. followed by the

order to relax. (lct go). After a few seconds (wailing at the h<lr-

i
1
Ij

rier), release takes place and the muscle lengthens (dccol1~

tracts) for anything from a few seconds to half a minute.
Clearly, a subtle, yet important differcnce exists in the mcdl~
anism of release in PIR rdati \Ie {O olher techniques of IIl~Ulip
ulation: whereas connective tissue must be' pas!'iin:ly
stretched during rclca:-e. ~llthnl1gh wilh lillie force. muscle de.,;.
conLrilction is an llct;I'e process. just as is muscle cOlllraclioll.

and is only monitored by the therapist. "You cannot relax the

t.

ii
I:

:~

I
I
I
I
~

patient's muscles for him, he has to do it himself." The moment the therapist tries to stretch the musclc, the patient produces the stretch reflex, which is counterproductive. If PIR is
not satisfactory at the first attempt, we repeat the procedure
(from the barrier reached after the first auempt) and prolong
the isomclric phase.
Post isometric relaxation is highly specific. tlnd it is important during the isometric phase to contract precisely those
muscle fibers that are in spa!im. especially fal1~shapcd muscles such as the pectoralis major. It is also essential to usc'minimum force, because we then increase the likelihood of
stimulating selectively those fibers with a low threshold of
stimulation. Le., those harboring TrP. Relaxation of the muscles brings aboUl relief not ani)' of the painful TrP, but also of
the painful attachment point. as well as regions of referred
pain (Fig. 11.1.4).'
As stated for the techniques described so far, accurate diagnosis is essential to the success of PIR. In some types of
muscle spasm or cramps. the diagnosis may be obvious. Some
TrP. however, may be excessively painful on palpation and
yet are not felt spontaneously by the patient; these must be

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

sought alll.! illclllilied. C1illl,:;i1ly. thl:)' m;lllifest thL'l1l.. . dn.~ . . hy

referred pain. which call ~ far from its SOlin.:..::. and il is important to know the sitcs (,f pain referral. Palpation ll.:('ht\iqtl~
must also he mastcred. L' "ually. slight hypenolllls is no Led
;lhon.: a muscular Trl'. hut it is frequCl1lly so di . . creet ;IS 10
avoid tktcl.:tion ;lIItl'di;lglllhi,. By making the lllu:,de harhoring a TrP slip 1I1H..!L'r our lill~as. howc\"L'r. we prodlH':c a fL';lClion in precisely those 1i~. . rs thai arc perceived as ;1 ""tau!
band'" The rrP lies within Ihis band. and at this point. we
should be able lO evoke refared pain and the twitch reactio[\
(Fig. 11.15). Interestingly. the mOTe superficial a TrP, perhaps
in the forearm or the erector spinae. where the pmient is Illore
likely to be aware of it. the better he or she tolerates examinntion. The hidden TrP. such <IS in the m. psoas or sllhst.:aplllaris. arc most painful on palpation or when merely touched.
in its b'lsic fofln. as ju~t described. PIR has some serious
drawbacks. Many patients. even when. instructed. have difficulty putting up minimal resistance only and show their C<lgcrncss to cooperate by a display of strength. Other~ have difficlIlty rclaxing. although prolonging the isometric phase to
20 seconds and more prO\'cs effective. Finally. many practitioners find it difficult to distinguish the patient's relaxalion
from "gentle stretch,"

,;

Using Eye Mo\'cmcnl'i, Respiratory Synkinesis. and

Gra\'it), with PIR
For these reasons. combining the lise of PIR with other "neuromuscular techniques" ha, improved our results and is particularly of value in promoting self-treatment. The Iirst such
combination is with eye movements. If the patient looks to the

.>

I'

I .. ~

It

I
~
~

ii

J
Fig. 11.14. Post isometric relaxation of
wrist extensors (left); self-PIR of the
wrist extensors (right).

I1------------.--------.- ----

-----

>.

CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION

205

and to inhal~_Whil.e_looping, This principle is equally lrue for

side bending, and even during backbending. maximum exhalation is required to obtain synkinetic contraction of the thoracic erector spinae (producing mobilization into trunk exten-

sion, Fig. 11.17).

o;xhalation is coupled w;.!.h forward nexioo in a neutral
erect position. whereas in a lordotic or prone pOSItiOn, the reverse holds true. This fact is borne out by IsomcLr'lC m~ll1ual
traction \vith the patient prone; owing to lumbar lordosis, the
erector spinae contra(:ts during exhalatiori. moving the buttocks upward. This'movement is resisted during the isometric
phase. During inhalation, the erector spinae relaxes and the

bUllOCks move caudally (Fig. 11.18). In lhe cervical area, lhe

opposite occurs: on inhalation, the neck muscles contract

(isometric phase); on exhalalion, relaxalion lakes place. For

traction trealment (Fig. 11.19), il is sufficienllO cradle the patient's head during the isometric phase, followed by relax-

--_.-..--_."....:::

,..;....

ation during exhalation. This traction technique is apparently

the most gentle and the most effective, particularly in acure
wry neck, because no active put! i:; required (it can also be ap-

plied wilh the palienl sealed).

Respiratory synkinesis applies tn particular ro respiratory
muscles (the scpleni, ~~,~~~ocleidom~.lil9.i,d~,JtI,~~.t5?~~,les.
ansLgt}il~.t":~.l!~ lumbQ...~f.I!2!.~hich con~~ct ~uring inhalation
and decontract during exhalation. The rcversc'hoids-for-t"tte
abdOmiri"arandin partlcuiar-for the masticatof)' muscles.
which arc aClivated during ex~alation and inhibited during inhalation. In contrast. the digastricus and mylohyoideus are facilitated during inhalation and relax during exhalation. This
action is best monilored with the Ihumb in contaci with (he
latcral proccss of the hyoid, where it is possible to sense resistance at inhalation and relaxation at exhalation-when the
thumb sinks toward the midline-witham exerting prcs-

()

{)

sure(!) (Figs. 11.2010 11.22).

D
:,)

Fig. 11.15. Palpalion of a trigger point by identifying the taut

band. (Fmm Travel! JG. Simons OG: Myolascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, Williams & Wilkins,
1963. p 61.)

right. he or she facilitates rotator muscles th<ll can be resisted

during (he isometric phase: if the patient looks in the opposite

direction. Ihese muscles will relax. If he or she looks up. the

muscles in the ba<..:k and neck contract and can be resisted;
when looking down. they will rclax (Fig. 11.16). Here. too.
Ihe pmicnt must lir:a sense the b~lrricr.J7
Respiration plays an import:',"t role in PIR. inhalation
having a fncililalivc and exhalation an inhibitory effect, particularly as it affects structures in the head, neck, and trunk
and less so the extremities. The effect of respiration is particularly evident in rcspiratol}' synkinesis. This term dcscribes
when movcmcnt in onc dircction is coupled with inhalation,
whereas movement in the oppositc direction is coupled with
exhalation. As an example. straightening up is linked with inhal.ltioll whereas bending down is linked witlfexhalation, indeed because it is difficult to exhale while straightening up-

Respiratory synkinesis is <1lso noted in regard to eye

movement: looking up is coupled with breathing in and looking down with breathing out. This correlation i~ c;J,sily explained. because under natural conditions. looking up is followed by straighlening up (the body follows Ihl: eyes). and
looking down by stooping. In fact. it is diffkult to exhale
while looking up and to inhale while gazing downward.
Therefore. combining looking up with inhabtion (double
facilitation) would be effective for lreatment. whcrc;J,s combining looking down with inhalation would be counterproduclive.
Whenever possible. Ihe force of gravity i~ u:-;cd for both
isometric resistance and relaxation. Gmvity is lI:-;~d for rcsislance when the pmient isometrically contr'lets tht:' muscle h'lrboring a TrP, and again for assistance as the patient relaxes the
tense muscle. According (a Zbojan. when gravityinduccd relaxation is used alone, the contraction and relax:ltion ph.lscs
should each last for at least 20 secondsYlf thi~ tt:'chnique is
combined with respiration. however. the timing of contraction
and relaxation should coincide with that of tht:' rcspir.<.\wry
phase. Therefore. respiration must be slow. The patient is told
to hold his or her brealh after inhalation and. if necessary.

"

"

.._---""_.~~---"-_._---"------"-"-"-"

206

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

.,

.......
,

.""\

Fig. 11.16. PIR of the short cervical

extensors using facilitative eye move
ments during resistance phase {left}
and inhibitory eye movements during
relaxation phase (right).

.,,,
'..7

Fig. 11.18. Isometric manual traclion 01 the pelvis.

Fig. 11.17. PIA 01 the thoracic erector spinae using respiralory

synkinesis.

Fig. 11.19. PIR traclion of the cervical spine using respiration

only.

,
'.J-.

CHAPTER" : ROLE OF MANIPULATION IN SPINAL REHABILITATION

207

Fig. 11.20. PIR ollhe scalenes.

even after exhalation. Gravity-induced PJR lends itself naturally lo sclftfcalmcnl (Fig. 11.23 to 11.28).:n
All of the neuromuscular methods described (0 this
point can be combined to obtain the best possible effect.
This combination is accomplished by a summation of
physiologic stimuli. making the entire procedure automatic.
so the paliem <.:an apply treatment 'even morc than once
a day.
However adval1lagcous ,lOd effective the combination of
methods m;ty be. it requires careful thinking'to identify the
mOl-a dfecti\"c method ;.md to avoid incompatible or useless

Fig. 11.21, PIA of the maslicatory muscles; self PIA of the

ticalory muscles.

combinations. An ideal combination to obtuin relaxation of

ity is

the stcrnoclcidom;.\stoid (also sclf-Illobilii'.lltioll of occiput!

atlas) follm\.'s. The patient is supine. with the hcad rotated
over tile end of lhe table acting .1$ a fulcrum. The patient is in
structed w look ww,ud the forehead i.lnd to breathe in: at II
cCr(<lin singe of inhillalion. lhe sternocleidomastoid contracts.
slightly lining thc hcud. \Vhen the p'ltieot looks down (toward
lhe chin) and bremhes out. the Illuscle relaxes and the head is
lowered (scc r-ig. 11.27). Another example is gravity-induced
PIR of the m. quadratus lumborum. The pnticnt stands with
legs apart and leans to the opposite side until the slack has
been taken lip. The patient then looks up and breathes in
slowly uOlillhc quadratus lumborum automatically contracts.
slightly straightcning Ihe trunk. The patienllhcn holds his or
her breath. looks down, and slowly breathes out: during ex
hill at ion, side bending increases automatically while he or she

relaxmion.

ma5~

rehlXCs (sec Fig, 11.28). In both c;IS~~. looking up f;h:ilil~ltCS

inhalation. which in turn racilit::lte~ the muscles in yucstiOll
and lifts the head and straightens the- trunk. The fon.'l.~ 1...... ( gravadcqu~te

for r~siSlimcc and for obtaining rcka:,l.' during

Wheneq:r the combination of eye movemcnt <llld rt.'spinltion is lIsed. the eyes should be direl.'teo lirsl. In thi:, way. the
direction of muscle pull is de(cnllill~d ;lI1d lhc-fc :,lh\ulu be
timc for th~ isometric ami the rL'iaxatiol1 phases. t-!l..\ldil1g lhe
brc~lth is helpful for the same reastl!l.
An illuSlration of how to .\Void mistakes in l"llllli:'inalioll
involves the upper trapezius 1ll1lSI.:!C. The head is fir:'! sidebent away from the involved muscle to take up the :,Lh.:k. The
patient is then instructed to look Illw;lrtlthc affccted :o:.ide and
to breathe in (sec Fig. 11.29) whik' the operator rcsi:,(:, his or
her automatic attcmpt to cxen pressure tow<lrd till.' ;lfkctcd
side. During the rckixatiofl phase. h(lWCvef. the thefari:'t must
not tell the patient 10 look to the l)thcr side. bccml:,c the response \\'ould be (0 rotate the head and no rehlxati('n \.If Ihe

208

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANU':'!...

Fig. 11.22, PIR ollhe digastricus and mylohyoideus; self-PIA of the digastricus and mylohyoideus.

Fig. 11.23. SellPIR

l.sing gravity.

(ji

ihc lJpper irapel.ius

Fig. 11.24. Sell-PIA of t!1e infrtlsplnalus using

gravity.

CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION

209

Fig. 11.25. SelfPIA of the subscapularis using gravity..

()

Fig. 11.26. Self-PIA of the piriformis using

gravity.

tnlpczius would occur. Therefore. the correct command for

the relaxation phase is: "let go ;lIld breathe OUl.'
For l1lobiliz;uioll in the ccrvicOlhoracic or thoracic region
inlO side bending. the operator instnlcts the pmicnl to look lip
and to breathe in (after ttlking up the slack into side bending).
followed by "hold your breath" and then "relax and breathe
our.' The oakr to look down would make the patient bend
forward. which would be incompatible with ctTcctivc mobi~
lization in Ihe ccrvicothoracic .uH.lthoracic regiolls.
For gravity.induccd PIR in trunk muscles. we make usc of
the facilitative cffcl.:l of inhal;ation during the iSOI11Clril: phase
and of the inhibitory effect of exhalation during lhe relaxation
phase. beginning by telling the patient 10 look up. to fadlit'lte
inhalution. and thcll (wilh a few exceptions) to look do\vn be
forc breathing out and relaxation. To make the rhythm as slow
<IS possible. Ihe patient holds his or her breath after inhalation ilnd possibly after exhal:ltioll. In muscles in lhe extremilies. howe vcr. the effect ofbrculhing in or out is doubtful. ;jml
so we rely 011 the patient to hold the extrcmity (or part of
it) slightly raised for abolll 20 st.:<.:onds (or lllnn:) follmved

by relaxation for at leas.t an additiOlml 20 se<.:onds (sec

Figs. 11.23 to 11.26).

.JOl:\T \IOBILIZATION (MANIPULATION

WITHOUT THRUSTING)
Joint

mobiliz~ltion

without thrusting makes usc of the same

principles tlwlapply to all the manipulative techniques so far

dc~cribed. namely. engaging Ihe barrier (laking up lhe l'lack)
,lIld obtaining release. This goal CUll be achien:d by simply
waiting and ~\pplying slight pressurc or by repctitive springing of the barrier. Many practitioners lind these techniqlll'~
time consuming and in the end less effectivc than Ihrul'ling (front Ihc barrier!): it has been Ihe mcrit of oSleopaths
to COll1illllC with their usc. This situution hal' changed greatly
since {he introduction of neUI"OI1111SclJlar techniques into manipulation. m<'lking mobilization more clTcctivc ;lIld working within the barrier gelltler. safer. and Icss time consuming. The reason for this result is that in a restricted joint. il is
Illusck spasm that is first met at the harriL'l". making slo\\'

210

REHABIU IAIIUN Ur I Ht:. ~t-'lNt:.: A t"MA0. II lVPH::n

.:J

IV',..," ............

.,
J

Fig. 11.29. PIR 01 the upper trapezius using a combination of

methods.

Fig. 11.27. Sell-PIR of the sternocleidomastoid or self-mobilization 01 CO-C 1 using a combination 01 methods.

.~

<J
--~-

Fig. 11.30. Mobilization ollhe sacroiliac joint.

Fig. 11.28. SelfPIR of the Quadratus tumborum using a combi

nation of methods.

IIh 1bilizaiioll less SllCCC ......J ul. Wilh the ;.tid or IlCUHlllluscular
Il..: hniqlll:.... this muscle :-.pa";lll i~ ~l\'crcomc :'\lIo. in some
\.';1:'1.':". the p;'lticn(s l1lu\ch;" may even help in lllobilizOl'
IiI 111.

i.e..

WI.:

make lise

(If

the

1110,,1

phy\iologil.: means-the

illh..'n:lll I"nn':l;S or the patient's nr~;\nism. Exceptions han;

hl..'l..'11 nOled. hO\\'c\'cr. For jllinls thai afC not 1110\'1.'0..1 by lllll~
d ..'~ and there fort: .,:,mllol ht: rt.:stril."tt:d hy l1111sck :-pa:-'Ill. ="llch
as the s;'lcroiliat:. acnllllit!t'la\,i(ular. ;lI1d lihi(llil'lll;lf jt\int~.
simple passive mobiliziltion is slillll1o~l ..:frecti"t.' (Fi~s. 11,30
III 11.3J unL! 11 A.i 10 110451.
~'Ios( 01" whal has hCl:ll "aid about IlCUrolllll." . :\l\'Il' ll.'dlniqul..'s in the treatment of musek SP"~lIl (TrPl is "'\j\lally lrut.'
fl1l" joint mohiliz:HillJl: indeed, \\"111.'rl'\'(:r muscle... ;\1\: rt..'laXl..'ll.
lht.' r;lI1gc of !11O"cllh,:nl ill,o innl.'a",\,.'s in joints. ~ S\'m,,' ;luthnrs
maintain [hat 11I0Vt:lllt.:nt n.:,tricti\lll is lllo,tly ;l\lribul:lhk' t\l
lllll:,d.: spasm: in 11Iy vil.;w. this l'\lllClll'.. ioll C<\lIll\'l ill' dra\\-n
in "',,cry <':i1SC, ;IS l.'xpliliJll.;ll in Iht: prC"iOll'.. dist."lI:-:-i\\JI of tilL'
"';\l,:roili"c anti other juinb, ". ;'.
i\ parti<.:ubrly dfct.:li\"C Ilcurol11uscul,u" tl.;chniqul" for 111(\biliz,\lioll was dcscrihcll by Gaymans for side hl."ndill~ Ill' Ill1.'
lI.'I"\'ical and thoracic spine,l" Dllrill~ inhalation, Ilh:rl.' is altcl'nating in<.:rc;'lscd rcsistar\t:c ag;lil\:'1 sidc bcndill~ ill lhl.' i'l'('//
,\'C',l.:I1I('III,\', sudl as CI (1I1In"Clllelll helween oc<:ipul :lnd albs)"
C2 (lIloVclllcnl bl.'I\\'t.'t.:l1 C2 allli C:;l. ('4" dl". \\ hi.."1i ,-dax
lI';,lt I'.rlwlcllhm, ResiswllCl: illt.TI.';Isn. Oil IhI.' \'IIII,,'r hand.
:lgaillst side hl:lldill~ al exhalatillll in thl.: odd SI'.<..:III('/IfS \C \.

.>

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I
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...... no"'r 1 c:n II . n""l-l- vr

IVlfW.jI/""ULI-\IIUl~ 11'1 ::Jt""INAL Ht:HAtlILlIP.IIUN

(rig. ! L~J~. Th;~ cffc::t !~ ~!r,:,~~g('''1 in the upper cervical region and dccrc:;,\scs in the lower thoracic region. in particular

in the odd segments.

The ~mol\gcsl effect of inhalation and exhalation is in the
segment COil: it is felt in all directions. The first order is
"look up (toward YOLlr forehead) and breathe ill:' followed by
"look dO\\'I1 (ww,m! your chin) and breathe OUL" except into
rClroncxion. in which eye movements \\lould he ;,It \'ari,l1H':c
with the direction of l1\obiliz;,lIion (Figs. 11.35 to 11.37). In
C2J3. postisom~tric traction secms as specific as side bending.
So strong is lhe release effect of exhalation in thesc segmenls
thal usually no or only one repetition is required.
in rotary mobilization. we combine inhalation with the
isometric phase and exhalation with the rclax:.uion phase. In
the cervical region. however. it is usually more appropri:ltc to
give the order "look up" during the isometric phase and "look

::1

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.;

.........

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211

Fig. 11.31. Mobilization of the upper part of the sacroiliac joint.

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~,

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Fig. 11.32. Mobilization 01 the upper part of the sacroiliac joint.

C3. CS). which relax dar;",; i/flwlar;rm. making mobilization

casy. Resistance in all segments of the ccrvicothorac.:ic junction (from C6 to T2) increases during inhalation. and rclax:.ltion occurs during exhal.ation. From T2 onward. increased
resistance during inhalation is again noted in the cven segments (T2. T4. T6. T8. and TIO) followed by relaxation during exhalation: conversely. during exhalation. resist:mcc in~
creases against side-bending in (he odd segments and
relaxation (i.e.. mobilii'.alion) lakes phlcc during inhalation
(T3, T5, T7. T9):'"
The most effective coml11,lncl for mobilization into siCie
bending in the even segments is: "look up nnd bremhe in,"
followed in the cervical region by "look down and breathe
out:' In the cervicothoracic and thoracic regions. the command again is: "look up and breathe in:' followed by "relax
and breathe out:' to avoid increased Ocxion of the cervicothoracic junction and the thoracic spine. which is most unfavorable for mobilization. In the odd segments. however.
combination with eye movemcnts is unsuitable. bec:'lUse look~
ing down would not increase resistance against side bending
and looking up would not help mobilization into side bending

Fig. 11.33. Mobilization of the lower part of the sacroiliac joint.

Fig. 11.34. Side-benning mobilization of the cervical spine.

" ... , ,............. , , ...... , ' ...... ,,, ...... ,

down" during thc relaxation phase instead of "look to the

right" if movcment restriction is to the left, followed by ','look
to the left," as is required in the cervicothoracic or thoracic region (Figs. Il.3S '0 11.40).
Just as in PIR for muscle spasm. il is esscntial in the mo
bilization of joints to wail for the release effect. Release usually occurs late during exhalation (or inhalation). and it is best
to avoid useless attempts to force it-it must be sensed and be
free of intcrfcrcl:ce. evcn by the order to breathc out, as long
as relaxation continues. Once release has set in. it goes on.
even if the paticnt continues to breathe normally.
Postisometric relaxation is not the only neuromuscular
technique. We may inhibit antagonists by active motion, e.g.,
inlO rotation (Fig. t t AI). In some cases, we may use rhyth
mic contraction of a muscle for mobilization, e.g., of the
scaleni for mobilization of 'he first two ribs (Fig. 11.42).
The original Muscle Energy Technique (MET) as described by Mitchell, Greenman, and others is similar to PIR,
but more complicated in that it tries to reach the barrier in
three planes at the same time and to apply resistance accord

., .......... "" ........... , " ........... " , 'v''' .... n v

IV' ..... ''1U ..... L

Fig. 11.37. Mobilization of COC1 lateral flexion.

Fig.

Fig. 11.38. Mobilization of restricted rotation in the cervical spine.

Arrow. fixation by the thumb from behind,

Fig. 11.35. Mobilization of COC1 retroflexion.

Fig. 11.36. Mobilization of COCl an!ef!exion.

ingly. "Functional" and "counterstrain" techniques achic'Yc

release by moving the patient to a relief position in which
spasm subsides, and then carefully bringing the patient back
into neutral position. finally making sure that the full range of
motion is well tolerated without recurrence of spasm. Such
techniques can be useful in the acute stagc. being gentle and
well tolerated by the patient..t1A~
As described in this chapter. PIR has the advantages o(
simplicity and the possibility of combination with eye mo\'cment. gravity, and respiration-making many of these techniqucs automatic and thcrefore well suited for selftreatment.
onc of thc requirements of the rehabilitation process.
In joints that cannot be moved by thcir own muscles. it is
important to remember the absence of spasm that could inter~
fere with passive mobilization when the barrier is engaged.
Simple passive mobilization can be obtained by a minimum
of force just by springing those joints, The importance of minimum force lies in that the joint has to spring back into neu~
tral after applying a springing force. and the intrinsic forces of

lix

'1"\1'<U/'"\L.

21:;

...... HAI"" I tH 11 : HVLt VI"" MANWULAIIUN IN ;jI""INAL Kt.HAtHLlIAlIUI\l

j'lillb h.\:" an cXL"cptional position. Here. the barrier is engaged

in a "illldar way, but then a fast impulse
(rdatively) little
t'on:e and s111.111 amplitude is applied. separaling the joint
faL'l'b \\ hell a click is usually heard. At this 11l0lllelll, the resiSlallCL' ,lr the barrier "uddenl)' breaks dowll (Figs. 11,46 to
11.-1~ l;b it is "taken by surprise." In other words. whereas all
method .. described so far only normalize the barrier. the thrust
suspend ... it. and with it. its protective effect. As a result,
hY/lcnllohilily is produL"t.xl. which is ,Issuilled III be only temporaL;>. ~, ":

or

Fig. 11.39. Mobilization of rotation at the cervicothoracic junction.

It i... easily under"tood that most complications ascribed to

manipulation and related to thrust techniques and that repeated thrusts at short intervals produce permanent hypennobility. 3. condition cvery experienccd clinichin \iews with apprchen"ioll. Complications arc, in fact. most frequently the
result of repeated (ullsuccessfult thrust manipulation at short
illlcn ;t].;.. il is clcar that the question of contraindication for
manipulation 'mainly concerns thrusting. Propcr techniquc is
of vital importance when using a thrust. \Ve should never
thrust until the slack has been properly taken iJut and the patient ha~ relaxed: therefore, \Ve should never thrust in a painful direction. Nor should thrusts be applied where movement
restriction is pronounced; in fact, if therc is scvcre restriction
in all directions. this is in itself a contraindication for a thrust
manipulation. Because most serious complicmions after manipulation arc caused by vertebral artery injury, the comb ina-

CI';,I~ve

i.~lnch

ILL.'lCk
~ngc of
.'\\Jch
:Ic"imd

Fig. 11.40. Mobilization in slight kyphosis, with the lower vertebra

fixed by the therapist's hand and thumb,

'-.,-,--I_r~--'c-~---=--_
!====~~,~R~\=*\===
Fig. 11.41. Active repetitive mobilization of the lumbar spine with
the patient lying on a side,

such joints arc smalL Examples include the sacroiliac joints

(sec Fig. 11.30 to 11.33) as well as the acromioclavicular.
sternoclavicular. and tibiofibular joints (Figs. 11.43 to 11.45).
In all techniques producing release. the operator is constantly in a diagnostic situation. making correction possible
and knowing when and where release has been achieved.

THRUST MANIPULATION
For many if not the majority of practitioners, the term manipulation is synonymous with thrust techniques. To this point.
our main criterion has been the barrier and release phcnomcnon dcaling not only with joiiHs but also with most structures
of the molOr systcm. In this respect. thrust manipulation of

j-

Fig. 11.42. Repetitive mobilization of the first and second ribs by

isometric rhythmic contraclion of the scalenus.

Fig. 11.43. Mobilization of the acromioclavicular joint by shifting the clavicle against the acromion ventroctorsally (a) and craniocaudally (b).

lion of rotation, retroflexion, and traction should be excluded

from our techniques on principle, because for the most pan
such complications do not arise with signs of clinical in-

volvement of the vertebral arteries.

Thrust manipulation should be carried out with little

force; if a "little lUg" is not effective. we should change to

neuromuscular techniques. the thrust (tug) serving as

<I

tcst to

sec whether the joint or mobile segment is prepared to accept

Fig. 11.44.

Traction~mobilization

of the acromioclavicular joint.

Fig. 11.45. Mobilization of the fibular head against the tibia.

it, but ncvcr as a forced procedure to achieve the click. Our

aim is not a click, but rather relcase and nonnal function, obtained by thc most appropriatc mcans.~~-52
The usual list of "contraindications" involving tumor,
acute inflammation, fracture, etc. is out of place becausc no
competent practitioner would knowingly usc manipulation in
such cases as those. No one is infallible. howevcr. and diagnostic errors are a possibility. particularly in the carll' stages
of disease. Even in such cascs, howcvcr. neuromuscular techniques are usually harmless and may even give temporary
relief.
Clearly, to rely mainly or exclusively on thrust tcchniques
is bad practice, the more so as it deprives the practitioner of
such effcctivc manipulativc methods as soft tissue trcatment
and PIR. Nonetheless, a successful thrust gives intense, immediate relief and therefore remains a popular and useful pro~
cedure. \Vhen thrusting is properly administered and judi~
ciously used, the ratc of complications remains small. and
therefore it is important to know when thrust manipulation is
particularly uscful. The most frequent situation is whcn symptoms persist and release and relicf is not fully achicved aftcr
application of neuromuscular techniques. In this situation. the
patient has also been well preparcd (by these other methods)
to receive a thrust.
The utility of thrusts if joint rcstriction is the cause of
nervc cntrapment is understandable, as the irritated nerve may

-------

.rl

vM ..... r- I cn

I I

nULc v r 1VlJ-\I\llr-VLJ-\IIVI\I 11\1 ;:,r-II\lML nCMMOILlll"Il 'V'"

~IO

TIC\CTlO:\ TIlERAPY

"

\0

,~

T('n$IOn on kq

"

Fig. 11.46. Relationship between distraction force and joint surface separation for a joint that cracked when a distraction force
was applied. (From Roston JB, Haines RW: Cracking in the
metacarpo-phalangeal joints. J Anat 81:165.1947.)

The nbjL' . :t l,lf manipulation is to n~ctify mechanical problems.

Thc S:Il11c is trll~ of traction: in our opinion. the bcst form of
tractioll is lI1(//lIIa{ tructiol/. Curiollsly. manipulators show remarkably link interest in traction and. more frequently than
HOt. al'(' nil{ well ;lcqu:linted with the t~chniqlle of manual
tr:lCt i!.l11.
ThL' most (:ff(:ctivl' techniquc for therapy in the cervical
arca is postisollletric traction. which has already been Jescribl.'d. It is indicated for individuals with acute wry neck and
root syndrollles. and is specific in the treatment of e2/3 restrict ion (SCI,": Fig. 1l.19).
For anatomic re:tsons. traction in the lumbar spine affect
joints only minimally. but it is specific in the treatment of disk
lesions. ~n fact. clinical improvement after traction is potentially diagnostic of a disk lesion.

---=='~'

E,
E
S
c

"0

o
~

.:; J

;f;r~

I
t

._._' --:---:-~---::-,,---~
6
~
10
12
\4
16
Tension in kg

Fig. 11.47. Comparison graph to that in Fig. 11.46 for a joint that
did not crack when distraction force was applied. (From Roston
JB Haines RW: Cracking in the metacarpo-phalangeal joints. J
Anal 81:165,1947.)
t

be edematous and therefore profit from the extra freedom

given by temporary hypermobility. Its value is evidclH \vhcn
the carpal bones <lfC thrust into traction (Fig. 11.49) in a carpal
tunnel syndrome. and in the ccrvicothoracic outlet syndrome
(Fig. 11.50). It can be equally succcssful in root syndromcs.
by judicious usc of a technique by which the intervertebral
foramina arc widened and little or no rotation takes place, and
in simple traction tcchniques in the cervical and cervicothoracic area and in llexion techniques in the lumbar region (Fig.
11.51). Again. however. even if successful. a thrust should not
be repeated at short intcrvals: likcwisc, it should never be repeated if the lirst thrust did not succeed with little force.
Thrusts arc useful for areas with minimal pain and spasm, so
that only minimal resistance is met. Sometimcs thrusting is
the only possible tcchnique to usc in small children who do
not cooperate and where fast action is required. but only experienced practitioners with faultless tcchniquc should vcnture into this arena. This caution applies particularly to the use
of traction manipulation in the upper cervical spine.

Fig. 11.48. Radiographs of the third metacarpophalangeal joint

during the resting phase and distraction phase, before and after
manipulation. a, Pretreatment. nondistracted joint space; b, Pre
treatment, distracted join! space; c, Posttreatment. nondistracted
joint space; d, Post-treatment, distracted joint space and gas
arthrogram.

, . . . . . . . . ~,_ "

' ...... , . . . . .

, ...... ,

"

..... 1"\

r n/"\ ..... 11 I IVI'lc::n ;:) IVlf"\I'llUI-\L

til{' hack of 111\' !":lticn(..; knl,'~ lln~r his or ha thigh and u:-;~~
lhe pt.llient"s kg as a leva. rhythmically lifting the patient's
pelvis and low back from the aable and rocking it (Fig. J I .)_"' lI\s mentiolled prc\'iollsly. postisolll~tric tral'tioll in thc
lumbar region makes usc of respiratory synkinc:-;is: the..: tha~l~
pist resists the buttocks Illo\ing.upward during exhalation and
make:, usc or rcl:lx.uion during inh:llation (~Cl' Fig. 11.1 S J.
Whill; prone. with the kgs hanging over the end or a high
table. the patient may carry out sdf-treatment. lifting the but
tocks on exh'llation .md dropping them. rcl'lxing. uuring inhalatioll.
As with other mtltlipulativc techniques. tr<lction must he
adapted to the patient in such a way as to be painless and. if
possible, to give immediate relid. If the patient experiences
pain we mu:\t changc the techniquc or desiSl altogether.

b
Fig. 11.49. Traclion highvelocHy thrust on the os capitum: a;
Finding the os capilum and making contact: b l Taking up the slack
and making the thrust.

The following techniques are mO~l useful. In rhythmic

traction prone (Fig. 11.52). the patient holds the end of the
table while the operalOr pulls rhythmically with his or her
hands around the patient's ankles (which should not be
squeezed!), after first making sure that the patient is relaxed.
The operator must then establish the correct rhylhm to localize the effect in the low back. If the rhythm is mo slow, the
patiem's whole body will move up and down on the table. By
quickening the rhythm, the therapist will find out when only
the leg and pelvis move while the rest of the back remains
still. the low back being like a nodal point in a sianding wave.
Rhythmic traction prone can also be carried out by pulling
only one leg. which also produces a slight sidebending effect
at the same time.
If the prone position is poorly tolerated because of forced
lordosis. traction is carried out in kyphosis with the patient
supine. The therapist stands at the side of the table (which
must be lowered) and place5 his or her foot on the table. the
thigh and knee should be horizontal. The thcrapislthcn places

.>

.,~

THEORETIC CONSIDEIlATIO:-:S
All manipulative tcchniqucs dcal with mechanical probkl1l:'.
The barrier phenomenon. with all its rcllcx implic.ltion:-;. i:,
:llso it mechanical problem. yet its nature is not surlicit:'lllly
understood. However important muscle spasm and TrP may
be. they cannot explain rcstriclion in such joints as the sacroiliac and others. let alone barriers in connectivc tissue SInK
tures. One fact pertaining to joint and spinal mWlipulation that
is well established. however. is that manipulation restores nlO
tion and that its object is revcrsible movement restriction. The:
implication of this statement is thaI the imponance of the relative position of bones or vcnebrac should not be overrated.
This has practical relevance, because asymmetry, particularly
in the pelvis, may appcar considerable. bUI asymmelry with
out dysfunction does not require manipulation.
Recent experience and research have shed some light on
this question. First, it has becn shown that typical pelvic dbtortion with clear asymmetry of the anterior and posterior
iliac spines is not regularly related 10 sacroiliac dysfunction
and C<:ln. as a rule. be treated. successfully by manipulation of
struclUrcs outside the pelvis. m05t frequently those of the
craniocervical junction. Second. lindings show that th~ nt:u-

..

_~

, ... ~

\ .. }

Fig. 11.50. Traction high-velocity thrust on the cervicothoracic junction.

.)

~~

.,,

I "J
<

Ii
I

Fig. 11.51. Thrust manipulation 01 the lumbar spine with the pa

tient on her side. in kyphosis, the lower leg bent and upper hanging down over the edge of thi table.

ti

I~
q

~
"

",'\

Fig. 11.52. Rhythmic traction prone of the lumbar spine.

'~

lfal position in the spinal column is not absolutcly consHmt;

aftef maximum side bending of the ccrvical spinc or rotation.
the vertebrJe do not return to exactly the same position (Fig.
11.54).~" Finally. we hav~ learned thal static loads can change
the positon of \'cnchrae.
If we rC~lOrc nonnal mobility oCthe spinal column and the
pelvis. it will adopt the optimum individual position required
for the prc\'~ljljng conditions. which arc by no means constant.
If. for example. ventral and dorsal flexion is restricted, we arc
fully justilicd in mobilizing in both directions without regard
10 the position of the adjacent structures. For the sacroiliac
joint. for example. it is adequate to restore springing at its
upper und lower cnd. i.e.. in what seems "opposite directions"
(see Fig. 11.30 to 11.33), ..IS long as mobility is fully restored.

II
~

I
j

i
'~

I
I

dysfunction is pain with sitting or standing, especially when

ocnding forward.
Under nomlal conditions, static equilibrium should be
maintained without excessive muscular activity. Rash and
Burke fUI1her specify that, "in stationary posture the center of
gravity of each body segment should be vertically abo\'e the
ar~;] (1f ilS 5uppcrting base, preferably ncar its center. If pcr!'is.h~nt gravitational torques are being bome by ligamcnts. or
if excessive nuscular contraction is required to maiutain balance. this principle is being violatcd.":'>(,
For the slatic function of thc ~runk and the spinal column,
the position (tilt, inclination) of the base plays a decisive role,
but assessment by purely clinical means is impossible. The
exact position of the promontorium, of L5 and even of L4,
can only be revealed radiographically under standard conditions-standing. The ideal method is radiographic examination of the entire spine. If this study is not available, a plumb
line can show the position of the external occipital protuberance in the anteroposterior view and of the outcr meatus acusticus in the side vicw. The position of the feet must be held
constant; in the antcroposteriof view, they should be symmetric to a line of the noor corresponding to the center of the xray screen. In the side view. thc feet should be placed on the
same line at the site of the outer ankle (Fig. 11.55).
The mechanism of balance differs in the coronal and the
sagittal planes. This difference is readily understood if the effect of (1 heelpad is considered. An artificial difference of
more than I cm in leg lenglh is felt imi'iicdi<:atcly {~iid resented) in the coronal plane, whereas raising. (or lowering) of

~
, r

DISTURBANCE OF BODY STATICS

I
I

217

CHAe I eH 11 : HULe UF MANIPULATION IN SPINAL REHABILITATION

,)

l'

I ,)

Gutmann and Vcle sUllllllcd lip the import:'lI1ce of st<ltic function: "The dominating principle of the spinal column is body
statics. All other functions arc subordinated to the requiremcnts of the upright posture on two legs. Loss of mobility and
painful impingement of nervc roots is preferred to sacrifice of
the erect rlasturc."5.54_\~
Static fUllction of the spinal column is a specific characteristic of the bipedal hUlll;:\n racc. Its importance increases in
our technic.1I civilization in which static loads mc prepondcrmll (sitting .1Ild standing). The clinical manifestation of static

Fig. 11.53. Rhythmic

lraction supine of thl
lumbar region.

~
!i i - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - $

Ht:.HAIjILlIAIIUN OF THE SPINE: A PRACTITIONER'S MANUAL

I
,,
l

!
~

.~

Fig. 11.54. Radiograph of neutral position before side bending (left) and after side bending (right).

both fecI is hardly noticed. The responses differ bcc;.lusc. in

the coronal plane. the line of gravity passes between the tW(1
hip joints (stable equilibrium). and one can crfectively correct

pelvic obliquity by lifting one fool.

The physiologic reaction to pelvic obliquity-obliquity of

the sacrum (!)-is scoliosis to'the lower side. rotation to the

side of the scoliosis. and pelvic shift lO the higher side. The
summit of the scoliotic curve is in the midlumb.u region. and
the thoracolumbar junction should be above the lumbosacral
junction. 5
\Vith the most frequent type of abnornlality. Ihe thoracolumbar junction does nol stand above the lumbosacral junction but i~ deviated to one side. more frequently to the side of
scoliosis. Rotation depends on the degree of lordosis. If the
lumbar spine shows 110 lordosis or even kyphosis. there may
be no rotation or cvcn rot::ltion to the side of inclini.uion (not
scoliosis):'"
The most important point. howc\cr. is that obliquity must
concern the base of the spinal column. not the pelvis as such.
Unfortunately, neither difference in leg length nor pelvic
obliquity necessarily correlate with obliquity of the sacrum or
L5 or even L4. Therefore, we may easily create an oblique
b::L"ie of the spinal column by correcting pelvic obliquity
and/or leg length inequality. In other words. we correct the
morphologic appearance of the legs and pelvis. but seriously
disturb static function or balance of the spinal column (Fig.
11.56). Because lhis most relevant obliquity CimnO( be seen or
palpated. radiographs arc essential for correct ~ssessmen(.
Radiographic evaluation is equally es~cntial for the assessment of spinal statics at [he base of the spinal colul11n as
for lhe <Issessmenl of corrcclion. Unfortunately. the spinal
column decs not nlways "accept" our cOITcclion (heel pad).

in which casc nur intcnded correction may make thing5

even worse. This cirCulllsta11l.:c. too. c,m only bc rc\'cakd
radiogr.lphically (Fig. 11.57). This failure ofren occurs if the
pelvic obliquity is compensatory. as is the case in idiopathic
scoliosis.
The criteria of improvement after sUltic correction are
as follows: the lhoracolumbar junction returns to stand direclly above the lumbosacml junction: scoliotic curvature decrcases: and the pelvis and h~ad (plumb Iinc) return to mid-

C)

line (Fig. 11.58).

The same static disturbanc~'can be caused by obliquity at
the base of the spinal column. thus erell/illg pdvic obliquity.
hut normalizing spinal statics (Fig. 11.59). In this case. obliq\Jity is caused by asynH11ctry inside the pelvis. This obliquity.
unlike that caused hy leg length inequality. pcr~isl!' when lhe
subject is sc.::.ltcd .lIld should h~ corret:tcd by a board under the
ischial tuberosity on the 100.. . er side or obliquity.
If correction is (0 involve a hcclpad. it is essential to consider whether the spinal column can react clinically to m~
chanical com.:t:tion. Such a response is not possible in th~
acute stage of lumbago or a root syndrome with obvious alltalgesic posture. un.rol1l1ll<ltcly. the Silllle is true in the event
of movement restriction. c.::spccially in a key region. A good
example is pelvic distOl1ion rdated to a restriction (blockag~)
Ott the <,;raniocervical junction tFig. 11.60). It is therefore recomJ1lended to examine a pmicnt for segmenli.ll dysfunction
and to treill this problem tina. beforc radiographic re-exi.lll.lination with a vicw to static correction.
If static correction is likely to be useful. m.: first lest thl..'
patient's reaction to raising the fOOL with the aid of a board
less than I cm high. If the patient finds it pleas ani or is indifferent to it. it is probable that the mcasure will be well tokr-

..J

----------------------------_....

,
,"

CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION

219

Fig. 11.55. Radiographic technique of the IU,mbar spine with the patient standing. a, Positioning of the movable plumb line; b, Device
prepared for radiographic examination, anle'roposterior view; c, Positioning of the plumb line; d, Device prepared for radiographic examination, lateral view. (After Gutmann G.: Klinisch-roentgenologishe Untersuchungen zur Slatik der Wribelsule. In Wolff HO (ed):
Manuelle Medizln und ihr wissenschaftlihen Grundlagen. Heidelberg, Physikalishe Medezin, 1970, pp 109-127.)

. _ . , . ,

"""'V""'-"~"""V '''''M''IUMl.

A
Fig. 11.56. Pelvic ~bliQuity. a. Peh!is lower on the ~;ght (short right !'=-g) wilh a horizontal sacrum, the lumbar spine is straighl; b. V....i:h
a righl heelpad. sacral obliquity a;Jp~ars. with a dS':ialion ollhc lum::ar spine 10 the leI; and slight dextroscoliosis.

,
j

Fig. 11.57, Pel'/ie and sacral obliquity owing 10 a short left leg. a, Lea scoliosis wilh deviation of the thoracolumbar jllllction to the Ie:::
b. Less pelvic obliquity alter application 01 a left he~Jpad. but no imorovement in lumbar slatics.

,..

Fig. 11.58. Pelvic and sacral obliquity owing to a short leg.

a, Before correction; b, After correction.

Fig. 11.59. Sacral obliquity without pelvic obliqui::. a. Betore correction: b, Afler correction.

Fig. 11.60. Disturoed s!alics in pelvic distortion. a, Pelvis straight. obliquity at LJ with deviation of lumbar spine II> t:-::, ~~Il and sligr.t
sinislroscoliosis. b. No ~mprovemenl after IlppJying a left heelpad. c. Afler Irealm:?:,: ol <1 blocked rlilM,;,;oQcr.;ipilal jc:r': -ormal statics
and no pelvic dislorllon

RI::::HAt:HLlIAllON OF THE SPINE: A PRACTITIONER'S MANUAL

I1

aled and h~lpful. If, howe\'er. it is resented, but radiographil.:

findings show marked improvement. then the patient is advised to try to get used to it if possible. i.c., to wear a heel pad
only temporarily, so long as it does not calise discomfort or

i,

pain.
Once the patient has adapted. it is belief 10 raise the heel
of the shoe on onc side or 100vcr it on the other side; if. however, the difference is more than I CIll. il is best to recommend

a thicker sale on one side. so as not to spoil the shoe.

In the sagittal plnlle. the pelvis and spinal column arc po-

4
!
1
i<

I
I
~

I
,~

I
I
I

I
"

I
It

I
I
~

sitioned above the perfectly circular femoral heads. and b:.i1ance is maintained largely by muscular action, which should
be kept at a minimum. Spinal curvature is largely a result of
sacrum inclination: if this is considerable. lordosis will be
considerablc. Under normal conditions, the thoracolumbar

junction is somcwhat behind thc lumbosacral junction. so that

T12 lies 4 em behind L5 on average.~K If the thoracolumbar
junction is in front of the lumbosacr<ll junction. a forwarddrawn position resuJ(s. because of acute disk protrusion or
muscular incoordination (see Hg. II. I 3). This forward-drawn
position is <1150 importalll in the cervical spine and goes hand
in hand with increased activity of the m. erector spinae representing an increased load for the spinal column (Fig. 11.61).
Hence, static imbalance (overloading) in the sagittal plane is
the result of muscular imbalance and must be treated as such.
not by mech.mical corrcction,
In both [he front~ll and the sagittal planes, howc\'cr. spinal
curvature is an expression of stalic function. If the spinal column is in good balance. i.e .. if only a minimum force is re~
quired to assure sUltie function. then spinal curvature fullills
its task. The s:mlC is true for scoliosis (if not excessive):'5 for
lordosis or kyphosis. In the author's opinion. no other physiologic criterion is applicable for the assessment of spinal cur~
vmure.
One morc importam as.pect warrants mention. The less
curvature. the greater mobility. i.e.. the less stability. On the
other hand. the nlQrc cun-ature. the less mobility and greater

stability.
MANIPULATIYE THERWY AND
ALTERNATIVE ~IETHODS
From a method of treming mainly articular dysfunction. mOl
nipulative therapy has developed into a method thm is used to
tr~at dysfunction of any structure and tissue in the motor system. and it is possible that ~Oll1~ ,isceri.ll dysfunc'tion mny bc
influenced by manipulatiq~ techniques as well. The prerequi.
site for all this applicmion. is the (lrr o!po{pario/l. Palpation is
however. first and foremo.1:,( a di~lgll()stic procedure. and so
manual functional diagnosis has become the most important
dinical contribution of manipulation, enabling us to make
pcnincnt diagnosis of all tissllcs and structures in the motor
:o;y:-;lcm.
Prcciscly because of lhcs~ diagnostic possibilities, wc
have' learned thai importalll tissue changes lie far from the site
\vhcre the pmiclH feels pain. nnd th.lt. in f::let. slI<.:h changes

r-----
:1
,

.~

..

usu<J.ily <.tIl: Ilhm,; lIullh;l\lll:-O lhan those recognized by the patient bccnuse of pain. NOI only <Ire these changes frequently
nUlllerous. but also they form patterns or chain reactions thaI
arc the expression of dysfunction. conccl'lling not one. hut
111:1n)' structures. forming characteristic patlerns. Only whell
we understand thcse p.lth:rns. are wc <lhk to gel morc th;lll
temporary results by our trealmcnt.
Having m"lde the di"~JlOsis. we have UlallY methods Ilr
treatmCI\l from which to choose. In most of the s<.lft tissues.
methods of physical medicine C'lIl bc applied. from lllassage
to the v..lriolls forms of electrotherapy. to applications of heat
or cold. to lhe magnel as well as the laser. In fact. t~chnil.:al
progrcss is const;mlly providing us with new mcthods, It is.
however. neither the scope nor the purpose of this pllblil:atio!l
to discuss thc merils or disad\'alllages of these altcrn<ltiv~s or
of needle. and local anesthesia.
Manipulative techniques have olle great advantage OWl'
other methods: rccdb'1Ck resulting from palp.uil,ln. which
pbces the operator constantly in i.\ situation of therapy and di
agnosis. It is in this case that the barricr phenomcnon is parlicul:uly useful. givcn its greater precision borne (lut hy the
close correlation of the palhologic barrier. incrcas~d h.:nsioll.
and pain. Similarly. relief of pain is associated with the palpable sensation of release so we kilO\\' when a p,lint'ul sInH..
lure stops being painful. \vhich is why the focus of this discussion is on those techniques based on th~ barrier
phenomenon. In this connection. it call be said thai where,ls
most methods of "complementary (ahernativc)" medicine
treat mainly dysfunction, manipulative techniques pr(wide the
rational clinical diagnosis.

)
)
)

()

CLINICAL IMI'LiCATIONS

The importance of the diagnostic side of manipulati\c techniqucs has been stressed. It is the clinical implications that illustrate this point. The Illost frequent symptom of our patients
is rain. which is. in itself. a diagnos.tic problcm for most praclirioners. \Vc havc consistently shown that with our methods.
we arc able to dctect well-defined changes in almost all slrllctures of the molor systcm and beyond: in skin. the \"<.~nnective
tissues, muscles. fasciac. and joints in both tht:' ~xlrt:l1litics
and the spinal column.
Consider headache in a patient with "ncgati,'c.7''' Ilt:llI'O,
logic. orthopedic, otorhinolaryngologic. stomatologic. or
rheumatologic lindings. We may llnd tension in th~ masticatory and submandiblllllr muscles. with deviation of the hyoid:
a scalp that docs nOl freely move on lhe skull in som~ places
(and in some direction): hyperalgesic skin zones in Ihe cervi~
cal region: TrP in most of lhe neck muscles al1d in the cervicothoracic <Ire.!: movement restriction in the t~IllPOro
m'llldibuhlr joint: dysfunction of joints in the cen'ical spine
and the cervicothor<lcic rcgion. including the acromi~,clavicll
lar and the sternoclavicular joints: and p;'linful paiosteal
points wilh restricted mobility of slIbperiosteal tisslt", in SOl\H,~
direction. We may observe a forward-drawn positi~ln 01" the
he<ld owing to increased tension in the <lbdolllinal lllllsdes

_-------------------,---------

\.)

CHAPTER 11

ROLE OF MANIPULATION IN SPINAL REHABILITATION

Fig. 11.61. Forward-dra'.... ,: posture with thoracolumbar junction ir' front of the
lumbosacral (a) and with s:raighlening of a cervical curve (b).

with hypcrtollus of the glutei. and fauh~ motor patterns O\ving

to muscular imbalance. faulty rcspintion.md/or cxogcnic
rcasons. e.g .. al the \\orkpbl,,:c. This ,\C(Olll1! of the possible

findings is certainly not (Olllp!e(C. but what is true for

headache is as true for . . houldcr pain. leI\\" hac\..; pain, elc. in regard

10

"negative lindings.' The clinical impliGllion of func-

,I

tional pathology-nol a question of -.in1;lc method but of a

different clinical approach in which dy,>functioll is as real as
structural pathologic changl' ,Ind therefore must be adequately
diagnoscd, i\-1anipulati\'c !t:('hniquc.. have thu:, opened the
way to what i~ no\\' \\iddy ('ailed "m;oskektal" or "musculoskeletal" medicine. dcallllg with the l11(1st frcqucilt alTcction, of the motor sy'-.tclll and cvcryda;. ailmcllls,
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1i
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~

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muscular facililalion :md inhibition. J ~-tanual ~kd 2:101. 19S6.
37. Zbojan L AllliJ;ra\'il cna rcl<lX (:ia. jej plXhl;lla ;1 potl.leilic fgr,lvil)" induCl..'<.! relaxation. its principles anti pr.ltliec app!icatiouJ. Praktick lka
68:147.1988.

,-""

'V'''\:.rl .:>

.v

"lUJ-'oL

-,

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7-l:6JS. 1975.
"IJ. 11,c lIlus\'ul:tr anll ;tMl":llbr (;Klllr in 1\10\,'11\":111 n.str'i':lillll, 1 ~Ialll101l
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..tn. G:lym;lIls. I:: ni..: IkJ~'Il11llll! lk'r AICllll~T~1l fr die Mohilis;llinn der
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":2_ Gr~'Cllll\;1l1 PE: Prill~lpk .. "f "'t;mu;11 ;\k.h,lIl,. Iblli"ltlfl:. Wdh;lllI\ .'\:.
Wilkins. IIJX<J. pp 101_1115.
4". RU:'ItI11 In. I-I:lill...s RW: Cr:l.:kin~ in Ih..: lIk'I:I"::lrpt'ph;\I;lIl~""ill j"inK J
'\11.11 SI:HtS. 11)47.
":-1. Mi..:rau D. Cas.>:idy JD. Wmn:n V: ~'laniJllll;llioll ;lIIt111lllbiliz:llitlll tlfth..:
third met:u':;lfl'0-llhal'an:;e;11 jdill1. A 111I:lllIil:lli....: r;uJio~r;lJlhk f;tltg..: III
1II0lil11l Sllldy. J M;IIlU;11 ~ktI3:1~5. I'JXS.
45. Dvorak 1. Or..:lli F: Wi,' !:!L'lhrlih ist ,IiI.' I\Llllil'ubtioll lkr I-LllswirhL'I\IIL" ~
Malludlc ~...ted 2U:..:-I. It)S~.
-16. Grnssinrd A: Les a~'cilknls l1CUf(II'l~j(llle~ d,'\ 1I1ilnipliialitlllS I..'..:nkak....
Ann Me(I Ph)'s 9:21'.l. 1'J(}{l.
47. GUlmann G: VCfkIIUIl~""lI del" AII,Ii;1 \,'llchralis tltu'dl lllillllldk
111..:rallic. Malluelk ~l ...d ~ I :2. l I Jx.'.
..tH. MClllor::mdullI of til,' G...rm.m Assllciati\llI "f ""1;\11\1;.1 \'vkdi..in..... Zur
V..:rhlllng von Zwi\ch<:nrllell hci l!c/.klln !l;lIltl~rifrThcr;lpj.... all Ikr
tl:llswirtlo:ls\lle. M;llluclk Mel! 17:53. 1'J79.
oll). Smidt RA. E."lridge ~l\': Neurolu~ic \'olllplic;ltilll\S of h....,ld :nld IIct:k
m;mipul:llion. JMvl,\ [S~:5. 1%2.
5'" Fu\sgf\."\:11 J: EdiloriaL Cnmplic:lti\lll~ in m;ullI:.1 lII....dicill... J M;IllIl:.1
Med (diJ. 1991.
51. Dvorak J: In'lppwpri~l"" illdkaliolls ;lIId \olllrailltlit;llillll.>: of l11illlU:!1
themp)'.l M;IIIU:.1 Med ('I:H5. 1991.
52. Patijn J: Complic:lIion.. 111 m:U1l1almedicim:: A re,i..:w tlf Ih.: lih:ratur.... J
M,lIlllOll Mel.! 6:89. lYlJl.
53. KirOl.ll J: Persistence orynkin..:tk pallefll\ .. I" til..: .:cr,i\-"I spill....
Neuwr,ldiolll.Y 18: 167. 1971).
54. Gulmann G: Klinis... h-rncnlgcl1(l1tI~ishc Unll:r~m:hllllJ::cll I.ur Sl;llik d~'r
Wrihclsuk. In Wolff HD (cd): M;ultldlc Mctlizill IIml ihrc wi ...
\Cn\chaftlihen Grundl:.gcn. Hciddhc~.:. I'hy\iloi:llishc "kdi/ill. I'JiO.
pp lU9-J27.
55. Gutmann G. Velc F: D;l\ :llIfredl1c Slchl!. Wcsh.klll~ ...hcr V"'I'Ia<:L.
FllN.:hungstlo:ridllc tk_ L1f1dl:s Ntlrdrh..:in \\...."'If:lhl:l1l Nil ~7l)(,. Fadl
gruppc Medi7.in. 1978.
56. R;:L~h Pl. Burke RK: Kincsioltlgy and l\pr1it:d !\l1al\l111Y. I'hiJ:tddphi:1.
Lea & F~big~r. 1971.
57. Lovell R: L'ler:l1 CUf\:I!ure (11' the spinc alld ~hllulders. J>hiladclphi;l.
Blakiswn. 190i.
58. Cramer A: Funklillnclk ~lerklllak der Wirbd..ukll..:l:.til. III Wirhc!\uk
in Ftlrschung und 1'ra'j.... Slultgarl. I-lippul.r;,lc.... IIJ:;X. pp X.I-9.'\.

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;::,plnallnerapeutlcs tsasea on t<.esponses

to Loading

IL.

GARY JACOB and ROBIN McKENZIE

In this chapter, we explore the clinical reasoning for spinal as-

ria on which assessments and therapeutics of the spine arc

sessmenl and therapy, variously referred to as the McKenzie

approach. protocols. or system. Ou~ purpose is to explicate

the underlying philosophic and practical perspectives of the

predicated The Issue 01 when and how cntelld thct<lle the dr:
rcction and type of rorcc applied 10 the spine is critical to the
understanding of the McKenzie approal.:h.

MG~JE!= approach. as it ~.c_c_ounls for.p.~e!lQm.~Jl~u~J.ated to

spin.~~..ding :ind il~--':I'-"Jqu~!Jlanncr of satisfying the "de-

QUESTION OF CRITERIA

tTI mds"

of rehabilitation. This chapter is not intended

impart c1inicnl competency regarding the skills necessary to usc

the McKenzie protocols in practice. Such competency requires study of "The Lumbar Spine"] and "TIle Cervical and
(0'

Thoracic Spinc"2 by McKenzie, as well as the formal instruclion til.., applies the clinical rC<lsoning found within these
texts to assessment and thcr.lpy of patients on a day-to-day
basis. The material presentcd here can only hope to supplemcnt such study and instruction.

APPROACH TO CLINICAL REASONING

In the following attempt to expand an understanding of the
McKenzie system, new terminology is introduced. Hopefully
what such terminology distinguishes will stimulate established and future students of the McKenzie approach 10 further appreciate its imrinsic principles.

Relation of the McKenzie Approach to rvhmipulation

Rehabilitation

~md

Both

Jllillliplll~ltion

and rehabilitation usc movement

.IS

ther-

apy_ In milllipulation. movement is used as therapy when the

clinician moves the patient's spinal joint structufCS to end
range. The rehabilitation tradition also uses movement as
therapy. but with a preference for "activity as therapy:' i.c..
patients performing.the movemcnts themselves.
As with manipulation, the McKenzie approach uses spinal
movements to end range. As with the rehabilitation traditioll.
thc preference is for palient self-generated movements. The
significant difference belween Ihe McKenzie approach and
that of tradilional manipulative lherapy, however. is not thm
of rejecting manipul.ltion in favor of patient-generated movements, althmlgh the latter is always preferred. Manipulation is
aL:tually an option according to McKenzie protocols. when
patient-generated movemcnts prove only partially successful.
The most significant difference between the McKenzie
lpproilCh ;ll1d other melhods of treating the sp::1e is the crile-

The criteria according to which any inquiry is conducted for

the purpose of resolving a problem profoundly affect how the
solution is conceived. In Olher words. the am:wcr:, you get depend on the questions you ask. The McKenzie <lpproach predicates spinal asscssment and therapeulics on asking questions
aboUl the mechanical and symptomatic responses to loading
the spine.
P..tticnt., preselll with a variety of mechanical and/or
symptomatic: spinal l.:ompli.lints. and their rcspons~s to movements and positionings of the spine arc v'lriablc. Sitting may
exacerbme spine-related complaints in some individuals.
whereas others find relief while seated. St.ulding.. walking. or
reclining may similarly cvoke disp<lrate responses ill the same
or different individual. It is noted. tlll:rcforc. lh;lI patients h.wc
different stories to tell about how movement and positioning
affecl (heir spine-rdated complaillls.
Concerns rcg,lrding specific spinc-rcbtcd complaints.
which are cssenti;dly mechanical and SYl11ptolll~lIil' responses
to movement and pusitioning. motivate paticllts tu seek professional cmc. The details of how spine-rcl~llcd mcchanics
and symptoms me affected by movement and positioning.
however. 'Ire seldom of specific concern to the clinician for
purposes of assessment or therapeutics.
St..mdard mnge of Illotion examinations and ol1hopcdic
tcsts do not adcquiltely explore how the particular patient's
spinal mechanics and symptoms arc affected by specific
mOVClllCllls and/or positionings. Perhaps the greatest limitation of thcse examinations and tests is the supposition'that
each test movement need be performed only once to fathom
how the p<.llicnts complaints respond. The cffcclS of repetitive movements. or positions mainl'lincd for prolonged periods of time. arc not explored. evcn though sud\ loading
strategies might better approximate what ()~(:llrs in the "rcal
world."
The mcdwllic:al or symptomatic response to a movement
performed once might be r'ldiGllly different fnJl\1 wh'lt would
uccur if th'lt muvemcnt werc perfurmed lin: l)r ten times.
225

thcn.:by rC\'~alil\g an entirely dirr~n;1\l dini\:al picture.

Similarly, the mechanic.1I or symplom'lIit: rl'spon:-c.: iO aSSUlll
ing a particular positiol1 fllf a fe\,\, lllUllh':lIls miglll he r;luicall)'
different from what would O\.."'.:ur ;Ifl~r assliming Ih;1t idl:lllical
position for it fe\\'" minutes.
Just as l1lc,:hanical and sympll.llllalic r(;spOl1SC~ aTC rardy

consi(krcd

I
j

I
~

!
:f

n:~:lrdillg

their l\'bli\lll"hip III

n:pL'liti\"e,: tllO\'C-

menls :.md/or sustained pll~ilillllillf. Iillk inquiry i~ dircCh:t..I hI'

how mcchanil..";11 ;\lId :-ymptolllalK rc"pollsCS rel;I!\,: /0 ('((cli
other; i.e .. ho\\' [hey n:spLllld ill (;mdclII to lllO\,Cllll:111 ;mt.! po~
sitioning.
The possihility of 111l:(,.'hanical and symphull;uic responses
serving as Illcaningful criteria 011 whidl to prcdic'lt~ treatmCIlI
is precluded if cognition of such is wanting. Unfortunately,
many spinal examinations "ln~ all 100 often only cursory formalities, serving as preludc~ In prcdetcrminctl trcatnlc'l1I
plans, indepcndent of sped lic a""C"'''lllent linding...
Treatment \Vithout Spcdlk Criteria
Treatment for spine-related cOlllpl::lims is often routinely .lIld
ceremoniously applied in the exact ~alllt: llWl1I1t:r for each pa
tient. even though distinglJishing mechanical und sympto
miltie prcsemations <Ire potentially discerniblc belwecil indi
viduals. More often th'lIl not. the niteri" that motiv:.llC the
p<'lticill to seck care an: Ilot il1limutdv connccted with the criteria used by the c1inici'lIl to asses.. the patient. 10 determine
approprialc case management. or 10 monitor the effectiveness
of C<'Irc, Identical care applied to all patients with common
spinal compl<.lints is often the result of criteria th<.lt roUlindy
conceive of a universal problem underlying all panicul,lr
complaints.
A Priori Versus A Posteriori Approaches
Preconceived. (I priori notions about common spinal disor
ders can bli~d clinicians to meaningful and individlJating phenomena. A priori knowledge argues "from what is hdon:"
(I.e., from causes 10 effects) and attempts to bc indepcndcnt of
particular expericnce. On the othcr hand. (f {losterior; knowledge argucs "from wh.1t is aftcr" (i.e.. from effects to causes)
and uses empiric knowledge derived from experience.
Implicit in the McKenzie appro,Jcll is an ..I poslcriori. em
piric study or phenomt:na rdOlled 10 spinal loadinc. ,lftcr
which pathoanatomic cxplan:nions arc proposed. A -Glfl.:rul
description of clinically presenting phcnolllcna is possible in~
dependent of the pathO<ln,llOmic intcrpr~(ation of tile day. and
this description should remain <l<.:cur.He if th"t interpretation
changes tomorrow. \Vith thb i.lppro"lCh. a priori judgments .Irt:
less likely to prejudice [he perception or the clinically pre.
senting phenomena. It is acknowled!.?ed tlwt one C<ln onlv altempI this goal. as no one can trul; he free of all pn::con.
ccived notions,

PUlling Pathmumtomic Criteria in Their' Place

Predicaling treatment on a priori COl\struct:-> rooted in the
pathology model h"s led to wh<.Jt h'l:-> h~~l\ t:allcd the "r:lilure

..--

of the patholugy l1lodcl."'lllese :.I priori constructs. based on

hypothesized pathO;JmHomy. have gencrated trcatments that
may br.: t'llIgr.:lltiallO lhe patient's ne~ds and obscurc the clinical pcn.:eplioll of phcnomena :\pecilic to the individual pati~llt's si\ll:tlioll.
FtJr t.:xampk. if all spine-rcblcd complaints afe perceived.
a priori, tn hl' th~ result of inflammation. this preconception
limits the clinil'i'llls ahilil)' til appreciate the po:\sibilily of
mcchanical slratcgies for palielH C'lre. It conceptually pronltltcs tre<!tl11r.:1lI . . tralcgir.:s of rest anti anli-in!lalllmatory mcdiGltioll. whidl may not be eflic<lcious if, indeed. mcchanics
.md not t:hcmistry is the relev'lIlt component ill thal patient's

case.
Patho.1I1atomy :md the McKenzie Approach

The McKcnzic appmach recognizes pallerns of mechanical

and symptomatic phenomena th.1t arc labeled "syndromes."
Although the McKenzie <Ippro"lch names :-;yndromes according to certain p"lIhoanatomic suppositions. these syndromc~
refer primarily to phcl\ol1lcnologic patterns that can be discerned apart from any particul..lr pathoan<Homic interpretation. The assertion th:.u the syndrome patterns detailed in the
McKenzie approach accurJtcly describe the phenomena related to spinal loading illde/Jt..'lllh'lll of the pathoanatomic interpretation
,h~ day applies, as well. to those interpret~}[ions
forwarded as pan of the ~kKcnzic <lppronch,
By lirsl describing presenting empiric phenomcna before
making pathoanatomic interpretations. we hope to afford the
reader a fresh perspective without putting the "pathoana[omic
cart before the empiric horse." The ahertl<ltivc method of nrst
presenting the p~\lhOal1:'llol1\ic conclusions of the McKenzie
~lpproach runs [he risk of diminishing an appreciation for the
clinical uti lily of the approach. the basis of which is therapeutic imer.vcntion ~lI1d management made possible by careful
observations of spinerclated responses 10 movements and iiOsitionings, and not by the ability 10 ascribe meanings to th('$c
responses via dogmatic diagnostic conclusions based on
pathoanatoillic models.

-~

or

Objective Signs Alone Arc Not Adequate Criteria

Some clinicians maintain the a priori notion that conc~ntra[
iog on lllcchaniGl1 or other objectivc signs alone (and [ht.~r~
fore ignoring symptoms) is a more sci~l1tific approach. becalise signs are more amenable to measurement. Mechanical
.or other objccli\"c signs. however. such "lS range of tll('1,iOll
measun:lllents or spinal imaging. do not ::Idcquately ~K\'l,'1l1nt
for the phenomcna of spine-relatcd complaiTlls.
\Vh..1t might a[ first seem to be indistinguishable obj~~tive
me,lsurCl11ents between two patients. may. on closer in::~c
tioll. prove to be p.m of different ~linical pictures when
judged in the broader cOlllext within which they occur. The
identical mechanical sign may be associated with different
symptoms, or cven different other mechanienl signs, from pa
lient to patient. In nddition. thc OfJfUlI'l'lIlly salllc mechanical
sign may respond differently to identical movement and/or
pusitioning stimuli rrom p"llicn! to ""tien!.

---------------------------

OrtilUdox \".:rsu:'\ Alh:rni.ltin~ i-ic~lilil C:.tft: Signs

In onhodox medicil1\.'. the rm:us on signs and the a priori as-

sumptions of a patho:lIlatomic lllod(:1 is the n.:sult of. or leads

to. an inability or unwillingness ,10 r;,uion<tlly apprcci;l1c Spill\,>
related symptomatology. Thi~ same i.lpproach taken ~y Ihe socalled ":i1tcmmivcs" to onhodox medicine entails the lise of
'ahcrn;.nin:' signs. which also avoids the recognition of

symptoms . IS meaningful. In this regard. no alternative is n::-

I
t

.r",
-~-

,
,
!

Subjective Symptoms As Potentially Valid Criteria

I
I

I
I

I
,
N

I,
{I'

;;

Symploms are an impon3nt key to the puzzle of spinal complaints. Signs and symptoms are important diagnostic components in most health care specialties. Unfol1unately. when the
specialty concerns common spinal complaints. symptoms arc
usually denigrated to the status of epiphenomena. principally
because of the confusion that has resulted from the inability
to appreciate rationally the symptomatic responses to spinal
IO<lding stimuli.
Because health care disciplines have been unable lo make
sense of spine-related symptoms. these symptoms hilVC been
relegaled to the realm of nonsense. This lack of appreciation
nol only denies patiems a certain dignity and respect (the absence of a concerncd audience regarding their symptomatic
story). bUl it also denies health care practitioners the clinical
utility of that story.

Subjective Symptoms Alone Are Not Adequate Criteria

(J

I~

ally being offered.

Alternative approaches. often described ;Is "holistic:' frequently m<lkc the a priori claim to "treat callses not symptoms:' This predilection often Icads the paticOl and practitioner to a/lL'rl/ati\'(! signs so removed from tile phenomena ;.11
hand that both common signs and symptoms related [Q the patient's complaints arc ignored. The signs sought may be so removed from the patient's complnint5 that they better resemble
signs of "divination" (omens. portents. etc.' than <lny serious.
rational diagnostic endeavor. C01ll1l10n. mundane signs and
symptoms are ignored in the search for the miraculQus.
The <lhernaiivc health care complaim that symptoms
themselves cannot be treated is appreciated as a valid objection to the pharmacologic suppression of symptoms via i.lllalgcsics as a mcans of therapy. This concern. however. do.:s not
justify the total rejection of appraising symptoms as relevant
phenomenn.

$,,-,

As with mechanical signs. symptoms taken by themselves do

not account adequately for the clinical presentation of spine
rclaled complnints. Both the symptomatic (llId the mechanical
responses 1O spinal loading must be considered to best appreciate common spinal disorders.
Responses of Mechanical Signs nnd Subjective Symptoms
10 LO~lding As Criteria
Thc ML:Kt;J1zic .approach i\ <l system ()f assessment :lnd thcmpeUlits based on thc recognition of patterns concerning thc

Illcl'hanic!l and SYlllPIOJ1l~llic responscs to the !'timuli of

loading (applying forces lO) the spinc. This rccognition is
dcrin:d from historical information relal~d by thc paticnt
as wcll as clinical limlings that comparc mechanical .l1ld
symptomatic rcspunscs hd'orc. during. <llld after (I' singul~,r l11\l\-("lllc:lItS. (2) rcpcliti\'e llHl\'l,.ll1Cnts. and (31 sustaincd
positiuning:..
C01l1mon Connccling Critcria
Spine-relatcd complaims ;'\llli thc means for their resolution
become intimatcly conncl:tcd at c<lch slagc of the McKcn;o.ic
approach because of lhc l'OI1l11101l cOllllecting criteria. which
is the mechanical and symptomatic response to loading strategies. These criteria. on which the 'Ipproach is predicated. provide a rdtiollal (hread conncc1'1ng:
Compl<lints

Assessment
Therapeutic prescription
Monitoring the course of therapy

Prophylaxis
SPINAL LOADING
Spinal loading refcrs to the administration of a force lo the
spine. No matter what position the spine is in. at least the
force of gravity is IO;'lding the spine in thal position and imer/l(// Iorn'J (within [he disk) arc at play. Allhaugh it is understood that the 1I111001i/ed spine refers to the reclined position. it can also be viewed as a differel/r kind of loading.
Unloading thc spine. as il is cOlllmonly understood. may diminish external axial forces to a motor segmcnt while in~
creasing internal forces as a result of the inhibition of fluid.
These distinctions may havc some impon;.mcc considering
the con\'entioni~1 <l priori notion that any wllo(ld~f1g action is
of bcnefit to the spine. This is not necessarily true. For example. for a signillc'lIlt number of pnticnts. low back and leg
p;lin is worse in the morning.. and others respond poorly to
traction.

Loading can be viewed as a mechanical stimulu~ to which

mechanical and symptomatic rcsponses occur. Loading may
be considered the independent variable. with the resulting mcchanical and symptomatic responses the dependent
v;lriables.

LOADING TACTICS
l.oading tactics refer to individu<llioading stimuli. procedures
or methods that ,Ire components contributing to an overall

loading strategy. They include the following:

Dynamic loading
Static loading
Lmlding intensity
- Loading frequency
- Loading :lInplitudc (o\'crprcsslIn.:. mobilization. maniplll<Jlion)
Loading within ;1 ~pccilic JIlovcmenl plane direction
Loading within a specific range of a movement plane
Loading at a ~pcd(jc.:: point of a movement plane

l-':::...----~----------------------------------------------

,'il
f

Lll;l\lifl!; p\)sturc
Loadinl! SOlJn:~ \S\l\lrI;C \ll" h)r~c)
- l)alicnt~(,llaal('t1lacli ...:,
- P,lIicnt ;I:'C of :Ippliancc or Ill;u.:hill~
- Clinicia!l.!.!l~ll('rall.'d t:lI.:tirs
_ Clinician ~Sl' uf tool, 'lppli:llICC. or lll;lChtlll'

l)ymll1lic I,oading
This term rl.'rt:rs In ;1 sySh.:m of I1.H\:CS IHl th~ spinc ;f!
or 111ulcr~\)illg II/OI('IIU'/Il. under spL"cilk l"lluLiitions.

I1/(lT;OI/,

Static Lnadinl!

Static loading refers to a syst~1ll or forcc.s 0[\ the Spill~ at r~st.

or during positioJ/ing. ullder speLilic conditions. St:.Hit.= loading or th(' .,pint.: ill a specilic rmsitioll for a prolonged pcriod
or til1lt.: may h~ referred lO as ,'iIf.wui/f('d !'m;r;rl/l;"g.

thoughl to bring spinal joint structures beyond voluntary end

r;lIlge. to\\''lrd physiologic end r;.Ingc. M'lIliplilatie:~ is (hought
to bring spinal joint structurcs beyond physiologic end range.
just shon of anatomic end rangc,
For th~ McKcnzie approach. the mcchanical and symptomatic responses 10 overpressure .md/or mobilization arc
carefully lloted ill order 10 predict wh:.n the mechanical and
sympwm;Jti, responses would be to m:.lnipulation. In other
words. tltt', responses to 10~l(.ling at physiologk enu rallge
scrve ;IS a criteri;:l 011 which to predicate loading toward
anatomic end range. Only thcmpcutieally beneficial r~
SPOI1SCS noted with the former permit perfoffilancc or the
lallcr. Complete rccovery by IllC;lIlS of the former obviates thc latter. Manipulation is appropriate when loading of
lesser intensity evidences bencficial responses that are not
complcte.

Loading \Vithin a Specific Movement Plane Direction

Loading Intensity

Intcnsity is ddincd as tensioll. activity. or energy. Curiously.

the woro intensity i:-: derived. in pan. from the Latin vcrb. lCUdere. to strctch. Illle/Isity rekrs to the frequency al1~lIor the
amplitude accomp'lllyillg loading. To incrca~c thc intensity of
lo'lding. thc frequency and/or thc amplitude can be increased.
LOADING FREOUENCY

Loading frequency refers to the number of loadings pcI' unit

time (cycles). In dynamic loading. 10'lding frequency refers (0
the number of movements performed per unit time. In static
loading. loading frequency refers to sustained positioning per
unit time.
LOADING AMPLITUDE (OVERPRESSURE. MOBILIZATION.
MANIPULATION)

Loading amplitude refers to the :.unOllllt of force applied during c;,\ch cycle. For the purpose of thl': McKenzie appro'leh.
loading <.lInplillldt.: usually refers tn the amOUlll of force applied to promote movement of the.: spine toward a morc COII/
plete end range position. This movement is accomplishe.:d by
the application of overpressure or In:'lllipulation.
Overpressure applied during dynamic loading permits
further mOVCntcm into cnd range with cvery cycle. Ovcrpres.
sure applied during statk loading. :1( end range pcrmits posi~
tioning even further into that end range. It may bc accomplished strategically by the patient's <m'n means or with the
usc of a device or .111 appliance. It 111<11' ;,liso be <.K'Complished
by the application of a force by the clinician. using a "hands
on" wchniquc. with or without. alollc or in combin'Hion wilh
a device or appliancc. Whcn the clinician's hands perform the
overpressure in ;1 cyclic ,fashion. this practice is called mob;lizatioll, The chiropractic concept of "taking the sl;lck out"
corrc~ponds to moving a joint to end range. Th~ cyclic performancc of this movement is mobilization,
The greatest I(lading amplitude i~ applied by means
of spinal l1Jatlipnllllioll. Ovcrprt.::'surc :lIIU mobilization arc

Movement planes arc derived from dimensions in space.

'1

.r

Movement planes contain two opposite potential direction" in

which loading can occur. referred to as I/I(}\'cmem I'lmu'
l!irc(ticm.'i.
SAGITTAL MOVEMENT PLANE

in this plane. also called the anterior-postcrior movement

plane. movement occurs about the coronal axis. The opposite
movement plane directions arc referred to as nexion an::! ::;-~

tension.
Special featurcs regarding this movemcnt planc an: noted
for lhe cervical spine. Protrusion of the hC<ld in the :-.agiual
plane involves extension ot the u 'r cerVical s IIlC .lIlil n~x
ion of the lower cervical s inc. Retraction of the head in the
s<.lgiual plane involves Ocxion of the tipper cervic<ll spine and
extension of the lower cervical ~pinsJIllese movement::. may
be referred to as trall,~/athm througli the sagittal plane.
TRANSVERSE MOVEMENT PLANE

.J

Movcment occurs about thc longitudinal axis. The oppo:,ite

movcment plane directions within this pl<lIlC arc rcfcm:d to as
rotation right and rotation left.
CORONAL MOVEMENT PLANE

III Ihis pi<Jlle, also called the frontal or lateral n)(,w~ll\el1t

plilllC. movemcnt occurs .Ibout the :-:agittal axis. The l1ppo:-.itc
movcment plane directions used by the McKenzie appfll<lch
within the coronal movement plane arc different for lh~ t:crvical and lumbar spinc.
the cervicnl spine. right lateral
Ilexion and left lateral flexion arc noted. For the lumbar ~pinc.
right and left side-gliding arc noted.
Side-glid;lIK refers to a superior anatomic pal1 l1W\'illg
through (he coronal plane in the opposite direction rdatiyc to
an inferior un atomic part. It also refers to the lrunk lllo\'ing in
the relative opposite direction. through the coronal plane.
above lhe pelvis. This movement ITl~~Y ~~ referred to a~ trall.\'
lo{;oll through the coronal plane.

ror

-?

,.J

.. _ .......

,~ ..... v

.......,,;)

VI"\.:lC:V VI" H.t:~I""'UN::;e::;

P\I.. itilllling within this llH1VCl1lCllI planc results inlhe clink'"l I'rc"'I..'nt"lioll of Ill... ..t1Halgic Ii:,!." This <llllalgil.." deforllIit~. CI\ll:'liIUiing ~lll anile hunb'lf ...co!iosis. is a fC"'UIt of
Iran .. l;llioll through tht' ('oronal plant'. The :lntalgic li:-;.t is rcfl'rr...d hi :I" ;J letkntl shU/. and is nam....d ;tcI,:ording 11\ lh~ dir...clil'll I righl lll" kfll by which the supcrior an;l\omi( p;1I1 is

pll"iliPlh:d rclatin: till' inferior anatomic P:II1.

Luading Within .1 Spl'l'ilic Range of:.l rVlo\'cl11cnt Plane

.----;..

Whl'll dynamic IO;lding {1l:<:urS.il Illay involve movemcnt to

end ral1~c or only W wilhin mid-range of a movcment plane.
Dlirill~ dyn:lmit: loading. e;l<:h poim in the mlWClllclH plane
has a "dirct.:tional ('(lIllP(lllClll" defined by the int\}lidcd 1110VCIllCIlI pl<llle direclioll.
Luading at a Specific Puinl of a l'-'lo\'cment Phmc
Sll~ledJ~.01~~lillg.-(,,(;,\(iG-loading-) may- be at

end r;lngc;.

Susl~lincd po~itioning

mid-r.mgc or
in midrangc may have a di-

rccti(ln~J!

compollcnt n:I;ltive to :I previously assullled suslaillc;o positioning. S{~lli( loading al end range is usually referred to ;;IS h~l\'ing lh~ 1I1()\'Clllcnl plane direction of which.
that end range is the culmination.
Loading Poslure
Thi~

term refer:>: to thc oricnt~l1ioll of the body (~landing. sitting. t.:tc.).

Consider lhe ccrvic,ll spine lo.u.lcd in the movement plane
dircction of eXlension. The patient J11~IY be stmlding. sitting
erccl. siuing slouched. lying prone. or lying supinc with the
head and neck off the end of a lr~<IlIl1Cm lable-all examples
of different W;lyS to position lhe body (loading postures)
while extcnding the cen'ical spine.
LO~lding

Source (Source of Force)

Loadmg tactll.:~ ma\' bt: gCllclatcd or modified by patients

themselves. appliances or machincs. as well as by lhe clinician's intervcntion. Certain npplianccs or machines ~lrc rC~ld
ily used by patients themselvcs. whereas other dcviccs (because of expense. mechanics. or expertise required) may bc
used only in a clinical setting.

IV LUADING

229

PATIENT USE OF APPLIANCE OR MACHINE

V,lriOUS devices lhal affccl spinal loading and do not require

tht:" assistance of the clinician or presence in the clinical setting :.Ire 'Ivailable to p.ltiel1ts. These appliances range from
maUrc;ss and dl.lir lypes to br<tccs. traction d~\'iccs. and cxcrc.::i",t:' ~quipmcnL
ClINICIANGENERATED TACTICS

Force introduced by lhe clinician may be combined with.

or aran from. pmicnl ..gcncratcd forces. Clinician~il1troduced
r(lfL";.. ... r;mgc from mobilization to manipulation. Mobilization
Ita:o; becn characterized as forces that do not bring joint struclUrt~ beyond physiologic end range. whereas manipulation
has b~cn characterized as bringing joint structures beyond
physiologic end range. but short of anatomic cnd range.

CLINICIAN USE OF TOOL, APPLIANCE. OR MACHINE

This category includes certain appliances or machines unavailable to patients because of expense. mechanics involved.
or thc need of a c1inician's expertise. Examples include sophisticated traction units. "drop tables" that enhance manipuI,Hive procedures. treatment tables permitting various spinal
positionings. and continuous passive motion units designed
for the spine (Fig. 12.1). Surgical interv~mion is certainly a
ITlcc!mnical illlcrvention lhat reprcsents a loading tactic.
I'REFERRED LOADING STRATEGY

Str<Hegy refers 10 a plan dc\ised to auain :1 goal. Loading

strategy refers to the choice or rejection of panicular loading
lactics and lhe order in which those chosen loading tactics arc
employed. A pnferred loadillg strategy is fr~l11cd by deciding
which:
Loading taclics 10 avuid
Loading taclics In purslle Sill111It'IllCOllsly
Loading tactics III pun;uc st:ttu~llli<llly
- Immcdi<.lIC ~CqUCllCC

- Delayed sequl'ncc: introdllctitm of prcviously avoided loading

t;sctic

PATIENTGENERATED TACTICS

I-t
~

t.;..}

t%
l
-lJ

!:>'

MovcmClHs or position:-;. may be accomplished by patients

themselves. Patients may perform movements activcly by recruiling muscular struclures that specifically move or maintain posilions of spinal joint structurcs cQnccrned. They arc
also able to stralcgically perform "passive" movements of lhe
spine. For example. palients Illay rotate the cervical spine by
using the pressure of the hand against the check without recnliling the intrinsic neck musculature. Similarly. passive cxtension of the low back may be accomplished by performing
;1 "press-up" from the prone position with the pelvis remaining on lhe cxercise surf'K:c. lhus recruiling only elbow cxtcn~
SOfS and not lhe extcnsors of Ihe b;lCk.

Fig. 12.1. McKenzie Repex (Repeated End range Passive

Exercise) unit.

::;;--'..:.~-;-----.,-------------------------------------------------~

LvV

"" ,

,n.'

dt:t:m~d

Fig. 12.2. Right lateral

shift as a resull of clinician
overpressure during right
side-gliding.

Tactics to Avoid

Specific loading tactics

therapeutically detrimemal

arc to be avoided as comaitucnts of the preferred loading

strategy. The practitioner Illuq lake into ;lccount the effccts of
avoiding specilic IO;'lding taclics ;'IS much as he or she considers the effects of pursuing spccific loading tactics. Avoidance
can be of equal. if nol greater. illlpol1ancc in resolving an
individu;I1's spinc-rdah.:d complaints than which tactics 10
pursue.
Tactics to Pursue Simultaneously

The preferred loading slr.ueg)' always involves the simultaneous performance of loading tactics: for example. it may concurrently load the cervical spine dynamically. in the movement plane direction of extension. while sitting. with
ovcrpres~lIrc. and a CCI1<1in frequcncy of rcpetition.

Tactics to Pursue Sequentially

.--~

, 7

Loading tactics applied one afler the mher.

IMMEDIATE SEOUENCE

This term refers to loading tactics applied immediately.

onc after the other. c.g., loading the cervical spine in the
movement plane direction of left lateral flexion. immediately
followed by loading in the movement plane direction of
extension.
DELAYED SEOUENCE

This term is used to describe the application of loading tactics

separated by a significant length of time. h usually refers to
the timely re-introduction of previously avoided loading tactics. Loading tactics once considered therpcut;cally detrimental. may. after the appropriate delay. prove to be of significant therapeutic benefic For example. on Day l. it is
detemlined lhat right side-gliding (Fig. 12.2) is the most (hcr~
apeutically beneficial movement plane dircction for the IUI11bar spine. and loading in all other movement plane directions
is considered detrimental. On Day 2. it is detennined that the
previously avoided loading tactic of extension is now ther:.!peutically beneficial. and in fact. necessary for fUrlher resolution of complaints. On Day 5. it is determined lhat the previously avoided loading tactic of flexion is of benefit for the
patient so that full function may be recovered.
PROPERTIES COMMON TO MECHANICAL AND
SYMPTOMATIC RESPONSES TO LOADING
Although mechanical \~ersus symptomatic responses to loading have unique features or perspectives, they have certain
common response properties or parameters. described here <IS
response value. response temporal factors. poim of response
elicitation. movemellt plane-specific respOfl.'ies. and m(~cl/{lIli
(:ally impeded end range.

Response Value
Mechanical and symptomatic responses may be considered
the S:'lIllC. better. or worse after:J particular loading strategy is
pursued. Considering before and after possiblities. responses
may be:
Nonnal before and remain nomlal afterwards
Nonnal before and remain abnormal aftcrw<lrds
Abnonnal befoTC and remains abnormal aftcrwurds with
Equal magnitude
Greater magnitude
Lesser magnitude
Abnonnal before and remains normal afterwards

Response Temporal Faclors

factors include frequency (~r camp/aims. timc required
to dicit a respm,...e. ::md n...tpmJs( persi.wem.:' a}[cr loading
ce.t.'latioll.

11lCSC

FREOUENCY OF COMPLAINTS (RESPONSES)

)

The frequency with which mcchanical or sympwl11;,uic rcsponses to loading occur during a specified time: paiod milY
be charnctcrizcd as OIlC of the following:
Tot;'11 absence of the response (no complaints)
Intermittent frequency of the response (intermitt~llt COIllpl:.linls)
Constant frequency of the response (constant complaints).
A plltien( may have no symptoms. experience symplOllls intermittcntly. or experience symptoms constantly during a
spccillcd period of time. Similarly. a patient may hayc no restrictcd r.mges of motion. experience a restricted i.mgc of motion intermittently. or experience :1 restricted r<lnge
motion
constantly during <l specified period of time.

or

,--J

CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING

TIME REOUIRED TO ELICIT A RESPONSE

Thi~ p;lraHh~lcr

n..f.:r.' 1(1 th~ lHlmh.:r or duwtion of dyn:llllic Of

st;ui,: IO;lding q'<.:k:-- required 10 elicit ;1 mechanical or s)'mp101ll:ltk fl.'SPOllSC as. wdl as the tlday. if ;lIly. for the r,:"ponsc

W OL\:ur aria lo;ulil1:; ((,;lSCS.

Till' I/lIl/Ihcl" (lOom/illg cycles refer.:. 10 the frequency of a

mt)\"I,.'llll,'1ll ~lr susl;lincd positinl1ill~ pl'f unit time: Ihc:,c may
hl' rd:ttin.:ly few (11' m:lll)'. IJllmlifJll r..:krs to the amount of.
timl' a -.u'[;tlncll pll,,,jliulIlng is held. All illIIJ/cdi(l((' I'('SI'0Il,H'

to

d~

n;llnit.: loading or :'\waainctl positioning m:t:urs Oil the ini(If the loading t:ll.:tic. A tlcla.wd rcsprJ11sc occurs some
lilllt.' ;,1'11..'1" loading l:cast."s.
The [;luge or pl.ls.,ibilili~s arc:
tialion

No

rt:"'p\III~l.:

dicil..:d. r...~;lrulcss tlf Ihe numher anUltll' uuralitll1 of

loadin~ l,:ydc.. . ~
RC"'I'0n~ ... didh.:d tlll Illiti;llioll uf h};JdillJ,; eycle (illlllledi;lIC rc-

."plll\'-':'

()

Re~p"n~t:

didtcd after relalively fl'W and/or slu.lfI duration of

cycles
Rc"pnn.. t: eliciled :tlkr rdalivdy l1l:lIlY and/or long duration of
lO:I\..lill~ cycles
Re ...ponw dicItcd aria l.:cSsatioll of l(ladin~ cycle (dcl:l)"ed rcloadill~

slwn"c)
COI1~idcr (h~

following scenarios.
Rc"pollses elicited 011 initiation of the hlading cycle Omll1edi~ltc response). for eX~llnplc. would be the patient who.
during the performance of one dYlwmic extension or on initiating ~tatic extension. expericnces symptoms or dc\'iation
from the intended movement pl.me direction. Another pa
tient's rc"pol1se could be the relief of symptoms .lntl <Ibcrrant
movement.
f{c"pollses dicited after "rcl~lli\'ely few" or "short dura
tion" of loading cycles. for ex~uilple. would be the patients for
whom 10 spinal extensions or .) lninUl\:s of static loading
result in thc onsct or resolution mechanical and symptomatic
rcspon . . c....
Rc\pollses dicill.:d aflcr '"relatively man>,' or "long dur'ltion" of loading cycles. for eX~lI11ple. would be the patients for
whom 50 dynamic ~pin;11 extensions or sustained extension
endr;lI1gc positioning for 30 minutcs is required to expericnce the onset or resolution mechanical and symptomatic
rcspon ...cs.
Responses e1iciled .tfter cessation of lhe loading cycle
(delayed response) are. by definition. responses that oc
cur after the responsible dynamic or static loading stimuli
ceases, Medicolegal bsues arise concerning the meaning
and the credibility of delaycd responses, proportional to the
delay.

231

Responses do not persist afler loading ccss;ltion

RC~POllSCS persis! for a short period 01: time aftcr loading cess3tion
Rl:sponscs remain aner loading cessation

Consider <l patient who has 10\1,.' back symptoms that. at

the end r~ll1g.c of flexioll, radiatc to the calf. If the radiation reM
soh'e~ imlllediately, every time the patit.:l1t returns to lhe neutral st,ll1ding position, this individual experiences a symptom:uic n:spollse that docs not persist.
If calf symptoms remain for a cl'uplc of minutcs afrcr reHlming. from flexion. to Ihe neutral posture, this person has
a response that persisted for a short period of time without
remaining.
A response that persists is evident if dynamic flexion
causes calf symptoms that rcmain for days after flexion loading ceases.
Mechanically. consider a patient with 50 c/c flexion loss.
Dynamic extensions result in a 25% flexion loss. Dynamic
flexion results in a 75% flexion loss. After resting for a momcnt, however, after either dynamic H1Ctic. the 50% flexion
loss returns regardless of the movement plane direction pursucd. These scenarios are examples of mechanical responses
thar did not persist after loading cessation.
If the patient has 0% flexion loss for 30 minutes as a
result of performing to extensions, after which 50% flexiOIl loss returns, this individual offers an example of are
spollse that persists for a short period of time after loading
cessation.
A response that persisls is evident if dynamic extensions
result in 0% flexion loss and rcmains so.

Point of Response Elicitation

Mechanical :mdlor symptomatic rcsponscs may occur as a result of loading at end range or between the two end ranges
(mid*r,lIlgc) of a particular movement pl<llle.

i\:lovcment PlaneSpecific Responses

Loading within ;\ particul~lr movcment plane dircction may
have mechanic<ll and/or symptomatic responses that are
movement plane (or even movement plane direction) .'ipecijic:
spinal loading in onc movement plane direction may affect a
response in the same or another movemenl plane, The possibilities include onc or morc of the following:
No responses within the same or any olhl:r

tlHlVCI1lCill

plane
Responses in lhe sJme lllO....ClllCIl1 plane direction a~ loading
occurcd

Responses in the movemcnt pl;tne direction opposite

RESPONSE PERSISTENCE AFTER LOADING CESSATION

Mechanical and symptomatic responses may demonsrrate a

v;lrying dcgrce of persistence after cessation of the loading
slrategy responsible for generating the responses. The possihilities arc as follows:

10

the load-

ing direction
Rc.o;ponscs in

iI

movcmenl plane differcnt from Ihe lo:uling

lUm'l'-

ment plane

Responses in the s<Une movement plane din.::clion in

which loading occurs arc tina and foremost in the minds

""'"
of most clinicians. The patielll wh<? extends the spine and
experiences a limited. symptomatic end range exhibits a
mechanical and symptomatic rcspom:c in the movement
plane direction of extension. Repeated extensions cause
further extension loss and symptoms. If no other movements afC affected. these responses arc occurring in the
same movement plane direction in which loading
occurred.
Consider (wo cases in which responses occur in the move
menl plane direction opposite (0 the IO<lding direction. Two
patients have flexion limited by 50%. One palient. after performing dynamic extensions, can achieve full flexion. The
other, after pcrfomling dynamic extensions. is unable to perform any ncxion at all. These eascs arc examples of loading
in onc movement plane direction that affects mechanical and
symptomatic responses in the opposite direction of the Same
movement plane.
Responses in a movement plane different from the loading movement are noted in the following example. A patient
with nexion limitcd by 50% due to symptoms c,m achiC"vc full
flexion after performing dynamic right side-gliding. but is in
too much pain to perform any flexion after left sidegliding. In this case. loading within onc movement plane
(coronal) affects the mechanical and symptomatic responses
in an entirely different movement plane (saggital). In fact.
loading in the OPPOSilC dircction of the coronal movement
plane (side gliding) had opposite effects on mechanical and symptomatic responses in the saggit:tl movement
plane.

Mechanically Impeded End Range:

The Mcchanical-SJ'Olptomalic Interface
"Mechanically impeded end range" is a signilicam phI>
nomenon that call be perceived by both the clinician and
the patient. That it is recognized from both perspectives makes mechanically impeded cnd rdnge an "interface:'
in a sense. bctween "objcctive:' clinically assessed mechanical and "subjectively" perceived symptomatic phenomena.
Consider patients who have restricted range of motion.
but no significant discomfort; i.e.. symptoms do not interfere with the progression of movcmcnt. Thesc patients repon
that further movcmcnt is not possible. Not only is this limitation observed clinically. but also. if the clinician attcmpts
to move the spinal area passively. an early cnd range is
detccted by the clinici<ln. It may be stmed thnt further m()~
tion is "mechanically impeded:' This abnormal early end
range resulting in mechanically impeded 1ll0VClllcill is rc
ferred to as a "Ulcc!wl/icalty iUl/Jcd,,(/ end rangc. .. with loss
of global motion of which both thc clinician and thc patient
are aware.
Mechanically impeded end range docs nOI refer 10 motion
palpation of vertcbral scgmcnts wherein the clinician oftcn
detects restrictions or rixations unknown to the palicill. .lIld in
fact. full global range of motion may be present.

REHA~ILlIATlON

OF THE SPINE: A PRACTITIONER'S MANUAL

PROI'ERTIES UNIQUE TO MECHANICAL

RESI'ONSES TO LOADING

I.

Mech:tnical responses or objective signs constitutc c1inic;11

cvidence (signs) pcrcepliblc to the e:<ntnining clinici~n. Th~
signs include observed ;lngul~tion. list. fixed deformities.
rangc of motion phenom~na. and mcchanically impcdetl end
raoge. TIle last tcrm rdcr~ (0 mechanical interference witlllhc
progress vI' lIlotion tv lh.lnnal. full end fange. The signs need
not be associated with symplOI11s.

Normal End Range and Curve Reversal

Curve rcvcrsal rcfers to the ability to movc the spine from the
extreme of one movement plane direction to that of the opposite movement plane direction. Curve revcrsal includes both
the ability to revcrse the "normal" anatomic curves in the
sagittal plane and the ability to introduce curves in the opposite directions of the coronal movement plane.
Flexion in the sagi:tal plane 1"('l'ff.'ieS the cervical lordosis.
increases the thoracic kyphosis. and reverses the lul1lb:~r lordosis. Extension in the sagittal plane increases thc cervical
lordosis. rel'i?r.w.'s the thoracic kyphosis. and increases the
lumbar lordosis.
I-,tcral flexion or side gliding in the coronal plane promotcs a convexity in Ihe direction opposite that of the movemcnt pcrfomled. TI1C "nannal" ncutml spine has no curves in
the coronal plane. These curves ilrc introduced or created
when movement in this plane is performed. Under normal
circumstances. full range of motion from onc extreme of
the coronal movcmenl plane to the other is, accompanied
by the ability to rel'er.H: curves th~lt were introduced by
movemenl and arc 1101 present in a neutral. resling. anatomic
position.
OBSTRUCTION TO CURVE REVERSAL

An obstrm;l;oll 10 oint' rtl\'crsClI i.s a significant mechanically

impeded end range lhal prc\'cllls spinal Illotion frolll progrcssing past the neutral position il1to the opposite movcmcnt
plane direction. Loss of the ability to reverse spinal curves result.s in such clinical conditions as torticollis. acute scoliosis.
and fixed kyphotic or lordotic deformities.
MECHANICALLY IMPEDED END RANGE

Althoul.!h loss of run~c of motion may resull from factors

othcr tl~all ll1ech;lllicali y impeded end mngc. only lhis factor
is considered in this di~cussion.
The degree 10 which curve reversal and normal end range
lllay be accomplished mfc:lulllicafly, when compared before
and after loading. is listed in the order of diminishing succcss:
Reversible cur"..: achic\"ing full. mechanically unimpeded end
range
Rever.-iblc cur\-..: Wilh mcch:ll1ically impetlcd end ran~\.
Ohslrucliul\ {(l ~llr\'c IC\'crsal wilh nleCh;Hlically imp\.'dcd end
range

,.

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UN RESPONSES TO LOADING

A revcrsibh: curve achieving full end rnngc would indicate

that 110 mcchanically impeded end rnngc is presenl. A mech.mic;,llIy imr>l:dcd end mngc may be present. but curve revers,lI is pcnnittt:d nonetheless. i.e.. the progression of movement is mcchanically impeded after curve reversal is
accomplished.
If the progr~ssion of movement is mechanically impeded
before curve re"ersal is accomplished. the result is a substanti .! loss of movement and an eXlremely early mechanically
impeded end range. referred to ns a deformity. antalgia.list, or
shift.

I
!
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111L;nl"'lf'""t:U II

"

.\

ivtoycmcnt Quality
Moyement quality refers to the ability to remain within
the course of Iltt:: intended motion plane direction. It is tlSscsscd as:

.'''''.,

"'-,}
,I' ' )
.~

.~

No t.lc\j"tioll frum movement plane direction

OJ

Value of i\Jlechanical Responses

It is generally considered beneficial to effect mechanical responses to pcnnil curve reversal with a full range of morion.
as well as the ability to accomplish. without devialion. the intendcd movement plane direction.

s')

1
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PROPERTIES UNIQUE TO SYMPTOMATIC

RESPONSES TO LOADING

The symptomatic responses related to spinal disorders

commonly considered amenable to mcchi.1I1ical care arc
pain. paresthe~ias. and' similar symptoms of discomfort.
Other symplOmatic (subjective) phenomena. however. arc
equally impor1anl. Symptomatic (subjective) phenomena
refer to:

.,.~

<y

.'''."

.....)

~.J

Symptoms of discomfort
- {opography of symptol11atic responses (ccnlr<lli~ali(1I1 or
craliz.'llion,
Judgmcllt of fc,lr
Subjectivc perception of mechanically imp'Cdcd end range
- with or withoul symptoms of discomfort at cnd rangc

II ,
<c.

...$

<

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~riph

Symptoms of Discomfort

I
.

-~

These symptoms include pain. numbness. p,ucsthcsias. burning. and the like. They may be experienced during motion
or .It Ihe end range of morion, Not only do the symptoms of
discomfort havc different qualities. but also their location
may change in response to spinal loading. The location or
topography of symptoms is a key feature of the McKclli.ic
approach.

.j

<)
Topography of Symptomatic Responses

, t}

Symptoms may be cenrral, which means they arc experienced

about thc midline of (he spine. Symptoms may be symmetric.

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CENTRALIZATION RESPONSE

In this symptomatic response to loading. lllore peripheral

symptoms diminish or resolve and more ccntml symptoms remain. ;:Ippcar. and/or increase in severity.
PERIPHERALIZATION RESPONSE

This symptomatic r':sponsc to loading. wherehy more peripheral symptoms incrcnse or appear. mayor Ill'l)' not be associatcd with chiJngcs in central symptom::ltology.

Judgment of Fear

_.~

.,...

meaning they arc equally positioned on opposite sides of the

spine. Unilateral symptoms affect one side of the spine only.
The further from the spine symptoms arc experienced. the
more peripheral arc the symptoms, \Vhen the topography of
symptoms ch:lIlgcs in response to loading. they may become
more central or peripheral, referred to a~ the cclltrali:.m;oll J"l'sponse or the per;p!taoliwr;oll rcslumsc. respectively.

Devialion from the intendcd movemcnt plane direction

~.. .-"

233

i ,
'-.j

-,-

Fear of symptoms of discomfort. or fear that they might

worsen if experienced. is also an important li'ubjeclive phenomenon because it may affect an individual's willingness to
pursue a specific loading str"tegy. \Vhen possible. it is import:'lIlt to dislinguish berween nn individual's willingness and the
individu<ll's ability to perform spinal motion,

Subjective Perception of Meclmnicall.y Impeded

End R:mge
Patients often report lhe inability to perform a spin:.il motion
p.ISI :'1 certain point because of a sensc of being "blocked."
They may report thaI. "Something is in there." "It feds like
there is :.I rock or ball in there:' "A wedge is in there:' or the
like. This subjective perception pn:n:nls further movement.
Often. il is the perccplioll of a mech:'1I1ically impeded end
range. wilhOlU any symptoms of disl:omfoI1. that is rcported
by the patienl as the reason for r"ilure of further mo\cment.
The patient's subjective pcrcepliol1 rc~cmblcs what is felt at
the end rangc of norlllaL unrestricted spinal range of motion.
At other times, symptoms of disc(,lml\m occur at lhe sallle
time the subjectivc perception of thc "carly" mechanically
impeded end rang..:: occurs.

Value or Subjective Phenomena Responses

It is tltcmpeutic:'lily bencficial to diminish the subjcclh'c perception of mCc!l<lnil',llIy impeded end range. because the typ
ical result is impn.)\'cd mechanics. II is also therapeulically
bcnclicial to diminish a palient's fear because fear prevents
the resumption of ;\t..tivitics of daily Ih'ing,
It is not alw,lys Iherapeutically belldlcial 10 ;:\Void symptoms of discomfort. however. The Me Kenzie approach puts
into perspective which symptoms ,Ire therapeutically benefi~
cial and which arc thcr<lpeutic,l1ly dctrimental (0 pursue. It is
hcndicial to c1idt the centralizatioll response. even though

!
I,
i\

I
1

the severity of central symptolllS may incrl,?asL::. This mcrease;

is usually followed by improved mechanics .md Ihe ultimate
reduction of central symptoms.
Peripheralization responses ::trc therapeutically detri~
mental if they remain after cessation of the responsible IO<ld~
iog action. (0 special circumsl.l11ces, periphcralization tl1<1t
does not persist after end range loading CC..ISCS is considL::rcLi
beneficial.
The McKcnzie appro:lch dcmonstrales it is therapeutic'llly
beneficial to pursuc cL::rtain symptoms and 10 avoid certain
symptoms. This principle becomes clearer subsequcntly when
the syndrome patterns themselves arc discussed.
Putting symptoms into <l perspective patients and clinicians can understand, rather than fear lmd avoid, provides a
handle by which activity may comrol symptoms. The more
common practice is actively avoiding all symptoms, which
results in symptoms controlling activity.

LOSS OF RANGE OF MOTiON

II

Loss of range of motion plays a considcmblc role in Ihe cV<lI~

uation of impairment and disi.lbility. It is curious. lhcrcfmc.
that the mechanical and symptomatic responscs ass{)ci~
rued with range of motion loss do not ordinarily merit much
attention.
Ostensibly, range of motion loss is an objectively measured, mrchanical entity. Symptoms that the patient cxpcri~
coces with range of motion loss arc recorded. if at all. withoul
discriminating as to whether they occur during motion or <:It
the end range of motion. As stated previously. range of motion loss may not be associated with any significant symptoms. The patient's only subjective experience may be that of
perceiving the abnonnally carly end range. \\o'hich may be perceived in the same manner as the "normal" proprioceplive cue
to halt movement.
Range of motion studies usually have the patient perform
only a single motion in each movement plane direction. The
effe<:ts of repetiLive movemenl or sustained positioning on
range of motion loss in lhe same or in a differenl movcment
plane direction. are rarely a~!\csscd.

I
~
~

"ReasonsH for Loss

Loss of r~Ulge of motion d()e~ not result soldy from mechan . .
ical factors that can be observed clinically or ~olcly from
subjective factors thm can onl)' be reported by the patient.
Understanding range of motion loss requires integrating both
of these perspectives. In slllllmarJ\ wnge of Illotion loss nlU)'
be attributed to symptom:- of discomfort. judgment of fear.
and mechanically impeded end range, which were described
previously. This underlines the imponance of appreciating the
patient's symptomatic experience in order to .H.:count full)' for
mechanical disorders of the spine.
The clinician, howevcr. continues to 1'1..1)' a ke)' role. The
clinical decision regarding the value of symptoms based on
their topography. ,md not just on their intensity_ is critically

. __ .

impurtant. Till'; \\L1~ Ihl.: diuician educates thc P;l\i~lll t1r;lll1~H'"

ically affcl:IS thai p..Hknlsjudgment as LO whcther ur nOI fear
is appropriate. Laslly. regarding mcchanically il1lpeded end
r'lllge. patiL::l1ts oftcn p-:rceivc Ihis carly i,,:lId rangc ;IS "normal"
hecause th~ir subjt.:L'livc perccption (lr tll1.: ill1pclkd t.:11l1 range
may he idcllIicli {(l how "noflll;lF \.lId range feeb. The dinid:m's assessment of lllct.:h'lllk;dly illlpeded r;lIl::c a" ;1 Illl
("hallical sign play~ all import anI ft_lt.' in l!losc l':l~t.' ... ill whk'!l
p:l1iel11s do not realize any motion has heen 10SI at .111.
~IECHANICALLY

".

...

.....

,
;

IMI'EDEIl END RANGE

The lerm f1!e('/ulI/inllly im/)l'dnl n/rl IW1,t:C refers 10 an "Ihnonnally early end range that interfcres with the progress (If
motion and mayor may not hc act.:lllnpanicd hy ~ymplollls.
Patients m"l)' perceive the samc proprioceptivc I.:UCS (10 11:111
Illotion) m lhe mcchanically impedcd end range :1:-. they do :Ii
normal and full end range.
The c1inici:tn and the patielll bOlh. in their own ways. may
perceive lllcchanic:llly impeded end range. Thc patient sllhjcctively perceivc:, <I mechanically impeded cnd range pn:venting fllnher movcmcnl. whilc Ihe clinician may deduce it:'
ex.istence by obscning the manner in whit.:h motion is illl~
peded, or may "feci" it by passively moving thc patient's
spine until the mechanically impeded cnd range is dClect~d.

Increasing Loading Intensit), to Differentiate Restricted

from Obstructcd End RangL'S
If loading of sufficient intensity (cycles or ovcrprcssurd is
not applied, the mechanically impeded end range may be unaccompanied by symptoms. Ov<:rprcssur~ is imponalll ill
order to load joint structur~s funher :\t lhe mechanically impeded end range. thereby "overslating" typical end range rt.'sponses that occur there. The mechanical and symplOmali<.- rt.'sponses to loading mechanically impeded end ranges with ;1
greater intensity differentiate mechanically impeded end
ranges into two types_ res/ric/ed end range ~nd ObslrllCll'd
end ran.f!.('.
RESTRICTED END RANGE

This mech~lI1ically impeded end range behave:-. as if lh~

progress of Illotion is limited. restrained. or "held back," It i:,
slow to develop or resolve, wilh no mechanical or SYI11Plll~
matic responses during motion. Any mechanical respol1:'t.'
(e.g.. dcviation from the intended movemcnt planc direclitm-'
occurs at the restricted end range only. If no symptoms arc rt.ported at the restricted end (;.lnge. incrc'lsing the inlensily I I I
loading at the restricted end range will elicit mechanical and
symptolllatic responses in a characteristic fashion. Celltral tlr
periphcr<ll symploms ;:lre experienced immedialely .Illd only at
the restricted end range. and they do not persisllong after IO;ld~
ing ilt the restricted end rangc ccases. The centralizalion ft.'sponsc never occurs. The pcriphcra1i:t.ation response, whcn il
tiDes occur. tloes nO! persist. Overpressure simply exagger..u\.':,
the symptomatic response at end range. whereas increasing {ll~

,)

CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING

i
i

frequenc)' of restricted cnd range loading docs nol change the

characteristic rc~ponsc. During the initial examination. no

1
~

change in how mechanics or symptoms respond to dyn<ll1li~ or

s(;l{ic loading at the restricted end range is appreciable.

I,

OBSTRUCTED END RANGE

'~

I
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1
i

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I
B
'
~

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I

This mechanically impeded end range behaves as if an "obstacle" or "blockage" is interfering with the progress of motioll. h ma)' oc quick to develop or resolve. Mcchunical :'ll1d
symptomatic responses may occur at any point of the involved movement plane direction. 3$ well 35 at the obstructed
end range. Mechanical andlor symptomatic responses may
develop immediately or aflcr a delay in response to a particular loading strategy. If no symptoms occur at the obstructed
end range. increasing the intensity of the loading will elicit
mcch:.mical and symptomatic responses in a characteristic
fashion.
The centralization response or the pcriphenllization response may be noted durin!! motion or at an obstructed end
r;.lnge. Elicitation of, or changes in. mechanical andlor symp
tomatie responses to loading may persist after cessation of
loading. Overpressure or increased frequency of loading at
the obstructed end range may radically change the mechani
cal and/or symptomatic responses during motion or :It the obstructed end range. Overpressure at the obstructed end mngc
miJY result in Ihe centralizi.ltion response. the pcriphemliz;.Ition response. or the -resoiution of mechanically impeded
end range, or it may cause its occurrence earlier during the
runge of Illotion. During the initial examination. an appreciable change in how mechanics or symptoms respond (Q dynamic or static loading at the obstructed end range is usually
notcd.

235

Assume that with rcpctitin: dynamic loading to the obstructcd end range. every cycle of mOVClllelH results in a
lesser dcgree of mechanic~i1ly impeded end range. i.e .. permining morc and Illore extension range of Illotion with each
cycle of 1ll0WmcnL If discomfort was associmcd with loading:
at the obstruct~d end range. the Giscomfon would occur furlher and funha into the range of motiol\ with cat:h cyl.'1t. as
the stepwise pattern of improvement occurs,
Rcg:mjin& ~lalic 10<lding. assume again thaI the spine is
mechanic'llly im~dcd in extension. Loading is pcrformc:d in
a static manner at the obstructed end range. The patient then
assume." a neutral posture and agnin performs sustained extension at the obstructed end range that is now encountered
after a greater range of motion. With each cycle. any di~co11l
fort at the obstructed end range would occur further and further into the range of motion as the obstructed end r;'\Ilgc
moves along, again in a stepwise paHem,
On occasion. obstructcd end rangcs resolve rapidly
and, almost spontaneously without any special effort
needed. In other cases. an increase of loading intensity (cycles or overpressure) may be necessary. after which [he
obstructed end range rapidly "gives way." The stepwise
pattern just described may nO[ occur if the obstructed end
range "retreats" so rapidly that it appears to "melt away:'
If loading at an obstructed end range causes its rapid retreat,
accompallied by a symptomatic market: the phenomenon may
be construed mistakenly to represent symptoms during me
chanically unimpeded motion. It should be recalled in these
cases. howc\'er. that initial examination revealed a mechanically impeded end range before aggressive loading t;:lctics
were pur~ued.

Differcntiating Obstructed End Rangc Symptoms from

Symptoms During Alotion. Mechanically impeded end

McKENZIE ASSESSMENT OF MECHANICAL AND

SYMPTOMATIC RESPONSES TO LOADING

ranges have been described as exhibiting two differcnt response-s. one lypical of;) restricted end range. lhe other of an
ob!<>tructcd end range. LO<lding at the restricted end rangc
shows no significant change during [he initial examination,
and may show no significant changes for quite some time.
Loading .It an obstrucled end range. on the other hand. ilia)'
demonslrate rapid changes concerning mechanical and symptomatic responses.
Ordinarily, differentiating symptoms during motion from
symptoms at an obstrucled end range is not diftlcult. \Vhen an
obstructed end range resolves rapidly. however. symptoms
occurring at a mcch;.Il1ically impeded end range may be mistakcnly construed as symptoms occurring during motion.
Confusion in this regard may muddle the proper choice of
therapeutic measures.
Assumc a C,ISC in which a mechanically impeded end
r;,ulge interferes with the progression of movement to full extension. Dynamic loading to the mechanically impeded cnd
range of extension resolves the mechanically impeded end
ntngc within a minute or Iwo-a typical response of all obstnlCleu <':l1d range.

The McKcnzi~ npproach is that of assessing the responses.

rc.lctioIlS. or effects of spinal loading. During Ihe inilial
encounter \,"ith the patient. this ~lssessment is performed
by evaluating Ihe history. posture. and quality of mo\'ement
of the patient. and by using dynamic and static testing procedures.

History
In addition to the usual history taken regarding neck and back
compl;'lilllS. the McK~nzie assessment makes particul;;lr inquiries regarding the following:
Arc ")'UlplOm" consl~uu or intcrmiucnl?
What is the t{Jp0gfaphy of symptoms?
Arc symptom" bcucr (lr worse with :Illy of the following?
- Bending
- Silling
- Rising from ~iuing.
- SI;;lI1ding
- Walking

- Lyin,e

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H.t::nI-\CILlII"IIIUl~ u r

1 Me .:::)t-II'H:: !"'l t"'l'"'IAv IlI1Ul\lcn ;:, IVI ..... I'iUKl.

- Rising from lying

- When still
- On the move
Inquiries regarding whether patients arc better or worse with acthj
tic!; of daily living yield clues regarding the loading effects thai
movements :md positionings have Oil mcch:lllical and :i-)'mplo1l1:ltic
responses. Ccrt:lin m:tivitics load Ill\.' spine within the 11l0vcmcnl
plane direction of llcxi(Ul (hcndillJ;. siuingl. whcf\;;\!'- Hlhcr :Ictivitks
have the rdati,'c cffct:1 uf lu;tding. the ~pinc ill the 1I1U\'CIllCIH plane
direction of extensioll (standing).

posture
On initial examination. the patient's sitting and standing postures are noted. This inform<'ltion rcvci.lls how the spine is habitually subjected to static landing by the p.1ticnt. An inquiry
may also be made as (0 what posture the patient assumcs at
home or at work.

Ql!antity and Qualit) of Movement

The patient is usked to perfonn a singk movemcnL fur cach
movement plane direction examined. The cxaminer conccntrates on mcchanics (qu.unity and quality of movement). llot
on symptoms. At Ihis poiIll. the examiner .llso docs nol concentrate on mechanical responses to loading. Quantity and
quality of movcn~ent refers to the ability to achievc end range
with curve revers.l} and without deviating from the intendcd
movemcnt plane.

Fig. 12.4. Cervical flexion.

Fig. 12.5. Cervical retraction.

II

Modifications from typical range or motion studic:, include udding protraction and retraction to Ihe cervical :,pill~
examination and replacing rot.ltion ;.md lateral nexion ,,ilh
side gliding movements to the lumbar spine .cxamination.

CERVICAL SPINE STUDIES

}1

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Fig. 12.3. Cervical protrusion.

Protrusion (Fig. 12.3)

Flexion (Fig. 12.4)

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rc::Vllv,:, OM':'C.U Ut~ Kt:.tit-'UN::)l::S

TO LOADING

237

repetition ()( lILt: S;lllll: 1Il0VClllCnl. Till.: etfcl.:ts of

loadillf 111 a certain 11l0WlllClll plaUl: llircClitlll ;\l'C n:vc;i1cd
hl:st h~ rqlclitioll or sU~lail1cd st;,uic IO;lding, I)yn:llni.., loading or "lHaillcd positioning (sttltiL~ loading) hCltL'r dCll1\lllslrale:- m~.:halli<.:al :md:-~ mptolilatic respOllses to h':lding thall
dtleS (11k' 1ll1l\TIl\Clll (Ir :\ !Ilo111Clll'S positioning_ \\ hi\:h may
give a 1";:1,.. . lirsl illlpre".. j()!1.

;;:-: ..,;- :",:, ,:1..:1'

Fig. 12.6. Cervical extension.

Retraction (Fig. 12.5)

ExtelJsion (Fig. 12.6)

Sidebending ri~lll
Sidt:-bcndin len
Rutation right
Rotation left
LUMBAR SPINE STUDIES

Fig, 12.7. Lumbar flexion.

Flexion (Fig, 12.7)

Extension (Fig. 12.8)
Side-gliding right (sec Fig_ 12.2)
Side-gliding left (Fig. 12.9)

The mon:mCnl plane directions evaluated for both the cer\'ical and lumb'lr spines arc those within which the clinically
prcsellting Cinlalgic postures occur, The movements required
to achieve these antalgic postures arc thought to be or value
f(,lT both assessment and therapeutics of the respective spinal
areas. Complaints. assessment, mtd therapelltics arc. therefore. connected by similar mechanical considerations.

Dynamic and Static TcSl')

Aflcr quantity and quality of Illovcmell( is assessed by the
performance of single movements in each movement phlllc
direction, dynamic and static tcsts arc performed. These tests
load the spine in a morc aggressive manner than the single
n.:pctitions lIscd (0 evaluatc quality of movcmcnt. The paticnl
is monitored closely concerning the mechanical and symptol1l:Jtic responses to dynamic and/or static loading, especially
concerning the most pcripheral symptomatic compl<lints.
The mcch;'lllical and symptomatic responses that occur as
a result or one or two l11o\,cmCIHS may change signiIIG::Hly

Fig. 12.8. Lumbar extension.

" .... ''"' .... , ..... 'f''\''VI~ VI

" , ' - ..... '

,,~ .........

r n .........

llllvl'lc:n~

lVI ..... I'IU ..... L

loading ill tht: 1ll0\'~1l1~1\I plan~ direction of concern ceases.

The usual progression of dynamic tcsts for the cervical .111<.1
lumhar spine follows:

Fig. 1:l.g. Left lateral

shift as a result 01 sidegliding left.

CCITiwl Spine
Fkxioll ~iHill~
Rl"lr.tl"lion ,illin1;
Rl:l 1':1(1inll-lllcll-C:..1CIISitlll ~illillg
Rcir;l(tioll lying. (h~ad off l'Og.c or Ircall11Cll1 t ble) (Fi1;S. 1:!.I 0
:tlllll:!.II)
RctraClitllll:xtcllsiull lying \hl:ad off cLlgc Dr treatment table) (Fig.

12.12 alld 12.13)

II
"

II
I
~n

I1
:~

I
I

Fig. 12.10. Retraction lying.

Dynamic loading in silgittal movement plane directions is

typically explored first. unless the patiem has signific<lnt ant
algia in a coronal movement plane direction, in which case.

the coronal movement plane is explored first. If the patient :lppears amenable (0 therapeutic spinal loading str.ltcgics in the
sagittal movement plane. dynamic or !-Otatic loadings tcsts in
other movement planes afC usually not pursued.
If a clear clinical picture is not revealed. dynamic loading
in the coronal plane is explored, which c"[(iils lateral I1cxion
for testing the cervical spine. and side-gliding movemcnts for
the lumbar spine.
Should loading in the coronal plane not provide s.llisfactory answers. the transverse movement plane is explored. For
the cervical spine. this process entails rotation. whereas for
the lumbar spine. rotation is performed side-lying combined
with flexion. This lumbar movement is typically loaded at cnd
range and is a stntic test.
Static loading tests gcnerally arc used when dynamic tc!-ts
do not provide u clear prcferred loading strategy. As with dynamic testing, the sagittal plane is explored first. Olhcr movcmem planes and static tests arc secondary con~idcr.ltions to
sagittal dynamic testing.

Fig. 12.11. Retraction lying with clinician overpressure.

,J

DYNAMIC TESTS

Dynamic testing proceeds by performing a single mution

within the movement plane direction being studied. followed
by repetitive motion in the same movement plane direction.
The clinician closcly monitors how mcchanics and symptoms
respond during motion. ,il end r,mgc.llld "ftcr the dynamic

Fig. 12.12. Retraction-then-extension lying.

_._---_._----, '_._._----------~-----------

..... n""r

.:ti

I t:M IL : ~I""II'H\L 1Ht:.HA .... t:.U IH.

tiA~ED ON RESPONSES TO LOAD,o,'G

239

if required:
Protrusion :,ining
Retr'H.:ICd :-iJe-b":l\ding ri~ll\ .. ll\il\~ t Fig.12.141
Relr.lclcd :-iJc-hending. 11..'(1 _,inillg
Relracled wlalinn righl Sillill~ ll:i~. 12.1:\ I
Rclr:\ClCd rol:.tliUIl k'fl sillill~

I.umbar Spine
Fk\ion ,1:lllJillJ;

EXICnsi(lll ,I:.mding
Flexion in lying (SUpillC kllL'C \(1 (:hesl) (Fig. I ~.Ifll
E:((cnsiol1 in lying (pnHlc "~kKellzic pn:ss llpl (Fig. 2.17)

if required:
Side.gliding right !\landing or prone extensiun with right );lh;ral
shift (Fig. 12.18)

Fig. 12,15. Retracled rolation right silting.

Side-gliding left st.mding (scc Fig. 12.9) or prone

left I,ltcral ~hift

I,.~xtcn$ioll

wilh

STATIC TESTS

Fig. 12.13. Clinician traction-retraction-extension lying.

Static loading is often used as an of/cillary test 10 cOllllnn dy~

namic testing or to further explore the effects of loading when
dynamic testing yields no definilive conclusion. In panicular.
headaches of cervical origin often require sustaincd static
loading to diagnose or treat the syndrome pattern in\"(;lvcd.
Choices for static testing folio\\'.

Cervical Spine
Protru~ion

Flexion
Retraclion (siuing or supine)
Retr:lclion lhen eXlcl1!'ion (silting. palilc. or supine)
Retracled .. ide-bending right or left
Relracted rotation right or left

Lumbar Spille
Sining sloLJ\:hcd (Fig. 12.19)
Sitting crect (Fig. 12.20)
Slanding \Iouchcd
Standing crecl
Lying prone in extension

Long sitting
Laleral ~hift right or left
Rotation in llcxioll

USE OF OVERPRESSURE
Ovcrpres~urc Illa)'

Fig. 12.14. Retracted side-bending right sitting .

..
i "~y
l

be used in comhination with dynamic

and/or st'-ltic \(';sling. permitting further I,,;nd r.II1gl,,; PI-l:-'ilioning.

REHABILITATION Of' I Ht::: ::iI-'INt::: A. I-'KALi

240

1IIIUI~C.M

,;:)

IV ..... I'IU .... l..

A loading tactic may he L'onsidcred <\ loading stimulus. A

loading stralcgy is considacd the Slim of stimuli. A reSp('~lSe
is iI n:;lClioll to loading stimuli (lactic or strategy). whereas
hdl:lvior rckr~ to the sum of responses.
The lvld\.col.ic <.Ippnl:lch rc(.'ognizcs behavior paHcrns as
syndromes ;uncnahk to tllcch;mi(.'<11 lO;'ldillg strategies.

1
I
t

-,

,\ '-',
.-~

':5:.~.,:

__

~1'r-~';:~~ :.",-:~.~~:~~i~~,
Fig. 12.16. Flexion

i~

!)

lying.

Fig. 12.18. Prone extension with right lateral shift.

l d

Fig. 12.17. Extension;n lying.

Such overpressure may bt: paticnl

craled(Figs.12.21 Lo 12.231.

gcncr~ltcd

or c1inici"lll gen-

,)

Spine.Related Responses Versus Behaviors

A response may be deli ned <lS the reaction elicited by a ~till1
ulus. In the McKenzie approach. the stimulus is mechanical
(spinal loading), and the response is the mcclwnical or symp-

()

tomatic reaction.
The McKenz.ie approach di<"tinguishcs between (ondi
lions thilt demonstrate beneficial response!'> IU mCl.:h;lllicul

loading stimuli and those thaI either do nul respond or demonstrate detrimental responses. !'eedless to say. it Illay not be
fruitful to pursue mechanical therapies in cases thaI show 110
or dctrimenwl responses to Spi;l<t1 IO:lding strategies.
Regarding terminology used to dcsl:fihe mechanical ;.md
symptomatic responses to spinal loading. behavior is often
used interchangeably with responSl'. Behavior. however. is
considered a broad tcrlll used to connote all the lllcch;'lIlic;l1
and symptomatic responses to a pilrticular loading stl':lh.:gy.

Fig. 12.19. Sitting slouched.

-'"''

...... , . , . ~'ll'l""'L.

Int:.HAPt:UTlCS BASED ON RESPONSES TO LOADING

241

or

resrxlHd In the mechanical inllucnce

loading strategics in a
predictable l11allncr. Retrospectively. these conditions arc con.
sidcn..o I1\c(:hanical spinal disorders arter they prove
amcnahk.. to Illcchank'll mel hods. Spinal complaints that do
not rL'spolld Itl. or arc made worse by. the mechanical innu.
I.'IKI.' (II' l(lading strategies arc screened out. including those
ctlllditioll.., that Illay rcprc.:scllt meclwnic:'11 disorder!' not
;1I11cnahlc to IO:lding. ps)'chogcnk' entities. inflamuwtory COI1dititlllS. ur those of e\'CI1 more pernicious ci.lu!'ation. In these
conditions. responses 10 lllcch'l11ic.1l Imlding strategies arc
:.!typical. I:'l(:king. or delrimental.

t,

Fig. 12.20. Sitting erect.

Fig. 12.22. Cervical retraction with cliniCian overpressure.

Fig. 12.21. Cervical relraction with patient overpressure.

THREE SY~DROME PATl"ERNS

Tile clil\ical reasoning illlrinsic to thc McKenzie approach or

g'lllizes mechanical and symptom.Hie responses 10 lo'lding

into three syndromc patterns. These patterns describe :J dis
cn.:tc sel of mcchanic.l1 spinal conditions that respond to loading Slmtcgics in a specific m'lllncr.

Clinical

Rc~..soning

'

and Utility

Tile syndrome pallcrns do not encompass all spin,11 C(}I11pl.dnts :llld conditions.lnll rather dclinc spin:d condilions IIl.1t

Fig. 12.23. Extension in lying with clinician overpressure.

5i

_::.'v::'
.:;;

>(>~"'~/,ill'~'i>J~~~"''i~~~:.;~,~~>~'MMkI""-,,,"'<=J~''Wi''"\'>:f''''''~JWi>'''''''!.';\W'';;'''~:'',WJ,'>'i"'"'J'>'''''''~'iJ'''ij~~\'l'<~~1,,*,,\~,'''.'~M"",\\:U4,\'","".,".,!-\,~<>,"t""'">"",'"""",\,.I.,,

"~'I,\

"""""'"'''''''''~~''~'''''V'''''''~'''''''''''''''''''''''' """ . . ""...,,.. .,

".,,;"~_.:.. 1:=,e<~'\>"""':

Table 12.1 Summary 01 the Three Syndrome Palterns

Rate or
Syndromo
Rosolution

Responses
During
Molion

Ocl3yod onsel
oller SVSllllllOC
olld fnnQO po.
Si!ionillg

None

Weeks

No",

Sympl~tic

Nono ollisl

Movement pl3flC
dJ/celion
spocllie

AVol(j symptoms

Igr,l/oflCo, IntlQvo, solfconscious

RCSlriele<! cnd
rango

'mmcdjlllO O. resl~ted end

/3ngo

Nono

Mon!l,s

Non"

Nonc

McchnnleiJl and
symplomatie

Movemenl pl3nc
dircctiOo spt!
eirlC

Pvrsuo symploms

Avoiding SyrTlptoms

Dvriog motiol'\.
obslructed or
unobslrueted
end rllngo

Imm~3toor

Olien persisls

Days

Yo.

Mcdlflfl!eltl and
symptomatic

MecMnical and
symplom:t\iC

ton<f<O!J In ono
movement
plano dirC!Clion

Pursvo ccnlrllfizo
lion. avoid poriptloraTiz:tlion

Avoiding symproms of ccntrlllizalion

Frequency or
Complaints
(Responses)

Point of
Response
Elicitation

Rale 01
Response
Elicilalion

Postural

Symplomatic only

InlormlUenl

Suslninod ond
rango

Dy!>!unclion

$ymplomatic and
m"ehllnic,1!

Ifllorm,tlcnl

Oerangomcnl

SymplQrnilliC nnd
mceh3nical

tnlcrmitltmt or
Coo!>t3n!

t:::: "'"

,',"

'~

,~.~)

(foI3YOcl. dvring motiOn. 01

obSli'\Jcte<lor
ullOb$l:ucled
cnd rango

...4

'V

Responses at
Mechanically
unimpoded
End Range

Responses at
Mec!'lanieally
Impeded End

Movemont
Plane
Specific
Rosponses

Rosponse
Persistence affer
loading
CCssolion

Mechanical or
Symptomatic
Aesponses

Rango

Preferred
Loading

Aoasons lor
Potient
Falluro

Strategios

may affect un-

othcr

/'

<"Mf!

;'

WH'

;",;)

...J

,,)

'""

",,,,,j'

,;

,,.,

."'

...... " ... ,

I .... ' .

'<:'

uf'

P,ltho;lna(UlIli<:

.~

' ..

...
~

I,

,,

..

I
~

Ii

-,
)

nCt1f\t"'t:U 11l.,,0 tjAot:U UN

S~'IHlnlll1C

Ht::~I-'t>NSES TO

NOl11cllcbturc

Till.' syndnlllll' p;llll'rns ar~ idl'IHilkd by l'l.'(ognizillg groupings or Gltl.'goril'~ \If lll~l.:hanical ,\ltd symptom,nil.: r~spons~s
10 loading. 111\1 lh~ p;lthO,Ill;IWlIlic hasis ror Ih~lH. NOHI.'tlJl..'kss. the sYllJnlm~s Il;Iv~ bl.'~11 lI:tllll:d al.l.:ordillg 10 the hypoti1l.'si/.~t.I p:lllh1;Ul'ltmni..: ba:,i", fpr their hdl:l\"iors. While
IhL'sC hypothL'sc, aI'\,.' lhe McKl.'ll/,ic s)'sll.:ln's "ilL'sl gut:s:-::' it
j", imp0rlalll (0 rl'memher t\V(1 ",,\lient points regarding the
Il;Ithoall;llomil lith.':-, for these syndromcs. Thc lirst is lh'1I lhe
'yndromc:-: arl.' gnHlp~d ;u.:nm.ling 10 responses and I/O(
p;uho;lI1aloI1lY. If resc.m;h provcs the rvkKcllzie palhonnawmic hypotheses aroncolls. the ohserved grouping or rt:spollses will remain as empiric f'lel. Thc. l<;cc:ond point is lhat
the p.lthoanatol11ic.: litles of the syndromes help the clinician
remcmber the conligllntliol1 of complaints so named. It also
helps hoth thc clinician ,111d the p..uient to remember the rules
~urrounding trcaimcll( of the ~yndrol11es.
Bcc:allsc tht: ulility of the syslem rests in its ability to 01'g~nizc. dassify. and predict associated mechanical <Ind symptommie responses to loading strategies, il may be granted that
the pathoamuomic c:oncillsions arc as If conclusions.
The pathoanalomic titles for lhe syndromes are tJ1C poswral. dysfunction. and derangement syndromes. These syndromc p;Hterns .HC summarized in Table 12.1.

Postural Syndrome

II

Symptomatic responses characterize this syndrome. No mechanical response.. :Ire noted.

<")

I
I
I

P.S. POINT OF RESPONSE ELICITATION

RCSPOllSt;S an; elicited .It :I Illechanic<llly unimpeded end
rmlge. llsllally in onc movcmcnt plane direction only.

P.S. RATE OF RESPONSE ELICITATION

This syndrome exhibits delayed onset of symptoms in response 10 sustained slatic loading at end range. Sustaincd positioning at end mnge l1Iust be assumed for a relatively long
period of lime (c.g., 20 minutes) before symptoms arc
elicited. The delayed onset of symptoms in response to sus~
tained slatic loading may 110t be evidenl during the initial CX~
aminatiol1 becausc of fOlilure to provide adequate static load
ing time for the delayed onset response to occur.

.,

l'
"~
.~;

P.S. RESPONSE PERSISTENCE AFTER LOADING CESSATION

\~)

-U

I
"{j

i
t:

}
t

243

P.S. RATE OF SYNDROME RESOLUTION

The charnCltristic responses of the Postural Syndrome may

take weeks 1(1 ch.\nge with propcr therapy. This period of time
may be rcquir~d before it is possible to sustain positioning at
the L'llipahl~ end range <lbsent a symptomatic response.
Changes in tht: cnd-r.lnge sYlnptomatic respollse. ch<lracterisIk of this ...yndromc, cannot be accomplished during the initial evaluation.
P.S. RESPONSES DURING MOTION

Curve rc\'cr~1 and the abilily to achieve mechanically unimpeded end range without de"i<ltion from the intended movement pl'lllc direction arc fully preserved. No symptoms occur
during motion. The centralization or peripheralization responses are never noted during motion.
P.S. RESPO"lSES AT MECHANICALLY UNIMPEDED
END RANGES

There is no deviation from the intcnded moveme.nt plane directions. The symptomatic responses occur only after sustained loading at lhc culpable mechanically unimpeded end
range. Ovcr~pressure docs not change symptoms significantly.
Symptoms are central, bilateral, or unilateral. depending on
the nature of the sustained end range positioning. The centralization or pcripherali7.3tion responses are never noted.
Responses that do occur do not persist ancr loading ceascs.

<"

.~

P.S. RESPONSES AT MECHANICALLY IMPEDED END RANGES

Mechanically impedcd end ranges do not exist in the Postural

Syndrome.

P.S. FREQUENCY OF RESPONSES (COMPLAINTS)

The frequency of responses is ilHcrmittcnL

",,",_-7

LOADING

P.S. MECHANICAL AND SYMPTOMATIC RESPONSES

C)

I,

""""L

Symptomatic responses elicited aftcr sustained static loading

at end range resolve once that loading taclic is terminated.
This bclmvior is typical of the Postural Syndrome and contributes 10 the intermittent nature of complaints.

P.S. MOVEMENT PLANE-SPECIFIC RESPONSES

Loading in the symptQIll<ltic m\,Jvemcnt plane direction does

not result in mechanical or symptomatic responses within the
opposite or \~ ithin 'other movement plane directions. Loading
in the oppo~itt: direction of the symptomatic movement plane
direction, or in :Inother movement plane. does not direc!ly of
fecI the mechanical or symptomatic responses of the symptol1l<ltic movement plane direction.
Avoiding loading at thc symptomatic end range is Iherapeutic in and of itself. Loading in <111 other movement plane
directions is equally therapeutic, inasmuch as they all :I\'oid
thc symptomatic end range, although they have no direct therapeutic bencflL
P.S. PREFERRED LOADING STRATEGY

In the Postural Syndrome, avoiding the symptomatic end

range is of paramount importance. Pursuing symptoms at the
culpable cnd range is detrimental. Whcn the symptomatic cnd
range is avoided over a period of time. symptoms at end range
are morc difficult to elicit, and cventually the PoslUral
Syndrome re~olvcs. Whcn static loading at the symplomatic
end range is frequently pursued, it rC!T~!uatcs the syndrome

.. __

and may diminish the delay regarding elicitation of symp

toms. Constant vigilance regarding. avoidance of the symp
lomatic end range is rcquired to resolvc (his condition. which
gencrally is accomplishcd ovcr <I period of several weeks.
P.S. REASONS FOR FAILURE OF PATIENT STRATEGIES

\Vhen paticnts do not sliccessfully resolve Ihis syndromc on

their OWI1, it is bCGmsc Illey :.Ire not avoiding thc symptomatic
end range for long cnough periods of time. Postural correction
is required. and the paticnt mUSl be \'igilant to ..\Void the pm;
tural habit that holds the spinal joint al the "offending" end
range. Pntients may feel too awkward or be too concerned
about their appearance if this requires them to maintain <Ill up~
right. ncutnl1. sitting poslllrc. The p;uient may expericnce <I
sense of fatigue in the corrected sitting position. or may ex
pcriencc new discomfort when performing proper sitting pos
turc. The Postural Syndrome is a mechanical problcm for
"which pain or antiinflammatory medication is inapproprinlc
and incffective. It has a specific mechanical correclion-to
(lI'oid the symptomatic end range.
P.S. HYPOTHESIZED PATHOANATOMY

\Vhen joints are held at end range. whether they arc extremity
joints or spinal joints. noncontractile structures such as ligaments and joint capsules arc stressed. An example is the bent
finger illustration. If the index finger is hypcrextcndcd. dis
comfort is experienced almost immediatel~. !f :: ::; hdd just
short of the point of immediate discomfort, discomfort would
be experienced within 20 minutes. No pathologic condition
need exist for this abnormal stress to cause discomfort in <l
nom1al joint. These principles applied to the spine arc pro~
posed as the origin of Postural Syndrome symptoms. which
occur when spinal joints arc held at end range for a prolonged
period of time.
P.S. RELATED TERMINOLOGY

The particular PoslUral Syndrome is named according 10 the

movement plnne" direction of which the offending sustained
position represents the end range. The particular Postural
Syndrome. therefore. is named in referencc to the particular end range at which stntic loading occurs. Somc examples arc: sustained extension. sustained flexion. suswincd
right lateral shift. and/or a combination of movement plane
directions.
Susrailled extension of the lumbosacral spine may bc
experienced during poor standing posture. especinlly in
pregnant patients or lhose with a "beer belly:' In nddilion.
sustained extension of the upper cervical spine is experienced commonly with the poor sitting posture of head
"protraction.
Sustained fJe:(ioll of the lower cervical. thoracic. and lum.
bosac-ral spine commonly occurs with poor. slouched sitting
postures.
A sll.'ilained lateral sllift may bc seen when all weight
re~ts on one leg in a standing position. thereby shifting the

I I ,

'~L..

UMI..

,w,,,,'~

thorax nnd pel\'is in opposite directions wi!!lin !h':

movcment plnnc.

ce~~!l~~1

P.S. SUMMARY INCORPORATING HYPOTHESIZED

PATHOANATOMY

When noncontr.lctilc. lignmclHous. capsular. etc. slrlll.:tures

are held at sustained end r<lnge for long periods of lime.
symplol1ls develop in what is ,I II/edlllllicaffy /llIilllpl'(/ed nor
mal Spinal joim structure subjected to abnormal stresses.
Release of the abnormal stress on these structures is ~lCC()Il1
panied by immediate symptom:uic relief. As this abnormal
stress or static loading at end r.mge occurs with greater frc~
quency and/or duration. discomfort is easier to elicit. The
condition develops slowly. and the pain is intermittent because it is experienccd only when spinal joint structures arc
held at sustained end range for a prolonged period.
Examination reveals no loss of motion or deviation of
movement, i.c.. no abnom1al mechanical responses. In "lddition, no symploms ocqn during movcment or at end fi.ll1ge on
exnmination. To provoke symptoms. the joint must be held at
end range for a prolonged period. Therefore. the traditional
examinmion of patients with "pure" Postur<ll Syndromes r~
veals no objective or subjective findings.
Neverthcless, these patienls may report having had symp
toms in multiple areas of the spine. which occur because of
holding multiple areas at end range. These patients .Irc nm
hysterical. nor are they hypennobile. The best therapeutic i.\\"enue is one of avoiding symptoms (sustained end range) for
a period of time long enough for the offended tissue to extinguish the symptomatic response 10 suslained cndrange
loading.

Dysfunction S)'ndromc

.,

, Jl

Dy.S. MECHANICAL AND SYMPTOMATIC RESPONSES

Symptomatic and mechanical responses characterize (hi:syndrome.

Oy.S. FREQUENCY OF RESPONSES (COMPLAINTS)

Responses arc intermittent.

Dy.S. POINT OF RESPONSE EliCITATION

Responses are elicited al a mcchanically impeded end

of the restrh:lt'd elld range varicty.

raT1g~

Dy.S. RATE OF RESPONSE EliCITATION

The Dysrunction Syndrome exhibits an immcdi:'llc elicitation

of symptOimuic and mechanical responses at the resrrict('d
emf rallge when sufficient loading ovcrpressure is prescnt.

Dy.S. RESPONSE PERSISTENCE AFTER LOADING CESSATION

Mechanical and symptomatic responses elicited immediately

when loading at the restricted end range rcsolve once that
loading lactic is (crmimued. This behavior is typical of lhe

"'-'---~,-----------------------------------

:,J

CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING

Dysfulll:lion Syndrome and contribUlcs to the intcnlliucnl na(un.:. or ('otllp1:linls.

Dy.S. RATE OF SYNDROME RESOLUTION

The

charact~ristic

responses of the Dysfunction Syndrome

245

nnd pcrhnps pennits the mechanically limited end range to becomc marc restricted in the future_ Daily frequent and repetitive motion to the symptomatic end range is required to rcsolve this condition, which generully occurs slowly over 6 to
20 weeks.

may lake as I{lllg as 6 to 20 wceks to resolve. CIWllgCS ill

the lllccilimil:al ;llld symptomatic responses char;Il':lcl'istic of
the syndrome ('annol be m:complishcd during the initial
evaluation.
Dy.S. RESPONSES AT MECHANICALLY IMPEDED END RANGES

Restricted end range usuall), occurs in only one movement

plane direction. If it occurs in morc than one movement plane

direction, n:sponscs ;It the individu<ll restricted end range
have no clTcct on each other. Mechanical and symptomatic responses occur immediately at the restricted end range only.
These responses do ilot persist after loading at the restricted
end range ceases. Any deviation from the intendcd movcment
plane dircction occurs at the restricted end range only.
Restrictcd end range may be accompanied by the subjective
perception of mechanically impeded end range. If discomfort
i.\' /lot pre.fem at the rcstricted end range, overpressure creates
i(, but this discomfort resolves when loading at the restricted
end range ccases. If discornfon is presem at the restricted end
r.mge. overpressure increases it. but again. this increased discomfort resohes when overprcssure at the restricted cnd
range ccases. The centralization response does not occur. If
the periphcraliz<1tion response occurs. it is experienced only
during motions containing a component that achieves the restricted end range of the Oexion movement plane direction.
Typical of the dysfunction pattcrn, symptoms thm pcripheralize do not persist aftcr cessation of loading at the restricted
end r.mge of flexion.
Dy.S. MOVEMENT PLANE-SPECIFIC RESPONSES

Loading in thc symptomatic movement plane direction docs

not result in mcch.mical or symptomatic responses within thc

opposite movement plane direction' or other movement

planes. Conversely. loading in the opposite direction of the
symptomatic movement plane direction. or in another move~
ment plane. has 110 effect on the mechanical or symptomatic
responses in the symptomatic movement plane direction.
Frcquent Sialic or dynamic loading at or to the restricted
end r.inge helps resolve the syndrome over time. Swtic or dynamic loading in the opposite direction of the same movement plane, or in another movcment plane. selVes no thcrapeutic benefit. The only therapeutic action is thal of pursuing
the symptomatic premature end rnnge. All other movements
or positionings arc equally ineffective regarding resolution of
the syndrome.
Dy.S. PREFERRED LOADING STRATEGY

In the DysfLlnction Syndrome. pursuing lhe symptomatic restricted end range is of paramollnt importance. Avoiding the
symptomatic restricted end-range pcrpcLUatcs the syndrome

Dy.S. REASONS FOR FAILURE OF PATIENT STRATEGIES

l\tticl1ls may avoid th..: r~:-.triL:lt;J t:IlU ntllgt= UCt.:"IU:-,t:= ur lh~

discomfort involved as well as the proprioceptive clle of
reaching the limits of motion. In so doing. they avoid "therapeutically beneficial" restricted end-range discomfort and
perpetuate the Dysfunction Syndrome.
Pain or anti-inflammatory medication cannot correct the
mechanical problem underlying lhis syndromc. which requirc.1:; restricted end-range loading for its resolution.
Dy.S. HYPOTHESIZED PATHOANATOMY

As a result of chronic postural habits tha! avoid bringing

spin:ll joint~ to certain end ranges. or as the result of tissue
damage leading to scar fonnation. adaptive shortening or dysfllllctioll of tissue may occur. A loss of elasticity occurs causing restriction of spinal movement. If a perfectly nonnal
elbow is cast in a flexed position for I month. the ability to
extend it is restricted when the cast is removed, nn example of
the dysfunction behaviors just de~cribed.
Scar tissue. which shC'rtens over lime. may fornl at the site
of disk derangement or spinal surg~ry. After significant derangement or surgicnl intervention. an at/herem nerve roof
may develop. exhibiting the typical mechanical and symptomatic responses of the dysfunction syndrome. The ndherent
nerve root condition may involve the peripheraliziltion of
symptoms to an extremity without an associated "centralization response:' This pcripheraliz.uion response occurs at the
restricted end r(l1I~(' of the flexion mo\'ement plane direction
only. Olher special conditions must accompany this endrange flexion to elicit adherent n~f\'C root responses; e.g.,
extended knee for the lumbar spint:' and btend flexion of the
cervical spine combined with $houldt:'r ;:lbtluction. The pe
ripheraliz<1tion response noted with the adherent nerve root
docs not remain after the precipitaling loading actions ccase.
Trc<ltment is ri:lshioned according to the preferred IO<lding Slratcgy for dysfunction: i.e.. t:yoking the discomfort <It
end range. which. in this casco ill\'('\I\'l~s periphcralization of
symptoms.
Dy.S. RELATED TERMINOLOGY

The particular Dysfunction Syndromc is named according to

the movcment plane direction limilt:'d by r('stricted ('11(/ range.
EX:lInples include the following:
Extension dysfunclion
Flexion dysfunction Undudcs "adh~'r~nt nerve rooC')
Righi rot,llioll dysrUnr.:ll011
Len rowliu!l t.Iysrulli,:li~m
Right hl(Cral ncxion dysfunction
Lcft latent I lh:xion t.Iy:,fUtlClioll

.. _

pcd':-l'.:Il'!l<! r...n~~.!..:~. tlwi,,~'

range statil" loading.

Right sidegliding dysfunction

Left side-gliding dysfunction

Typically, rotation and lateral

nCXiOll dysfunctions upply to

the cervical spine. whcr..:as the side-gliding dysfunctions
apply [0 the lumbosacml spine.
Because of the predominance of flexion in the industrial

lifestyle, extension dysfunctions develop cOlllmonly in the

lower cervical spine and lumbosacral

~,

SpillC

by middle age.

Bec.lUse of poor sitling posture, protr<lclion of the head oc-

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motiol1. or during mid-

Dc.S. LOADING TIME REOUIRED TO ELICIT A RESPONSE

The Dcri.l1t~~ll1-.:nt S)'lldrol11~ nlay exhibit illlillediatc clicit:ltion or dclay-.:d onsct of SYlllPI{)l\l:lliL' <lnd I1lcchanical rcspons('s al the obstrw.;h:d cnd rallgt:. ;11 111l.'L'h:lllically ul\impeded end rang.es. during IlltltiOIl. ~lr with midrangt.' :-t~llic
IOi.lding.

curs, which involves extension of the upper cervical spine.

Flexion dysfunction of the upper cervical spine commonly

occurs as a result.
Dy.S. SUMMARY

The cause of the syndrome is shortened. nonclnslic structures

that restrict spinal movemcnt. Rcsolution involves stretching
these structures. The loss of range of motion or deviation
from the imcndcd movement plane direction results from in
clasticity. Avoiding symptom:: only perpctuates the syndromc
and may. in fact. slO\\lly enable it to develop funher by
approximating the ends of structures that arc then pcnnincd
to shorten further. Frequent and repetitive elicitation of
discomfort is required to improve quality of movement
Periphcralizalion to the extfemity occurs only when the
healing process subsequent to disk injury or surgery results in
the tethering of neurologic structures. which limits and is
challengcJ by the movement plane direction of flexion.
Therefore. adherent nerve root is a subcategory of flexion
dysfunction.
For didactic purposes. this syndrome has been described
as displaying syrnptomatic fesponses at a restricted end range
that cease once loading at that end r;;mge ceases. For all in
tents and purposes. this description is truc. To differentiate
this syndrome from the Derangement Syndrome, 11Owever.
one must be cognizant of the possibility of a symptomatic re
sponse that will not cease should overstretching occur. Such
symptom~llology is considered evidence of an inflammatory
response to overstretching and damaging tissue. The potential
inflammatory response to overstretching shortened tissuc
must be kept ill mind to differentialc this contingency from
the constant symptomatic response attributable to mech'lI1ical
factors of the Derangcment Syndrome.

Derangemenl Syndrome
De.S. MECHANICAL AND SYMPTOMATIC RESPONSES

Symptomatic and mechanical responses characterize thc Dc

rangement Syndrome.
De.S. FREQUENCY OF RESPONSES (COMPLAINTS)

Responses may be inlefmittcnt or constant.

De.S. POINT OF RESPONSE ELICITATION

Responses are elicited at mechanically impeded cnd r~ngc(s)

of the obstructed end range variety. al mechanically unim.

De.S. RESPONSE PERSISTENCE AFTER LOADING CESSATION

Responses or bdlaviors dicited as <t rcsult of loading <1t ~111 obstfucted end r'll1ge. at ~I ll1cl:h.ttlic~1I1y unimpeded end r.mgc.
during midrange mOlion, or with midrange st.ltic loading may
remain ~lftcr the IOiHJing tactic responsible is terminatcd. This
persislcllcc i~ lypic.::.11 or the f)('mllgt'lIlt'lIl Symlmll1t' whidl i~
the only syndrome with constant S)'IllPll.llllS. especially those
or pcriphcraliz;.Ition.
Dc.S. RATE OF SYNDROME RESOLUTION

The char;'lctcriMic responses of thc Derangement Syndrome

may changc rapidly and ntdically during the time provided
for the initial cvaluation. Resolution of this syndn.}mc may he
possible within a matter of da)'s.
De.S. RESPONSES DURING MOTION

The obstructcd end range may be significant enough to prevent curve fcvcrsal. An obstructed end range exists in :11 least
onc movement plane direction.md ma)' exist in multiple
movcment plane directions. Deviation from the intended
movement plane direction or symptollls during motion 11\:1)'
be nOled. The centralization or pcriphcraliztltioll responses
may be noted during motion.
De.S. RESPONSES AT MECHANICALLY UNIMPEDED
END RANGES

Deviation from an intended rnOVCJ1lell{ plane direction 'lIld/or

symptoms may occur. Overpressure may change mCl..hanic;,I!
and/or symptomatic behavior. Thc ('entn.i1iz~ltion rc:,pollse
docs not occur: the peripheralization re~ponsc may OCC\lr.
De.s. RESPONSES AT MECHANICALLY IMPEDED END RANGES

Obstructcd end ranges may occur ill ;1 single or in Illulliple movemcnt planc directions. If an obstruClcd end range
occurs in more than one movel1lCJ1[ planc direction. responses at the individual obstructed end range may affect
etlch other. Mechanical and symplOl11Jlic responses may be
elicited immediately or exhibit delayed onset as ~l result
of loading at lhe obstructed end ran~~. Deviation from the
intended movement plane dircction may occur at the obstructed end range as well as at thL' unimpeded cnd range.
Lo'1ding at the obstructed end range may bc accompanied by
the subjrttivc perception of a mechanically impeded end
range.

CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING

..

If discomfon is nor preselll nt the obstructed end range.

create it. and this discomfort may then ex
hibi( it cemf<llizJtion or periphcmli7.alion response. If discomfort is pn.!s(",. overpressure may increase or decrease it. as
wcll as prc::cipita(c a centralization or pcriphemliz:.Itiol1 rc
SpOIlSC. The centralization or pcripherali7..a tion responsl:s may
occur ~ll obstruCh::u end r.11lgcs. Centralizati(lll occurs only in
mOVl.::mcnt ph\l1c directions (during motion or at end r;jnge)
'lhal comain the ""key" obstructed cnd range.
(lvcrpressur~ may

De,S, MOVEMENT PLANE-SPECIFIC RESPONSES

Loading in a symptomatic or asymptomatic movement plane

direction may change mechanical and/or symptomatic re
sponses of the opposite movement plane direction or of <In-

i,

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<

olhcr movcmcnt plane dircclion, Thc,c changc, may bc thcr-

()

apeutically beneficial or dClrimcnwl.

In Ihe Derangement Syndrome, (he therapeutically bene
ficial IO<lding action to pursue involves loading at the "key"
obstructed end range. In other words. iftherc is more than one
obstructed cnd range. loading at onc" obstructeu end range
may be therapeutically beneficial, whereas loading at another
may be therapeutically detrimental or neutral. If there is only
onc obstructed end range. that is the "key." Avoiding therapeutically detrimental obstructed end ranges. moycment
plane directions. or other loading tactics is of paramount importance in resolving this syndrome.
In general. the celltralizarioll response is nnlf'd ~\, n r(',ult
of loading morions toward or static loading at the "key" ob
structed end range. Symptoms generally do not occur during
motion within the movement plane direction that leads to the
"key" obstructed end range. especially after the first few cycles of dynamic loading arc <lccomplished. As discussed previously. a rapidly retreating obstructed end range may mimic
symptoms during motion. when in fact symptoms arc occurring at it rapidly resolving obstructed end range.
The pcripherali;:.atioll response is noted as i.l rcsuh of
loading motions toward or at end ranges that do not cOllwin
thc kcy obstructed. end range. These end ranges may be mcchallicnlly unimpeded or may contain obstructions th.1t arc
not reduced as a result of loading and. in fact. may becomc
worsc.

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De,S, PREFERRED LOADING STRATEGY

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Pursuing and avoiding certain loading tactics. as well as lhe

ordcr in which lhey arc accomplished. is critical in the care of
this syndrome.
In gcncral. symptomatic responses arc pursued if char'lcterized by the centraliz.;uion response and avoided if ch'lraclcrized by the peripheralization response. The "key" obstructed end range is the one that exhibits the centrali7.<ltion
response when pursued. Avoided arc obstructed end mnges.
mechanically unimpeded end ranges. or loading within movement plane directions that evidence the pcriphcraliz<ltion
response. Avoidance of loading tactics that elicit the peripheraJi7.ation rcsponse is nor suitieicnt. as loading at the key obstrucled end range may still nor be accomplished.

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The preferred loading strategy revolves "round rcducin2.

Inc key obstruction. This effon may be ..ccompanied b\' th~
rapid resolution of symptoms. or by the temporary incr~ased
symptomalology of the centralization response. after which
symptoms resolve.
Phenomena related to the resolution of derangemcnts
exhibit varying degrees of complexity. The simplest GISe
involves only onc obstrucled end ran~c in the saginal
plane. which is lhe key obstructed end rang~. The c~ntral
i7.ation response may be noted at the obstructed end range.
The peripheralization response is elicited typically by
means of loading within the opposite movement plane direction. Peripheralization by means of loading in the movcment plane direction opposite to that of the obstructed end
range may be elicited immediately or by deluyed onsct: i.e..
mechanically unimpeded nexion may pcripheralize. whereas
extension to the obstructed end r.mge centralizes. The less
common. but opposite simple sagittal pattern. may also be
found.
More complex situations entailing multiple obstructed
end ranges, of which only one is the key. may mandate an initial preferred loading stra[egy within a coronal or transverse
movement plane. Consider a case involving an obstructed end
range in one sagiual movement plane direclion. a.~ well as an
obstructed end mnge in one coronal movement plane direction. In such cases, it is possible that loading in both the unimpeded and obstructed sagiual movement plane directions elic
its the periphcralization response. Loading in the coronal or
transverse movemCIH plane is at first required to elicit the centr;jlization rcsponse. Subsequently. loading in the sagittal
plane becomcs necessary for further resolution
the syndrome.
It is possible in cases involving muhiple obstructed movemenl plane directions. for loading at a single (key) obslrucled
end range to resolve all obstructions. without requiring the scquentiul end range loading just dcscribed.
p

or

De,S, REASONS FOR FAILURE OF PATIENT STRATEGIES

The ccntralizJlion response that occurs m the key ob:,tmcted

end range may entail a significant increase or creation of centr.ll symptoms. which patients understandably avoid. Because
the ccntralization responsc is associated with an increase of
marc central spinal symptoms, patients may choose the therapeutically detrimClHal strategy of pursuing loading tactics that
diminish spinal discomfort, even though 'lesser paiphcral
symptomatic complaints and significant mechanical disorders
arc perpetuatcd.
De-S, HYPOTHESIZED PATHOANATOMY

The model for this syndrome is the derangement of imradiscal

material or substance. whether it is solid (nuclear. annular).
liquid (watcr. electrolytes, etc.), or gm;eous (e.g.. nitrogen).
The bchavior of symptoms and mechanics changes according
to migmtion and/or accumulation of intnldiscal substance or
materinl in the anlerior. posterior. or lateral aspects of the intervenebr'll disk space.

 , .... " , .......... n, ''-'I~ ..... ,

Imagine a simple cas~ iii whid: :nli:idisc..: Iiia:.:ri;i: ...:..:ranged in a posterior direction. callsing ohstrucled end r.mgc

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to extension. Flexion would remain ullobstructed but would

further promote this posterior derangement, eliciting pcripheraliz<ltion during. or at the end range of. the dcmngcmclIl
promoting flexion movement pl.me direction. The c:t'JI{mli:/Ifioll respoll.\"l! would :.IcComp.ul), extension wilh oycrprcssurc.
as the derangement bcco:l1l::S rcdlH.:cd. The n:vcrsc case could

be imagined as well.
Consider a more complex situation ill whid. illlradisl.:..ll
malcrial migrated in a posterolateral direction; flexion may
further this migration. An obstnlcted end range could exist not
only for extension. bUl also for sidc~glidillg as well. If the Iilt~
eral component is significant. extension may only serve 10
squeeze this material more to the side. In Ihis case, both the
mechanically unimpeded flexion C1nd the obstructed extension
could elicit the peripherali7..C1tion response. Loading in the
coronal (sidc~gliding) or the transvc~c movement plane di~
rcction (rolation) may be needed to reducc the key lateral ob~
struction and elicit the ccntrtlliz;.nion responsc. After this step,
Ihc previously aVOided extcnsion component becomes lhe key
obstruction, and loading in extension may be needcd to furthcr promote the centralization response. The laleral component has been reduced sufficiently, and the task is then to n,>
duce the posterior component.
When disk material has migrated, both posteriorly and laterally. obstructed end ranges exist in the respective sagittal
and coronal movement plane directions. If loading in Ihe
movement plane direction of extension reduces both of the
obstructed end ranges, the lateral component is not considered relevant. If loading in the ~oronal movement pl<.lnc direction is required first. the Imeral component of disk migration is considered relevll'" to a loading str<.ltegy involving a
nonsagiual movement plane.

RELATED TERMINOLOGY

Postuml Syndrome terminology is predic..1lcd on the positioning that precipitates symptoms. Dysfunction Syndromc tcnninology is predicatcd on the movement of the person that precipitates symptoms. Derangcment Syndrome terminology
refers, in pan, to the lInatomic dircction of intradiscal derangement. In contrast 10 the Postural and Dysfunction Syndromes. 1\\"0 classification systems arc used to organize Der;.mgemcm Syndrome phenomena.
Similar to the Postl"lral and Dysfunction Syndromes,
the first method dcscribes dewngcmcnts based strictly on
the behavior of mechanics and symptoms in response to
loading tacrics, and namcs these bchavior patterns by p;'lthoanatomic inferences--derat,gemetll belwvicw tlomcnclalttre,
The second mcthod refers to the presenting symptolll lOpography ;.md deformities. in 'Iddition to the dcr;'lIlgcl11ent
behaviors-derclllgemcnf bellavior-fOpCJK ral'hydeforllli fy

(87D) tlomenclature.
Derangement Behavior Nomenclature, This tcrminology
is descriptivc of the anatomic direction in which the intradis-

" ' ....... '

" .......

1"\

rnr\\.... I II IVI'Icn ;:) IV1MI'lVJ-\L

Jer;lllgclllcllI i:, thought 10 h:l\'e occurred. SWlcd another

way, it i~ descriptivc of hdta,iors noted as ~,. (krangellh.'m
of imradisL'al 1l1:11erial occurrcd ill the dCSL'rih~d anatomic
directioll"
The Dcr;l1lgl,.'Il1~11t Syndrnmc" ~Ire named :lI,xording t\1 tlte
hypothcsirl'd ;1lI;lltllllil dircClill1l ill whidl disk ll1;llcri:l! Ir;l\'dkd and I.::lu"".. d ;1Il oh"tnll.:tcd cnd r;lIlgc: ~IIltCfior. po"t('rior.
and J:Hl'r;t!lkran;;l'!11l'llIS.
Am"r;or (/<'I'Ol/g<'/I/C/l1 d~s(rihes hcll:l\"iors liS ~r ;1l11crillr
migrati(lll ()(" intlatlisc;'11 m"h:ri,,1 (lL'currcd. An accuiliulati(m
in thc anterior companmcnt of lhe disk makes llexion I11C-.
<.:hani<.:ally difli<.:uh to perform. In cxtn:me cases. lord(l~i;'o is
fixcd <.Illd irn:\'crsibk. Extension pronHHes the migrati{lll 01"
lllateri;.i1 to the ;uHaior ('olllpartlllelll. Extensioll Illay bl' accompanied by pcriphcraliz<ltiUIl or symptoms during IIH)tion
or at end range as a result deranging material aIlH.:rillr:llIy.
Any limitation of cxtcl\:"ion woulL! he dill: 10 imolcr'l1ll:1.' of
symptoms but not to mc(:hanic:illy impcdl.'d end !";lngl.'.
Pcripheralizatioll generally docs not occur below the kllcl.: hecausc the nerve radicab arc nol idTectcd hy di~tortiol1 of the
antcrior aspect of the annulus. Flexion is ohstnH.:ted and accomp;'lI1ied by symptollls ..It obslrllctcd end range:. Flexit..'" to
obstructcd end rangc with overpressufe is ac<':olllpanicd hy thl..'
centralization response <.:orresponding 10 a redistributi()ll or
intradiscal marerial to a more cClltralloe:;.ltioll. ft.:sultillg in illlproved biomechanics as wcll.
Posferior (/erange/l1etlf describes behaviors (IS ~rposh:rior
migration of intradiscal material occurred. An acculllul:nion
in the postcrior compartment of the disk f11<.1kes eXh:n~inl1
mechanically difficult to pcrform. In cxtreme cases, kypl\()~is
is fix~d and irreversiblc. Flexion promotes the l1ligr:lli~'n ()f
malcrials to thc posrcrior comp<lrtmcnt, Flexion may be
,Iccompanied by pcriphcraliz;.nion of symptoms during motion or at end range as a result of deranging material postcriorally. Any limitation of flexion would be Jue 10 jllh,krance of sympwllls bUI not to mechanically impetkJ t:l1d
rangc. The pcripheraliz;'lIioll could extcnd belt)\.... IItt: knt'c.
because the ncr\"c radicals or spinal cord I1wy be afft.'l'!cd
by distortion of the po~terior ;.\:-;pecl of the annulus. E.\h.:nsion is obstrucled ,mel accompanied by ~YJllptolllS ;1I l,b~
structed end range. Extension to ohstrll('tcd end rang~ \\-jlh
overpressure is accompanied by the ccntraliz.uioll ph\.'llllmena, during which intradiscal material rcdistriblltc~ w a
more central location, resulting in improved bioll1c<.:h:lIlic~
as well.
L(/feral derallgeme/lt may occur alolle or in combill:Hil)(l"
with anterior or posterior dcrangement: most frequently. il \'l.'curs in combination with the latter, Unilatcral sYlllptOll\~. L':'
peei<tlly if they pcripher'llize, ;'Ire assumcd to have ;1 1:II..:'f:l1
component. If dynamic and/or static loading in the sa~itlal
plane centralizes symptoms, it is not considered a "rek\":lnt"
Imeml componcnt. i.e.. the "key" obstructed end f;l1I~L' is
in the sagittal plane. If the uniiater,,1 techniques of :,iJt.'gliding or rotation arc required to centralize symptolll:'. it is
considcred a relc\'<.llll lateral component. i.e.. the Imer;,ll'olllponent is thc "key" obstructed end range. With a rclcv:l1l1 Ia{-

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CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING

cral component. it is thought that an accumulation of in

tradisc;:IJmalcrial to one side or the other of the coron.l1 plane
is sufl1cicllt lO require a unilateral loading lcchniquc. Whcn
there is a "relevant" lateral componem. movCIllCll[ in the
sagitlal plane not only may f<lil to elicit the ('cntralization phc.
nomen a, blll also may aClu.111y elicit tile paiphcl'aliwrioll n>
sponse if further lateml mir:llion of intrtldiscal material n>
suits. After rotation or side-gliding is performed to reduce till'
lateral component in these cases. the situation may require
sagitlal plane techniques to reduce the cClllr;i1 anterior or posterior derangement.
An accumulation of disk malerial in the lateral companment resists side-gliding to that side becausc of the obstructed
end range. In extreme cases. a list or lateral shift is ilxed
;:lnd irreversible. Side-gliding in the movemcnt p!;:iIle dirt~c
lion of lhe patient's lateral shift has (he potential of promoting the further migration of intradiscal material. aCCOIllp~\I1icd by pcriphcraliz..1tion of symptoms during motion or
..It end range as a result of derangi~g material more latcrally.
Any limitation of movement in the direction of the lateral
shift relates to intolerance of symptoms and not to a mechanically impeded end range. Pcripheralizatioll may occur below the knec because lhe nerve radicals are easily affectcd
by latcml distortions of the annulus when a posterior component is prescnl as well. Side-gliding in the movcment
planc direction opposite 10 the latcral shift is obstructed
and <u.:companicd by symptoms ;It the obslfllclcd end
range. Side-gliding to the obstructed end range with overpressure is accompanied by the centralization response corn:sponding to a redistribution of intradiscal material to a more
ccntwl location, resulting in improycd biomechanics as well.
Derungemellt Be/zavior-Topograplry-Deformity (BTD)
Nomenclature. This tenninology uses a numeric system,
labeling various derangcmcnt presentations from I through 7.
Thc first subclassification of the dcrangcments is according 10 their /,e!/{f\'iOl; as described previollsly. Derangemcnls
I through 6 arc posterior derangements. Derangement 7 is an
anterior derangement
Dcrangcl1lcnl~ I through 6 .Irc arranged in couplets. with
lhe odd nUl1lbcr~ describing symptom topography. and the
subsequent even-numbercd derangemcnts dcscribing (he
S'II11C symptom topography i.lccompanying a fixed dcfonnity (alll<.llgia or deviation) of the spine. prevcnting curve
reversal. Therefore. the derangement number indicates its
behavior, symptom topography, and presence or lack of
dcformily.
This derangcmclll nOlllcndaturc is dcfined as follows:

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Derangement Two:
C~l1tral or s)'1l11l11.:!ric symptoms alwut the spine
With or without shoulderhlrm or hUl10ckslthigh symptoms
With defurmily of kyphosh

.("".

i)~r:lll':;Cllh.:1l1 Thr~e:

UnilLlll'ral or asymmclric SYlllPlOlIIS ahOlll thc :,pinc

Wilh ur \\ ithuut shoulder/arm tlr bllthld,~thi:;h ~Ylllptlllll ..
N(I deformity
J)~ral\gcllll't1t

Film:
Unil:lll'r:11 ur aSYlll1l1elrk ~YlllplOlllS ahoullhl.: spint:o
Wilh Ilr \\ilh.mt shoullkr/anll \If bll!hll.:bllhi:;h ~yl1lplllllh
With tkft1rlliity (If turtil,,\llli .. ,Ir lumhar "'l'lllill~i~

()crangclll~nl fivc:

Unilah.:ral or asymmctric ~YlJlptnms "hml1 lhe spinc

Wilh ur without shuuldcr/ann ur hUll ods/thigh S),lllph1l11";
With symptom..; cxtcnding bl.:low the dhnw or knec
No deformity
Denlngerncllt Six:
Unil;ltcr;:tl or asymmetric ~ymptOlns ahout the spine
With or witlluut :-;houklcr/arm (If bUlhl(,:ksllhigh symphllll";
With symptoms cxtending ot:lnw [hc dbow or knce
With dcfonnity of acule kyphusis. IUr1icullis. or lumhar si,.'i1!i(lsis
Derangement Seven:
Symmetric or asymmetric symptoms about the spinc
With or without Shollldc.:r/arm or bUHocksllhigh SYl1lptC01~
Deformity
accentuated lordosis m,ly or may !lot be pre5Cl1l

or

The "couplet" system of symptom topography. without and

with deformity. does not extend to the anterior dcrang-:ll1cllts.
An anterior derange1l1elll with central symptoms. unil:ucml
symptoms. without deformity or with deformity. is classilicd
as a derangement sevcn. The BTD nomenclature is reduced to
behavior nomenclature only for anterior dcrangel11~lH~. which
arc assigncd the number 7.
PARTIAL PATIERNS OF DERANGEMENT

One distinguishing feature of the Derangement Syndrome is

the exhibition of parli;ll patterns. Because of Ihc l'omplex mechanical and symptomatic responses associ"tco wilb the
Dcrangement Syndrome. the absclH.:c of some of the typical
dcrangcmclH responses docs not diminish Ihc ability w recognize thi!ol syndrome. Examples of partial beh'l\'ior pallcrns
of demngcmcnt arc as follo\\'s:
Periphcr.slization rcsponse persisls without Ihe ability 10 dicit a
centralization response
Periphcr<llizution response pcrsisls after sustained end rall~": hl:ldiug only: no pcripher;llizalion elicited during mo.... ement
Centralizati(ln response pcr~i.~ts without thc ability 10 di . : il a pcripheralization response
Pcriphcrulii'.ation resp\lH~e resol\'cs witlluut any l.'kar p;lll~rn of
ccntmliziltinn rcsponse
No pcriphcrJlir....ltioll. ccntraliwtion. or uther synlptolll .,:hanges:
howe\'cr. mechanical rcsponscs occur
No mcch;lnical resp~HlscS occur: howcver. symplumatil.' rl'spollses
dn occur
SUMMARY

The goal in the Dcrangcmclll Syndrome is 10 reduct:' the dc~

r;U1gcmcnl of illtradiscal material by having it migralt: back

t.)

~5~ "'",],
~
\i,
.
\~

DerLlllgl.:l11cm One:
Central or ~Yf11metric sympwllls ablHlt the spin(:
R~ln':l)' shuulder/:mn or butl()eksllhi~h symptoms
No dcfurmit)

249

- ------------

----------------------------

" _ ._ ~,. 'oJ'

~,,;"ai''::

;:.... n:::ntcr of the di~k Sp'ICC. Ohslructcd end r;U1gc in

purely ilntL'rior or poslcrior dcr:lllgcl1ll'J\ls occurs in one
movemem plane direction. Obstnlcled I.'nd range GIll CXiSI in
more lhan one mow_mcnt plilllC dircl.:tion \\ ilh eilhcr rdc\;Int
or nonrek\anl hueral C(lmpllncnts. If nlhtrU<.:tioll 10 mo\\>
Illelll in tilL' cornnal pl:tll~ is dilllill<lll'd by loading in Ihe
sagittal pbnt:. the lillcr:t1 h,:onlnal) t.:nmp"rll.'llt is not \,.'oll..;idered relc\ant.
l1Hcnnilt~n( sylllj111111l:Jlic n;sj11111sC~ \\ ilh .1 Dcr.lI1gcl11clH
Syndromc lllay involv\,. rq>ctitivc rcduction and der.lIlgclllcnl
of disk m'llcrial in rcspon~c to the patient's 1ll0VCI111::I1lS ilnd
pusilionings during thc d;'ly. A const'lIlt symptomatic response
involving the Dcr;'lllgcmcni Syndromc rcpn::scnts a mech.mi
cui dispbcclllcnt of disk material llO! reduced by the llSU;.iJ
movcments and positi()nill~s or the paticl1I. Prcscriptive load~
ing (a prd('rr~d IO<lding ~lr<lteg)') at the key obstructcd cuo
range is ofh:n slIcccs:-.ful in reducing Derangement Syndromes in these latter cases.
Relationships Uctwccn Syndromes
In a sense. the prefcrrcd loading stratcgy for the Derangellll:nt
Syndrome combines those of the Postural and Dysfullction
syndromes. inasmuch as ce.:nain discomfon!- must be avoided
and certain discomforts must bc pursued. Typically.1 IIlcch~
nically unimpeded end range is avoided while a Illcchunically
impeded end range is pursued. Therefore. the sh;'lrp distinc
tioll made between the syndromes may be, instead. diffuse
lines of demarcation; certain propcnics of onc mil)' mcrg~
into the other.
MIXED SYNDROMES

In the previous dcscriptions of syndromcs. each is presented

as if it exists "by itsclf. In clinical prilctice, multiple syndromes may coexist. .Ind all thrce may be seen in one p,ltiellL
SIMILAR SYMPTOMS, DIFFERENT RESPONSES

The importancc of invcstigating me.:chanical and symptomatic

responses to loading tactics cannot be overemphasized.
Information concerning a single mcch'lIlical or symptomatic
rcsponsc to a single loading tactic is not the nccessary and
suffieiclH condition by which to diagnose a syndrome.
Symptoms associated wilh siHing. may be aHributablc to a
postural syndrome of sustained nexion. a Ocxion dysfunction
syndrome. the promotion or a posterior derangcment, or the
reduction of an anterior derangemcilt. Symptoms associuted
with standing may be associated wilh a sustained extension
postural syndrome. an extension dysfunction, the promotion
of an anterior derangement. or the reduction or a posterior derangement. A thorough investigation of mechanical and
symptomatic responses to IO~lding helps to dirrerGntiatc
among these possiblc caus<ltivc factors.
The periphemfizalioll respo11.,\" may OCClir during the
Dysfunction Syndrome or during the Derangemcnt SYI1~
dromc. It docs not occur during thc Postural Syndrome. Thc

, , ' ......H-

.... c:.

1"\

r-H"'U., 1IIIUNt:H"t;

MANUAL

pcripherali/.~ltioll rcspun:'~ with i.I Dysfunction Syndrome

l<lrcly pcrsists .Iftcr ce.:ssation of the loading action th.1t prcc.:ipit'lll.':' it. and Ihis loading actioll typically has n componcnt
of Ikxion In end rang.e.:. In thc Dcrangcment Syndrome, periphcr;.di/.alion may occur a\ any point of a movement plane
Ihal promolcs the dcrall~e.:IllCllt. and pe.:riphcral compl;lints
typiL"ally persist ;Ifter heing dicih:d. The.: pe.:riphcmlizatioll re
SptHlSC of de.:rangclllelll is typil:ally associah:d with cClltralizalilHI rC~I}{)I\ses. Tilc pcriphcrOllization ..esi~l)nsc of dysfullctiOil
is IH1t.

-~

()

APPROPRIATENESS OF MANIPULATION

lvlanfpul;.Hioll. within the.: McKenzie <Jpproach, is considered

inappropriatc in l1lovcme.:nt planc dire.:etions that do not possess Illcchanici.llly impeded end ranges. Therefore. manipulation is in'lpproprialc for the Postur~ll Syndrome. Only postural
correction is warrantcd.
Rcgarding the Dysfunction Syndrome, manipulation l11ay
bc contraindicated at first. becausc of lhe danger of overstretching shortened tissue. Symptomatic responses to loading persist only when shortcned tissue is strctched too fast or
100 far. causing tissue injury that results in chemical. non mechanica I inflammatory pain. During i.l manipulative thrust on
a patient with a Dysfunction Syndrome, the operator may feci
as if he or she has "bounced off' as a result of the resistance
offered by shonened structures. In the Dysfunction Syndrome. manipulation is appropriate only after the adaptive
shortening has been reduced signiflcantly. Manipulation is in
appropriate as ~l main fonn of therapy in this syndromc be
C<luse of the need to stretch this tissue repetitively during the
course of the day over many wecks. This effon. is best accomplished by patients themselvcs.
The Der:lIlgcment Syndrome bcst represetHs the chiropractic concC\)t of the manipulmablc Icsion or subluxation.
Movement of the inlradiscal substance rcsults in asymmetric
relationships of joint Wrf'ICCS. The supposition that the disk is
n:sponsible for this disrcl'ltionship WilS nOlcd by Gonstcild,.l
ahhough thc critcriiJ on which he predicated mallipulation
wcrc mdiographic findings and not the mechanical and symptomatic re.:sponses to loading thc spine. The mechanical and
symptomatic responses to end-range 10ilding mobilizations
(taking the slack out) performed by the patient or the clinician
predict what the responses will be to manipulation ;'lccording
to similar loading strategies. A lack of response or a detrimcntal response to patiellt~gcnef<lted or c1inici311 mobiliza
tiOllS argucs against performing the manipulation, which
would rcprcscnlthc same loading stratcgy, albeit wilh greater
force. Radiographic evaluation or thc palpation of "sticky
joints" docs not afford the clinician this samc information.
The McKenzie approach recommends .manipulation only
aftcr sclfgenerated movcments have been explored fully and
cvidence partial therapcutic responses. Loading intensity is
then incrc<lscd by IllC<lns of clinician overpressure.: (taking thc
slack OUI) and frequency of loading (repetitions) to "test the
watcrs" us to the potenlial benefit or detriment of manipula-

.,~_.~_._-------------------~

.--"~

-)

._.. _-~-~~.
,

' .. ---'

CHAPTER 12: SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING

live thrusts. h is impol1am to note th:.u the 1lI0\l:IIICIll plall\.:

direction of the manipulation cOlllcmplalcd is tktcnnincd by
mcchnical and symptomatic rCSpOll$CS (0 loading. incJudil1!;!.

patient-generated movements. patient rcp0r1~ concerning ccnlraliziJtion. and bOlh patient and clinician ohsa\,;l1iolls 1.'011
ccrning mechanic;\1 observations.
Lastly. n;~3njillg the relationship In chirnpral'lic. Ih..
McKelvie <'lpproach docs not claim lO be the llfst or unly ;11"
pro<lch (0 include the movement plane dinxtion of extension
as a thcmpcutic possibility. Rcinart'\ referred 10 extension ex-

I (,I
~

ercise technique, therapy, and theory at (C.1SI as c<lrly as I96::!:.

The distinguishing feature of the McKenzie approach is not
the advocacy of extension in selected cases, but the fact that

'/"

treatment is predicated on medmnical and symptomatic responses to loading. In m;.my cases, extension .is indicated:
however, ill many C<lses. movements otherthall extension arc
wh:.n is required. The McKenzie approach is equ.lted incorrectly with an exclusive predilection for extension. Thc approach makcs. no a priori, dogmatic conclusions about what
every spine needs, which is perhaps the greatest virtue of its
clinical reasoning.
APPROPRIATENESS OF PROGRESSIVE
RESISTANCE EXERCISES

The McKenzie approach permits a thorough exploration of

which movement plane directions may be pursued and which
must be avoided. based on the mechanical and symptomatic
responses to spinal loading. A progressive resistance exercise
program is often possible much sooner than would otherwise
be permitted because the clinician possesses a clear understanding of how a patients' spine reacts to moyement and posilioning at the outset of such a program.

THE McKENZIE APPROACH AND DEMA:\DS

OF REHABILITATION

The McKenzie approach distinguishes itself among other rehabilitation methods as being useful to patients with either

acute or chronic spine-related complaints. As such, it is often

an appropriate first step before considering passive therapy or
other aClivity therapies. When explored first. it often proves

passive Ihcrapy is gratuitous and safely guides the course of

subsequent activity therapies. such as strengthening roulines.
"Rehabilitation:' (0 some, equates to therapy in general,
aflY kind of therapy. Used in this,manner. the term loses its in-

tended meaning and is even applied to passive methods. such

as hOi packs and ultrasound. Rehabilitation is not any means
to flllK'tional ends, but signifies fll11CfiOllCl1 means to rUrlCtion'll ends.
The key concepts defining rchabilit;.ttion relate (0 cswblishing an individual's skill (0 be able to "maintain :1 maxilllUIll level of independent functioning such as self C;'lrc ;.mu
emploYlllent'" In rehabilitation, the actions of the patient arc
of p;'lr~11110unt impol1ancc. Guidance is provided by the practitionl.'r. but the burden of treatment involves what the pmient
do(.... ,md nOI what is done 10 thc p;'llicnl.

251

FlIIlI.:iiulI.::d rcslOralioll.~ work cOllditiollill~.s and work

h"lfdening" pf(\~ral11s usc (his striCI dclinition of rdlf.lhilir~lion.
The <Ipproach ,tresses the physical and psy,.:hologic advantages of rehat--!liwtioll dclinl.'d as acti\ity.
The phy:-i.:;:l advantages of these programs il1\'olyc rcac
tivating thl.' ]i1Ji, idual who may hay\.' heCOlllL' fcarful PI"
1Il0Vt,;IIlt,;11I .:mJ I.:llllSCqut,;lltiy dccondition..:d. ilt The p,,~ dlOlogic ad\'anl':~:=;: i:.- to n..'''crSl' or prc\"I,.'11I .:Ihnonn:'11 iUne..... ht,;havior. ll hdpl:lf the paticlll idl.'llIify with :.-ocicl:l1 and wOfker
roles rather than the role of a patient 'IS .';1 p;'ls:d,\.' receptacle

of carc."I~
FUllctional restoration, \\"ork conditioning. and work hardening program, ufC used on chronic c;.lses. Oftcn patlclH:, arc
referred to surh programs af\l.'r passiyc lll~thllds. Ill~di('atioll.
or no lhcrapy at ;,111 (thc tincwrc of till1l:) fall 10 resoh'c the
chronic condition, III th~sc i,.. in':lI111stall~cs. passive cart:' h:1Snot helped the individu:'ll. but Ill:'y hayc .:ICIU;llly cncour;lgcd
lllusculoskeleull morbidity."
Patients presenting (Q 'rehabilitation" centers with acute
conditions often recl.'ivc passive therapy initially.n Thb therapy continues until the demands of an activity program le.g..
progressive weight rc~ist;'lIlce) can be tOlerated without harm.
The disadvantage of such initial passi\"l~ carc is (hat it 1113y ullimately serve a purpose contrary to that of the physical and
psychologic goals of rehabilitation. Passivc therapy. if ilHroduced first. has (he potential of ~poiling" the paiicnts
chances of progressing to unassisted. actlvc functional Jl..'tivilies as thcrapy.<~ and incrcases the possibility or thc dc\clopment of abnonnal illness behaviors.l~ Sl,ll1lC authors:~ state
lhat much lo\\' back disability is iatrogenic and results fr0111
the medical prescription of rest fm simple bnck;'lche that is
based on the misCOIll".'l.'ptioll lhat inl1;'ll11l11ation or olhcr p.:1thologic change pl:lys It ~igniticant role as a caus.ative faCll)r.
A rehabilitation approach in the a("utc phase can prlwidc
the physiC'll <lnd psychologic benefits of functional rcsh.)ration
and work conditioning/hardening programs that arc ll,t'd to
treat chronic disort\('rs. It can, thereby. prcvclll the Ilccd to rc
solvc chronic conditions by not Icttin~ tl1(:m t.lc\'clop in the
first place. The McKcnzic appro,Jeh salislics these requirements. It proyides self-lrealment f.lcti,ity techniques tokrablc
during the acute phase rhf.lt enl<lil th(' physicf.l1 and p:,ychologic bcnefit~ of more expensive and kngthicr rehabilit.uioll
pmgrams. It may c\'cn prevent the need fOf such sub~~quent
rehabilitation programs, as il employ~ 1110lny of the sal1l~ physical and psychologic principles.
If functional restoration or work ('onditioning/Ilan.kning
programs arc ncctkt.l subsequently. the initial liSt.' l)f the
Mi..'Kcllzie protocols is likely to cnh:u\i..'c the po:,sibililics
of their success, bl'c.:IUSC lhese pn,lgr;ulls arc a COIKCPWally consistent continuum from tha: initial acule carl' ac
tivily therapy. Through its physical effcct. the rvkKcllZic
approach addresses Ihe mechanical na!un: or lhe p'l,icnt's
disorder. Through its tcaching of mech;'lIllcal prilH..'irk':, of
sclftrcatmcnt. it is l.onsistcnl with the prinCiples llf n:habilitation tl1<lt prc\'l'nt the develupmcnt of abnormal illncss
behavior.

, ..... ' 'r\V''-' '''I 'UI,.

The paticlH lcarn~ that therapculic movement and positioning may be accompaniL'd by incn:a:,cd pain wilh improvcd
funclion .1Ild thaI ccnain p.lins ;lfC 1101 to hc avoided.
COllgruclll with the ~trictL'st rehahilit;ltiOli prillciplL's i.' the
"halld~ off' first approach. If rcsuh~ ;trc limiled. lh\.' ;Ipplil'ation nf passive approachc!'l is :.tl\\'a)"!'l p\lssihle. hut Iht' l'OI\1ml
of treatmcnt is returned to Ihc patiellt :IS !'loon 41S l)(l:,-"ibk.
R.egarding. thc 1!ll.\.'I!:lllil'i1I ;llld physiologi..: prilicipks of
rehabilitation. the r-vlr.:Kcll/.ic appro:ll,:h m:lkcs m:tivity and sell'
trcalment p(,ssihk duril1~ the itl.;utc ph;tsc. Pt'flllillillg continuous. rclativdy passi,'c spinal motioll to hI.": slrategic.:ally pCI'
formed by the paliclH. Tht:sc llHIVL'IllCl1tS cnh'lllcc tilt: organi.
zation of "ncw" tissue along lht: lines of stress. with th~
formation of Ikxiblc scar tisslle, Ii T<lsks arc ilHroduced OJ} a
dcmand-graded basis.
If McKcl1:t.ic activit)' thcrilpy is dispensed uunng the ,Icute
phase. fear of p'lin and the signs 01" pain avoidance or illness
beha\'iors arc nut cllcouraged. 11l and the protrilctcd treallnent
illlcrvcmion for piltients \Vilh chronic disorders is i.l\:oided.
Ttwt it is of potential benelit during the ,Icute phase should
not subtracl from considering McKenzie protocols as the log.
iClll first step for lhc treatment of chronic conditions. for the
samc reasons just givcn. Jr strength training is not needed for
trcmment of a chronic condition. the McKen:t.ic protocol rep
resents a relatively quick and inexpensive alternative.
The McKenzie protocol is an exccllent intervention 10
prevent physic:.ll and psychologic complications of injuric!'l. It
includes individuals laking an :Jctivc, responsible role in re
habilitation appropriate to their level of functioning. illl
provemenl in physical functioning rather than simply cOllcen
lrating on symptomatic relief. safet)' practices. maintaining
the worker role through minimal time iIWi.IY from the work
place. activity control of symptoms as opposed to s)'mplO
matic control or activity. and an attemplto avoid usc or anal
gesics or passive treatment methods.
As st;:ltcd elsewhere:
"By rcllucing the usc of llll..'rapist's t~c1llliqtle in the initiul ,tag\,;:of trC~ltlllellt ~uu..ll1la:o;imi1.illg paticllI tcchllilillC. the p:lticnl will
recognize that his recovery is largely the result of his own 1.:1'.

to a"sume rc~ponsibilit), for acti,c participation in their treatmen!. pruvi(Jing the inslructioll :1Il(J cducation process is firmly and vig(,rou~ly pursued."ls

forts. r:'cw patients filii

ur-

I Nt: ~t'INt::

A PRACTITIONER'S MANUAL

be CdllC:ltcd
in ;:1 mclhud of IrCatmcnt lhat ellahks him to reduce his own
pain and disahili!)' llsill~ his own underst:lIu..ling and resources.
hI.' should n:r.:eivc that education. Evcry palient is cntitled 10
!hb illfuflnation. and ,,:"l.'I"y th..:r::lpist ~h(llll(J he ohliged lo pro
\ ill..: it:""

"[f

there is the sliglllcst chance tllat ;:1

p~l\iCllt

C:iIl

HEFEHENCE.."i
~kKell/.ie RA. 1111.' lumbar spille: r..k..:halli\:;ll Diagnosis and Ther;lflY.
WaiLlIl:le. New '1...::11;md. Spinal Publkalions. 1981.
1
~kKcn/.1c RA: 1111: Cen'iI;al ;Illd 'nlOmdc Spinc: Mech:lIlic;l1 Diagnosis
:1ll~1 Tller-IPY. W:libu;lc. New Zcal:lIld. Spin:ll Publkaliolls. 1990.
.'. 11:IIdl:lll>l1l S: North AlIleril'all Spine $oeiel)': Failure ~\f the palhology
m\~ld III pn:dicl back p;lin. Spinc 15:718. 1990.
-l. Hcrbst RW: GCUlsle;lL! chiropral:llc scicncc and :m. r.,11. Horch. WI. Sci
thi l'uhlic;lliullS. J9XO.
:i. 1l:lrrak R. Di:lIl1ollll R. Fiboll R. 1.'1 011: M;lIlipulalivc m:lIl;lgelllelll hUHh:lr disc bulge. Chiw Tedl 1:87. 1989.
6. Dculsch P. Sawcr H: Guidc 10 Rchahilil:uiull. New York. ~t:ltthew
lIcncler.'<: Co., pp :W-'O. Suppl & Rc" 1989.
7. Mayer T. Gmchc1 R: Funclion:11 ReslOr:llion for Spin:11 Disorders: The
SP()rts tvk'tlidnc Approach 10 Low B:lck Pain. Phil:ldclphia. Lea &
h:higer. 1988X. hcr:lhagcn S: Work h:mlcning or work conditionillg.-whal's ill a n;II11C.
Il1du~1 Rehahil Q He:!l:7. 1989.
9.....lalhe:-un LN. Kelllp OJ: Work h:udcninl;: (kcupalion:lliher.,py in in
du~trial rchahitilalion. Am J Occur TIler 39:314.1985.
In. Troup J: 111e perccplion of musculoskdelal pain [lIld incapacil)' for work:
Prcvcnlicll1 :ll1d early lre:lllllel\l. PhysiOlherapy 74:435. 1988.
II. !'jtowsky J: Abnonnal illness behaviour. Psychialr Med 5:85. 1987.
12. 5..:11 J: Inter\'ertebr:tl disk heOlialioll in nonopcr::ltive tre;ltmClll. In
Phy~ic;11 Medicine and Rehabilil:ll;on: St.. lc llf lhe An Revie\\"s.
Philaddphi:I. Hanley & Dcllfus. 1990. p 185.
13. Mi\(:hclt RI. Carmen GM: Inlellsi'.e active c~ercisc pmgi,llll. Spin,,;
15:51-l.1990.
I-I. Dcrcherry VJ. Tullis WH: Dehl)'ed recovery in the palient with a work
(Ollll'ICns;Ihlc injury. J O~'cup Mcd 25:829. 191D.
I:; . Ww..k kll G: A new clinical lIlodel for the lreallllelll Ill' !OWh:1Ck pain.
Spine J2:(.32. 1987.
J 6. Allan DB. Waddell G: An hi~loric;11 pcrspccI.ivc on low b;le!.: pain and
di~abililY. 1\(1:1 Orltl(lp SC.Jlld 6O(Suppl 234). 1989.
17. E\,:.lns I): 111c he:lling process 'It cellular level. Physiolher:lpy 66:~.

I,

I\}SO.
IX. McKerll,ie RA: The Ccr\"ic31 and Thoracic Spine: Mechanic:\1 Diagno

..i\ and Therilpy. W:lik:lOae. New Zealand. Spinal Publications. 1990.

p Ifn.
19. MeKe",~ic !{A: nlc CerVical amI l11OT:lcic Spine: Mechanic:II Diagllosis
:Incl Ther:lpy. Waikanac. !'\cw Zealand. Spin~ll Publkatioll.~. 1990. p 113.

1'"

l'

:I

:1 ,-"
I

10

Ii

Manual Resistance Techniques and SelfStretches for Improving Flexibility/Mobility

CRAIG LIE BENSON

I
I
~

The origill~1 Ill;mu,d rt::-.ist.1l1CC h;(;hlliqll~:'\ (Miff) have tllci ..

origin in tht: pro:'rim:qHi\"c llt:llrol1l11~cul:.ir r;.Jc:ilitation lP\!:J
philos()ph~ of physiGd tha;'lpy and the mu:-;d..: energy pn.lCc
dun:s (\IEP/ of the oSIt:opathy. These techniques illYO!VC
manual re"ist;lllcc of a paticnt's isometric or isotonic museu
lar efron. This resisted elTon is typic"lly followed by a slrclch
of a light or tense mllscle. The MRT arc primarily used to
rcl<lx o\"cr<Jclivc IlHlsdcs or ll) stretch shone ned Illuscles and

1
I

I
II

their associated fascia. Many different methods have been de-

.~

I
iI

{)

~,

veloped depending 011 the clinical goal. To achieve these positive clinical dICciS. tvlRT t'.lke advantage of two physiologic
phenomena: postcontraclion inhibilion and reciprocal inhibition (RI), The MRT arc in":lluable workhorses in the re!l;Jbil
ilatian of the motor system,
These techniques ilre also used to facilitate or train an inhibited or weak musl:lc. Because the doctor or therapist pro
vides the resistance. precise patient positioning and movement cnn be controlled to;'1 degree not possible with machines
or even free weights. Manu;'11 COIlt;'lcts also allow for proprioceptive stimulation to facilitatc an inhibited muscle during ;'ll;'
live resistance. The v:due of clinici;'1l1 control over rcsistancl.~
exercise cannot be underestimated. especially when the go,li
of impro\'ed coordination is as importi.HH as lhat of strengthcning.
Publications about thc lISC of PNF to facilitate ncurologically weak nluscles lirst appeared in the late 1940s. ' Soon.
other reports followed. staling that spasticity responded to
this type of therapy as well.: This positivc response led to the
d<:vclopment or various forms of PNF (i,e.. hold-relax. COI1tracl~rc1ax. elc.) that could be used for onhopcdic ;'IS well ;IS
neurologic problems. The osteopaths primarily used Illuscle
energy procedures (MEP) to mobilize joints, They abo dc\'eloped <l \'aricty of applications designed to stretch shortened
muscular and connective tissucs and to strengthen weak
muscles.
Manual medicine practitioners in Europe werc nol far behind in incorporating these new methods. Gaym<lns and
Lcwit~ wrQlC of success in applying these techniques for joint
mobilization using specific eye movements and respiratory
synkinesis to cnhance the physiologic effecti\'cness of the
procedures (sec Chapter II). Later. Lcwit~ foclIscd Oil a gentic muscle relaxation tcchniqut.:. termed post-isolllt.:tric relax-

I,_t)."-----_. ------",---!

I t.)
~

alion l'"llil"r to hold-relax), which W;'IS npplicd

lrac-till: portion of ..In overactivc llHlsde.

lO

the con-

,,1;UIIO'IUSClII.AII ,\1\[) IIIOMECHANICAL BASIS OF

FI.EXIBILITYTII,\I"I1\(;

Two a:-.pects to MRT arc their ilbility to relax an o\'eractive

muscle lincreased neuromuscular lens ion or "spasm") and
their ability to enhance stretch of a shortened muscle or its assm.:iated fascia. when c{}nnectivc tissue or \'iscoelastic
changes have occurred. Whcn using MRT. it is important to
n:h\:-: the neuromuscular (contr:lclilc) componem before attcmpting any aggressive stretching maneuver. Often a "release phenomena" Ol..:curs so that a length change occurs llUtom;'ltically after merely relaxing excessive neuromuscular
tension (~ce Chapter II). In such Cases. treatment serves as a
di;I~Hl0qic lest. differentiating neuromuscular (contractile)
from nmnecti\'c tissue (noncontractile) probkms. Even if
noncontractile p;lthologic changes have OCCUlTed. it is still
wisc to relax the ncuromuscul"r apparatus before stretching.
This \ler \\'ill inhibit the stretch rdlcx and allow the patient to
tolerate more vigorous stretching.
Two fUlldill1lentHlncurophysiologic principles account for
the neuromuscular inhibition that occurs during application of
Ihcse Icchniques. The firsl is postc{)ntr~lction inhibition. which
stale\ Ihal ;'lfter a muscle is <':olltracled. it is automatically in a
relaxed q~ltc ror a brief, latcnt perioo. The second is RI (reciprol:tJl inhibition). which sl;.ltes lhat when one mu:,dc is contr<lctcd. it'" ;lIH;'lgonist is aUlomatically inhibited. For instance.
ir the quadriccps is cOnlructcd. the hamstrings ar(' inhibited.
tllUS allowing for easier stretching of the 1'1Itt.'r muscks. This
prol..:cdurc takes advantage of Sherrington's Law of reciprocal
inhibition. The purpose of Rl is to allow an "lgoni:,{ (i.e.. biCCPS) to achieve its ;.u.:tion (flexion) unimpeded by ib antagonist (i.e .. triceps). Different cxplal1iJtions have ~'el1 proposed
for how the effects of MRT arc ;u.:hicved. Whert:..ls only postcontr<tc.:tion inhibililll\ ami RI havc been validatt:'d. other suggcstt.:d mechanisms includc autogenic inhibition. Goigi tcndon org.1O stimuhnion. rccipwl.:;ll inncrv<Ilion. pr~syn<lptic
inhibition of la afrercnts. rescuing or the gamma system, <.\l1d
postsynar1ic.; inhibitioll.
11 hal., been demonstraled that the receptors r~sponsible for
this inhibition arc intramuscular ,ll1d arc not in the skin or

253

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joints." Measurements of the Hoffman renex activity (reprcsCnlativc of the excitabilily of the motor neuron pool) show
activity is inhibited ror up to 15 to 30 sCl.:onds after an agonist
or antagonist contraction. \\'ht:I\~aS inhibition only lasts about
10 sec~nds during sratiL' slr:.:tclling. 7 This effcL:1 has been
found to be neurologically m~di;.ncd .md not a result of any
mechanical dfl..'('t.:<
Mu!'clc fiber:' also han:: l.:LI"tain billlllt:chanical dmractcristics thai ..Iffecl their stilrn~ss_ SJ.:'.:lctal muscle f1bcrs arc
known to adapl to imposed dcmands. For instance, during
growth. muscle length incl"l.."lsCS as new sarcomeres arc added
(in serie.s) and inJividml1 libcrs illcrc.lsc their girth." Prolonged iml\\obitizi:llion of a limb joim in"\11 extended or shortc,;cd position resui(s in all increase or decrease in the number
of sarcomcres. respectively."I" Whcn immobilized in a shortcned posilion. musdc sliffness incrC\lSCS. 1O It has been observed that an il1l::rcase in connective tissue occurs with
iml1lobilizHtillll in ..I shortened positien. II
Conncl.:tivt: tissuc proliferation is minimized if the immobilized muscles arc placed in a lengthcned posilion or their
contruclile aCli\ity is m.lintaincd with c1cctric<.11 stimulation. IIl 11 Thereforc. either p.lssive stretching or maintenance
of contractile activity in immobilized muscles can prevent
muscle sh0l1cning and connective tissue proliferation.
Shortencd muscles that have becn immobilized require
about 4 weeks of treatment to return to their pre-immobilil..ation lcng[h. lU Muscles stiffncss in response to streich varies on
the basis of intrinsic molecular propcrlies of muscle fibers.
Muscles that are kepi still increase their stiffness twofold in just
a few minutes.l~ Conversely. oscillations and isometric or eccentric muscles contractions all reduce muscle stiffncss. I~"L\
:This plasticity of muscle fibers in response (0 passive or active
movements is described ~IS thixotrophic behavior. This
lhixotrophy relates [0 changes in viscosity and resislance 10 deformaliOlI of the intrinsic molccular make-up of muscle fihers
that result from shaking or slirring motions. Both intrafusal and
extrafusal muscle fibers have thixotrophic propcnics. 14
Thixotrophic bonds are thoughl to occur between actin
and myosin filamcnts. 14 .15 Such bonds or cross bridges form
casily in muscles. According to Hagbarth. "After stretching or
passive shortening. it may take 15 minutes or more before
muscle fibers spontaneously return to their initial resting
Icngth."14 He also statcd. "Strong iSOI11clric contractions and
muscle slretching maneuvers arc likely to dissolve preexisting
actomyosin bonds and thereby rcdul.:c lhe inherent stiffness of
the cxtr.lfusal muscle fibers."l~

stabilization. The HR technique involves isometric resistance

and is u..:d mostly for pain relief. Used for relaxing and
stretching tight musclcs and related soft tissues, CR incorp{)~
rates isotonic resist:.mcc and l1lultiplanar (usually diagonal)
movemcnt. Both "lgonist and <llltagoni:'it muscles arc used to
cre:.He a neurophysiologic sUlllmation of RI and postcontraction inhibition.
When ost~op:lthic physicians used these procedures. they
applied them 10 lllobilil.e joinls. as well as to strenglhen and
relax muscles. referring to them as muscle cnergy procedures
(MEP)."' Using a langu"lge familiar to chiropractors. they described the area where Ihey fell movement was limited, or if
resistance is perceived prematurely after moving a joint
through its full available range of motion or lengthening a
muscle as far a.c; it will allow, as a "pathologic" barrier (sec

Fig. 11.3). The MEP were developed by o,teopalhs as allernatives to thrust manipulation procedures for restricted joilll
mobility. In these cl.lscs. the usc of fairly gentle forces arc required. 1lley were also used on muscles in a way similar to

PNF.
In Europe. milnual medicine physicians soon began expcr~
imcnling with Ihese methods. Gaymans and Lcwit~ wrote ofsuccess when using these techniques in an extremely gentle
fashion. At first, they used the rhythmic stabilization appro~\ch
borrowed from PNF. Latcr. Lc\Vit~ focused on the HR approach. He found that by positioning an overactive muscle in
a full stretch position and then resisting a gentle isometric contraclion. exccHc.. ~ ;;dilAz.tio;~ und an improved resling length
of the muscle could be achieved regularly. Lewit lcnncd this
approach postisomctric relaxation (PIR). Gaymans and Lewit4
also incorporated specific eye movements. asking the patient
to look in the direction of contraclion and then in the direction
of stretch. For most muscles. breathing in facilitates contraclion, ..md cxhaling aids relaxation in the overactive muscle.
Lcwit believed only the gentlest force was requircd.~
Janda used HR with signilicantly greater forces for treating true muscular and connectivc tissue shortening. Ii This
adapt<ltion. tcnned postfacilitation strclch (PFS). is for chronically shortened muscles. The patient performs a maximal
contraction with the tighl muscle from cl midrange position. "
On relaxalion. the dOClOr quickly stretchcs the muscle. taking
out all the slack.
Today. work by Evjenth and Hamberg stands as the most
'luthoritalive manual for these muscle stretching procedures. H\
They demonstrate the exact doctor and patient positions for
paforming HR for e~lch joint and muscle. Other ..wthms Iwvc
also used MRT. including Holl.'' describing the scientific

.)

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DIFFERENT METHODS
Proprioceptive Ilcuromuscul<lr facilitation (PNF) is the 1110st
complex systcm of MRTJ(, In PNF. ncuromuscular reeducation is thc goal. Manual COllWc:lJ, {Jatlellf prepo.\'itio1ling. I1WSch~ ceJlltrm:tioll against resislClIIce. irradiation. lind \'erhal
co"",uwds are all uscll ill concert to begi" the process of imI,roving 11/ovcmeflf. The inhibilOry techniques used mas1com11I0nly arc hold-relax (HR). l.:ontracHclax (CR). and rhy[hmic

Table 13.1. Manual Resistance Techniques

Pcoprioceplive neuromuscular lacifilalion'C.
Hold-relax
Contract-relax
Rhythmic stabilization

Muscle energy procedures,)

Postisometric ee!axation~'
PosUacilitation strelch 11

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:,lrCII,:hing for spon D S sll'L'IL'hingl; Callil'l:". llsing l1l11dilil't1

rhYlhlllic ~[;,hilil.ati()ll: and LiL'bC'llSnll ..",': ll~illg ;\lo."livc lllU",eh: re1;\.\;11101\ lechniques. The various ~Hrf :11\' Sllllllll;lril.cd
ill Tab": 1.,.1

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Table 13.4, Goals of Manual Resislance Techniques

Muscle inhibi tion relaxalion/decontraction
Muscle stretch
Fascial stretch

Muscle

lacitita,lc~

Joint mobilizallc,n
CI.ASSIFIC\T10N OFTI!;ItT Olt TENSE \1l!SCI.ES

i,

:\lo."lo."unling to bllda. il is p{lv,ihk hI divid\'" lIl11sd~ hYPl.r

tOil icily inhl a vOlriety of diffl.'rCnl lrC;llllll'1\Ispecilil' l';UC'
g{lrics.: ;"ll1~de dysfullction i, typic;dly ;111rihul;,hlc tu cilha
neuromuscular or Clll1nCclin.~ li~SllC r.K(Ors. Dilfcrclll Iyp'-'s of
dysfulll:lioll include rclk.\ ~paslll. il1lCrneUHlll f;ll,:ilitati\lll
frolll j(Jint llysfuIlCli(lll. trigger pili Ills, cCllIr;,1 nel'\'\HIS systcm
inl1ucllccs (i.e.. limbic ill\o]vcmellt). or gradual uvcnl~"':~
(Tahlc 13.2). For a full discussion of tlll.,:se diffcn':111 rilctor~.
see Chaph.:r .::,
j\...1akill~ a precise asses~mcm of soft lissuc fUl\ctiol1<.l!
palhology helps to guide thc trcatll1cllt dC'I~loIHnakil\!.!
process. In the c'lse ur mu~clc tightness <.Ir tension (T<able
13.3). specific IrcatmcllIS <Ire appropriale for each difTerent
type of dysfunction.

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CLINICAL '\1'1'LiCATION

M~IlHl:lI1\' rC''1sted exercIses arc the perrCl'1 bridge to ~lcti\'c

carc because thcy take place in the lreatment room .Illd the
doctor providC's appropriate resistance to specific movements
tlmt are being trained. Whcn pcrforming rvlRT, it is hcl pl"u I 10
realize that although many different namcs Iw\'c been used for
different techniques (PNF. i\,1EP, PIR, eIC.). there arc certain
common clements to successful MRT applk:Hioll, The MRT
involve isometric. concentric. or eccentric COIltr:IctiOllS. They
arc used to relax muscles. stretch muscles or fascia, mobilizc
joints, or fucilitatc mllscles. The clinical indic:ltlollS for these
methods arc summarized in Tuble 13.4

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Table 13.2. Classificalion of Tight or Tense Muscles

Neuromuscular
Reflex spasm
Interneuron
Trigger point
Umbric

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Type

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Table 13.3. Specific Treatment for Differenl Types of Muscle

Tensionmghlness

l~_.J"

Rellex
Interneuron
Trigger point
Limbic
Muscle lighlness

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Connective tissue
Overuse muscle lightness

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dysjifllCf i01/. 1I1'1'Iyillg M RT may re.m! t ill iI/eli reet mob;!;:llIiOfl

l?f' a joilll or at least make (11/ mljltSfmellt ",On: comforrable
C//IClloflg-laslill:: for fhe plltienr. Thll.'i, their mai" a/,p!icar;(m

i.'i ill dirc('f {/Hlilllellt of fire IIlf1sclIlar ('oll/Iument so as to 1.:11lranee the efficacy of jO;nf adjf!,ttmenfs. For both acute situations. which involve muscular guarding (neuromuscular tension or spasm"'), and chronic cases, which involve muscle
and fascinl shortening (connective tissue changes). MRT

serve as invaluable c1inic.allools.

These techniques may be used 10 rcl'lx tension in muscles
before thrust manipulmion. If, however, we desire to stretch
shortened muscles or fascia. then chiropractic adjustments
should preccde any aggressive stretching. Following an ad~
justmcnt. MRT can be used to reinforce neuromuscular reeducation.
The MRT require activc patient participation and arc
therefore les~ llkely thun p<lssive methods to encourage patient dependency. They arc, howe vcr, more demanding: of the
patient. Methods involving RI or gentle PIR typically are
painless, and. with a little patient education, arc simple to per~
form.
.Compared to decp tissue massage <lnd trigger point thcr~
apy (myo(hcrapy or receptor tonus). MRT can be a faster and
less painful Wl.lY
reducing increasl:d muscle tension or lrig~
gcr points, except if thc patient has poor coordination or is
simply umtble to relax. Patients with diHiculty relaxing often
nCl:d moist heal. relaxation and breathing exercises, and some
type of gentlc, nonpainful massage (i.e.. effieuragc). The
combinalion of M RT and soft tissuc procedurcs can be used
with grci.lt effect For instance, if <.In area of tcnsion i:, found
as Ihe tissuc~ arc being massaged. thc patient can be inslructctl to contracl with that tissue, This combination can
ortcn overcome even stubborn "knots,"'
For some patienls who cannot tolerate llcep soft tissue
m<.lnipulation (j.e.. Rolling or lransverse friction m;js~age),
MRT may be used to reducc the sensitivily of the area.
Following MRT application. decp massage or ischemic compression techniques usually are tolerable to the palient. Any
massage or p,.~sivc therapy runs the risk of encouraging patient dependcncy. Their usc should ;'lhv;'lYS be combined with
some form of paticllI education. exercise. and sclf~tn~allnent.
Positional release (i.e . strain/countcrstnlin) or osteopathic
fUllction'lltechniqucs ;,m;: preferable to MRT when it j .. diffi-

or

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ivl'lIlua! r~:-i~lancc h:chniq'!es havc bcen presented as altern;'lli\,cs 10 thrust manCllvers. but in the context of this chapter. they 'Ire :-C'(:11 primarily <IS a complcment to traditional chimpraclic and m:mual mcdicine mcthods. III as much as
(}\'Cf(lctil'l' or .\/ItJr(('/lt'd II/ltsd('s are n!l(l/ed to a specific joint

Cause (i.e .. remove appendix)

Joint manipulation
PIR or ischemic compression'
Yoga, meditation. counseling
PFS or eccentric MEP

'Abbrcviations: PIA, poslisomnttic rcla:o:alion; PFS, postlacifitalion strclch;

MEP. muscle energy procedures.

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cuI! to flnd an active movement that docs not provoke the

symplollls. Th~sc posilional rclC'lSC n~clhods (finding a .r~.:ain
less muscle or joint posilion and holdlllg lhere) arc a pamless
and effcclivc means 10 n.::ducc irritability and incrcnsc motion
in II pntient with soft tissuc p'lin.
. .
The MRT and Spray .ll1d Stretch have sundar goals and
may be used interch:lllge,.lb.ly. ~~oth arc consi?cred alt.ematives 10 dry needling and IIlJccllon of anesthetic for relief of
painful trigger poi:lls or rcriostC.11 auaciuncl~1 poil1l.sJ-I Spray
and Stretch is p<lssivc and (hus 111<1)' be better IIllhe fust slagcs
of lreatment when a pmicllt has poor motor control (inr.::oordination ,lIld difficulty relaxing). Patients who 'lre cold intolerant may require even more passive methods. such as heat.
electrotherapy. oSlcopathic functional technique. joint mobilization. or m<J,ssage. Spray and Stretch Can be used as an
altemative to PFS for lengthening shortened connective tissue. SOI1\t:limes Spray and Stretch and various MRT can bc
combined. Trial af:d error often dctermines which npproach
h<lS a greater inhibitory effcct on the muscle. Bccause of Ihe
negative environmenlal profile of fluoromethanes. PfR and
intermittent cold and Sirelch have ocen proposed as altern ativesY
An alternative to PFS for musculofao;cinl shortening is osteopathic myofascial release method. which typically encompasses lifting the involved soft tissues and stretching it perpendicular to its muscle fiber orientation. 1(, This melhod is
onen advant&lgeous because it avoids engaging the stretch reflex. Postfacilitation strclch, myofascial release. and deep tissue massage can often complement each other.
The use of hot packs. ultrasound. electrical muscle stimulation. and other passive lhcfmal or electrical methods is common in musculoskelclal clinical care. Their usc is sometimes
<Ippropriate in acute and subacute care. but is inappropriate in
rehabilitation beyond lhe phase of early soft tissue healing..
Maflual resislaflce lechniques hav.c Ihe adl'amagc Ilwl
while easily lolermed. like passive melhods. Ihey also involve
Ihe paliem ill all aClll'f \IlIY. ihus limilinf! paliem dependency.

The thrust of modem management of chronic pain is aW::IY

from passive therapy (physical agents) and toward active patient involvement in the rehabilitation processY~1I This focus
does not c1iminmc the role of passive thcrapies. bUl rather dir~cts patiel1ls tml,'&lrd functional restornlion in nctivities of
daily Jiving. The MRT &lrc ideal bridges between passivc and
active carc.
To summarize. when wc lind an abnormal restriction of
motion in a certain dircction. we have encolJlllered a pathologic barrier at that point of resistance. This barricr may rcsult
from joim blockagc. muscle shortening. or II combination of
the two. Manual resistance techniques arc one approach 10
eliminate this barricr and to restore normal r<lnge of motion
(ROM). They achieve this end by relaxing Ihe shortened muscle and/or mobilizing lhe hypomobile joint. \Vhen true joint
blockage exists. a chiropmctic adjustmcnt is without peer .IS
the treatment of choice. The MRT can stand all their own. but
they are bettcr as a complement to the adjustment and <l
bridge to exercisc.

RULES FOR APPLICATION

\Vhen using MRT. Ihe more specifically we can facililiJ(~ contraction in Ihe dcsirt:d muscle, the betler our results Will be.
Table 13.5 summarizes some of the keys to 3chicving successful facilit:ltion. For inst.lI1ce. how the patient is prepositinned affects how easy or Iw,rd it is to actiV<lle the muscle.
Our verbal command is also importune not only for what we
sa\'. hut <llso Ihe inncction we usc. Triul and error wilh cach
pa~icnt will reveal which commands activ:llC the desired
movcment beuer. In gcneml. saying to a patient to push to thc
right or left is not as good as giving them an actual larget.
M.tnual contacts arc facilitative. so it is normal to place a conwct on the muscle you wish to activate. Massage while the patienl is attcmpting to contract the muscle Illay help 10 mvakcn
a panicularly inhibited musclc. Irradiation is somctimcs use.d
to facilitate a muscle that is especially "dormant:' ThiS
process involvcs using a synergistic muscle that is stronger to
pull its inhibited neighbor into action.
.
Various ouidelincs help us to avoid irritating patients
o
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..
whr.n !'trelching. \Ve must not put relaled Jomts In n position
of strain (Le. ~Iose packed position) during stretching. For
example. when stretching the iliopsoas. allowing the lumbar
spine to extend puts too much strain on the low back. \Vh~n
stretching in the spinal column. it is also irnporta~l to a~old
uncoupled movements. For instance. in the cervical spme.
proper coupling occurs when rotation and side bending o~cllr
in the same direction (srinous process toward the convcxily).
In the lumbar spine. it is the opposite. unless the spine is
flexed: in the neutral or extended positions. normal lumbar
coupling takes place when rotation and side bending OCcur in
opposite directions (the spinous process moves IOwa:~ ~he
concavity). This infonnation is important when mobl!l7.1~g
joints with MRT and when stretching muscles that reqUire
taking out slack in what would be an uncoupled manner for
the underlying spinal joints.
.
An example of an uncoupled joint position is the l:crvl~al
side bending awny and rotation toward an upper Ir<lpczl~s
muscle being stretched. Because this positioning would stram
the' cerVical'" spine. we slretch almost complctely over the
upper back and shoulder area and avoid any cOl~trac!ion or
strong stretching in the neck area. This situation Illustrates a
gcncnll rule in stretching-stretch over lhe largest. Ill.ost st;].~
ble. and le<lst painful joint.!'j Additionally. how we "Wind-up
the upper trapezius will reduce the potential for neck str::lin.
\Ve first take out full ncxion and rotation. {hCll gentl}' side-.
bend the neck away from the muscle. and finally firml}' take
out slack in the upper back :'lIld shoulder regions. The patient's contraction would be only from the shoulder ill <l diTable 13.5. Facililalion Techniques
Preposilioning
Hand contacts
Tissue stimulation
Verbal cues or commands
Irradiation

.'"'1.

l,;HA .... 1tH 13: MANUAL Ht:::SISTANCE ANl) ::it::LF-STRETCHES t-OH IMPROVING FLEXIBILITY/MOBILITY

Table 13.6. Safety Rules

Stretch over largest. most stable, least painful joint
PI<.lce joints in Mloose packed~ posilion
Avoid uncoupled spinal movemenls
Do nol streIch nerves. it iuitaled

n:t:tioll or ~kv;ltiOI1. Ouring relaxation ;1l1t1 strctch, we take

out the s1;l<:k o\'~r Ih~ larger, more stabk shoulder and avoid
taking out slack ill (he neck, ex.cept perhaps in ncxion.
AnOlher ruk is to avoid stretching related SlrUCLUrcs, such
.IS a nerve root, if il is irritatcd. N Hopefully, every clinician
kltlJ\vs not to streich the hamstrings if the sciu.tic nervc is irriwtcd. Another simil:.tr arC;l is the femoral ncrve anti rectus
femoris. or the br;lchi;11 plexus, which C:.lll be stretched when
;utcl1lpting to stretch the scalene or subscapularis muscle.
T"lb1c 13.6 summarizes these import:.lnt safety tips during
slretching.
How wc "wind-up' the muscle, in other words the order
wilh which we lake out the slack in the different movement
dircctions (rot;llioll, Ocxion/cxtcllsioll. side bending), dramatically :.liters when the p;lticnt fccls most of the streteh.~o,l
Playing with this v;'lri:.lblc allows for bcltcr isolu.tioll of the relevant tissue. Most people use too great of force when they
lirsl begin to usc MRT. According to Larricq, the forces used
during MRT should be "as little:.ls possible for as long as neccssary:'~'1 According to Lewit, the time of the contraction can
be lengthened for up to 30 seconds if inhibition is h:.lrd to
achieve.~ Whether to adjust joints before or after MRT is a
common question. If significant joint restriction is encountered during attempts to stretch, it is crucial to adjust the joint
first. Otherwise, adjustment is easier and thereby requires less
force if we wait until :.lfter the contmctilc clements have been
relaxed. Different ways to improvc MRT results ;lre listed in
Table 13.7.

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Success wilh Ihis method depends on precise posilioning

of lhe body part 10 isolale lhe lense muscular bundles involved. Il is also essenliallo lake out all the slack in the muscle and to stay at lhe end point of the available ROM throughout the procedure. Indications for its use include increased
neuromuscular lcnsion (i.e., trigger points) and joint mobiliz:.ltion (gentle).
A second valuable MRT, particularly for patients with myofascia1 shortening (viscoehlstic stiffness), is postfacilitntion
stretch (PFS).11 Tl,i:'> ,','ldIl0u ilhl)lve~ the following steps:

Postisomctric relaxation (PIR) is one of the most useful MRT.

This method is Lewit's modification of the gentle. indirect
isometric MEP that osteopaths applied to joints. s It is also
similar to hold-(clax. The main indication for PIR is relaxation (decontraction) of a hypertonic (contractcd) muscle.
Posti~omctric relaxation is the preferred method if the patient
has difficulty relaxing or you simply want 10 use a "soflcr" ap.proach until you gain the patient's trust. It is ideal for trigger
points, joint mobilization, and neuromuscular tension.
Postisornctric relaxmion (PIR) involves the following
simple s(eps:~

I,
li

3. Having "let go" and rela,.ed fully. the musclc is slowly, passively
lengthenLJ toward a new resting length as far as relaxation wilt
allow.
4. Without b;lcking away from the new end point. perform two (0
four 'ldditiOllal rcpclitions.
5. If rdu;atiun is nut achieved. tf)' the following:
Be slIrc the palient hrcilthC5 ill during contraction phase :Iud exhales during rcl;Jxation phase
Fur most (<<Illk and cXlrcmity Illll..dc...... the p3til.,nt o,;JulIlld look
in the direction of contraction and then in the direction of
stretch
Lengthen the lime of eonlfaction up to 30 scconds
Try a harder conI rae lion, although do not rcsist the contr.Iction
when the muscles arc in Iheir fully lengthened position
St<lrting from a midrange position. usc isotonic resistance of
movemenl by the antagonist muscle towurd thl: reslrieted barrier onc to three tillles
6. After nccornplishing the preceding sleps, instruct the patient to
pcrfonn active ROM exercise through the new range

SPECIFIC I'ROCEI)URES

oj

I. Passively Icnglhcn lense muscle 10 a point JUSt shon of pain or

where rcsist.lOee to movement (barrier) is feh. Avoid bouncing.
2. Have palient gently contract lhe ovcracti ....e muscle away from
barrier fur 5 to 10 seconds. 'ntis movement should he resisted
with equal cuulllerforce. creating an isometric cOlltr.lction. For
most muscles. the patient should breathe in while contracting the
muscle.

C)

N
, '4

l,
:g

Jr
~

;;

!..

257

.._....... _-------

I. Place shortened muscle in a position approximately midway between its fully approximated and stretched positions
2. Have the patienl contrJct isomelrically with m:.Lximum effort for
7 to 10 scconds. and resist this movcment to create a nearly isomelric eOlltmction
3. When the patient has "let go," perform a quick stretch to the final
end point (:lv()id bouncing) :U1d hold for up to 20 sl:conds
4. Allow the p.llicnt to rc!;\x for 20 to 30 seconds
5. Repeat three H) live times
6. Inslruct the patiellt 10 perform an activc RO;\t l.'xl:rcise lhrough
lhc new r;mge

After pcrfomling PFS, \V30l the patient that feeling

wannth, weakness, burning, or tingling in the :,tretched tissue
is normal. An appropriate series or such stretches \,.'Ould include six visits over a 2-wcck period.
[n PNF, two of the most famous MRT arc holtire{ax (HRl
and contract-relax (CR). The former invol\"t~:' positioning the
patient in the stretch position Jnd pushing ilHo the "barrier" of
resistance while u.sking the patient lo hold. Thi~ step encourages an isometric contraction. After the rc~i~tcd contraction.

Table 13.7. Ways to Maximize Results of Manual

Resistance Techniques

up" muscles 10 maximize isolalion

Slart gentle and add (orce only if necessary
Increase contraction lime up to 30 seconds
Adjust restricteQ joints first

~Wind

....,

SELECTED

Table 13.8. Matching Therapeutic Goals to Manual

Resistance Techniques
Techniques'

Inhibit
Muscle

PIR
HR

+
+

CR

PFS
Eccentric MEP

Stretch
Musde

+
+
+
+

Stretch
Fascia

~IRT PI~(}C:~ntJI~ES

Manual resistance techniqu~s can be used for a "ariet)' of purposes. Thc)' Jorc ahcrnativcs to adjmamcnls or soft ,issue
work. The)' ,Ire powcrful facilitation and strengthening techniques. They ar~ most famolls. howcvcr. for tht'ir <Ihility to
stretch Illuscks.

Mobilize
Joint

...
+
+

..

'PIA, postisomctric relaxation; HA. hoklrelax; CR. con\racHelax: PFS. post

facilitation stretch; MEP, muscle anergy procedures.

stretch may be increased either actively (by the patient) or

passively (by the doctor). When performed actively. the patient is activating the antagonist to move toward the restrictcd
barrier. This effort engages RI. which inhibits the tight muscle even more. When performed passlvcl)'~ the doctor must
not overstretch the tight muscle to avoid activating the stretch
reflex, which would only increase the tension in the muscle
and defeat the purpose of the eOlire exercise.
Con'r"ct-r~I;lx involves laking out the slack and then
commanding the patient to "push against mc" or "push toward.... (an objcct or t<lrgcl)." This step encourages a con
centric contraction because pushing implies movement
(whereas holding implies staying stationary). Unlike PIR, you
allow a greater force and Jccornp'lIlying movement. At thc
end of the contraction. Rima)' be used so it is the patient who
actively takes out the slack. Th!s combination is often called
contractrelcu alllagofli.w contraction (CRAC). This mcthod
is preferable to HR if the patient is using a stronger muscle
that would be hard for you to resist isometrically.
An alternative to PFS for stretching connective tissues is
the osteopathic eccelllric M/~ which involvcs starting at a
midrange position and having the patient push lightly ag.linst
your resislance (20% effort). Although they push lightly. you
lengthen the muscle. The patient must continue to contract
lightly so that it is a lengthening or eccentric contraction. This
maneuver is excellent for lengthening noncontractile clements.
Table 13.8 summarizes the choice of MRT depending on
the spccific treauncnt goal.
Self-stretching should be performed on a regular b'lsis to
prevent recurrence of viscoelastic stiffncss or elcv:ued neuromuscular tension. Oncc or twit:C'l day. key tense or stiff mllSc1es may be gently strctchcd. Simple guidclincs for selfstretching are as follows:
I. If possible. perform simple w;lrm-ups before stretching
2. Gently take out allihe slack in the ill\'ol\'l:d muscle until you fcel
a gentle pulling
3. Maintain good body posture so no str,lin is felt anywhere else in
the body
4. Hold the stretch position for 101020 sel.:ouus. t;lking OUI t'unhcr
slack as relaxation is achieved
5. Brc;llh deeply and slowly to encourage relaxation
6. Repeat stretches at least twice per session :mtl one to two times

PIR Procedures for Muscle Relaxation and Stretch

The format for this scclion is designed for casy clinical 'lppJi.
cation. Rei:ldcrs arc encouraged tu rdcr to Chaplers 5. 6. It
and IS for morc dct:.lil rcg;lrding spcdlit.: te~;(s. rclmcd
strengthening exercises, or treatment protocols. The following hendings are used for most ()!' the musdcs described:
Referred Pain: Location (If pain cmnpl:lilll
Clinical Result of Shortened Musclc: Relal~d dinic.:allimtlngs
Activation or Perpetuation: \Vlmt activ:l1cs (l( pcrpctu,lICS trigger point

Obscr\'<Jtion: Postur..11 analysis

Triggcr Point: L(X,;;\tio!l
Pcriosteal Point: Localion
E\'alualion for Qicr".JctivHy: How muscle

(lvcr:lCtivily w(luld

be seCIl

E\'aluation for Muscle Shortening: Test fur muscle tiglllllcss

Joint D)'sfunction: Rehllcd joint dysfunctioJl
Corrective Actions: Exercise <lnd educational :.lpproach
MRT Stretch:
Patient Position
Doctor Position
Patient's Activc Effon
Stretch

Other MRT Stretches

Self-Stretches
HAMSTRING (Fig. 13.1)

Referred Paill
Lower bunod: to upper c:lIf
Clillical Result oj Sltortelled Muscle
Recurrent pulled hamstring::-

/\cti,'atioll or Perpelllatioll
Compensation for weak glutcus maxinms
Compression of posterior thigh from a chair that is ton high
Being in a shortened posilion from prolonged silting

.J

Trigger Points
Midhdly

.J

Periosteal Points
Ischi:J1 tuberosity
Fibular head (biceps femoris)

E"alllati(JJJJor Oterar..'ti"ity
Knee flexion during prone hip extension tes!

per d3)'
7. Aftcr stretching. actively contract the muscle and move it throut!h
a full ROt\'1 a few times

"",

EI'allilI/iQil Jor Shortenillg

Strai~ht

leg

rai~illg

tcst (If less than

~O"

CHAPTER 13 , MANUAL RESISTANCE AND SELF STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY

259

Stretch

10illt !)ys!uflctioll
15SI

Flexion of hip while m~lintailling knee in extcnsioll

/:ihtll"l" hl,.';\d

C:"n'('din' Action
I::llililal..: {Ir "'lrlIlg,!..h;:J.L!J.~ ~hll":U~.!t!~~\illltiS
:\\oil! prnllllt,::..:d ~iHin~

COl1lmelll

Care should be t"ken whenever stretching the h:lIl1strin~... that

the sciatic nayc tcnsion tests (Lcsaguc's tcst or Str~i~ht Leg
R:lising lest) ar~Jlcgativc. Also. in lhe casc of lumb;.u- j\")int irritability. :he opposite hip and knee Illay be Ilcxeli h) rl'dllt::~
strain on the lumbar spine.
Other iURT Stretches. Additional hamstring PIR procedures arc shown for the medial fibers (Fig. 13.2a. L lateral
fibers (Fig. 13.2b). and the one joint hamstring-the biceps

:H NT .'trctch
PI/tina /'(I.\ir;/I/I
Supill":

llip Ikxcd ;1110 kllcc I.:xlcl1lkd

1l1l

involvcd limh

Slal1lling Oil ,id.. . of tr.. . aling limb

C.... pllal.ld hand proximal 10 patdlac maintaining. kncl.: in eXll.:n~iu[\
1';\lil.:lIl's h,.-g ,upportco 011 doctor"s shuulder or ill crook of dbuw

to pu"h kg down IOWi.m.lli.lblc

Effort i~ rc!'>i~tcd by doctur 10 keep cOIllr.lctinll ;IS close (0 isometrit' a:- ptl:-~ihk

Alh.:mpls

femoris (Fig. 13.3).

Self-Stretches. For hamstring self-strelches. the back

mu<l be stable. The patiel1l should feel the stretch in the

posterior thigh. but no stnlin in the lower back (Fi~:-. 13.4
and 13.5). Oncc the final strctch position is 3.:-hic\'cd
during the standing self-strclches. (hc paticnt will fed a
greater stretch if instruclcd to pcrfoml an 'antt:rlo( pelvic
tilt.
ADDUCTORS (F;gs. 13.6 and 13.7)

Referred Pain
Groin. inner thigh.

~Il\tl.:ri()r

knce. ;lIld shin

Clinical Result of Shortened Muscle

..

~ .

Hip or ,,;wrniliac di-.;ordcl's or medial kn.... t: pain

"). Diffkulty wilh squats

....;. Difficulty \"ith activation of gluteus mt:dius

';

Activation or Perpetuation
Hip arthritis. horscb;ll.:k riding. hill nl1lning. st!tkkn ~... \'t.~r1oad
(slipping)

Trigger Poillts
Muscle belly

Periosteal Poil/ts
Pubic symphysis
Fig. 13.1. Hamstring PIA.

Tihi;t1 tubcrdt: (pes

Fig. 13.2. Medial and lateral hamstring PIA.

;1Il:;.... rinu~)

(two j{lim ;Idductors)

.. ,_ ..,... ..... ',

EI'!ll!!~!f!.'::

,v,~,-n.;;)

IVII-\I,/UI-\L

,,
,,

for .':I::::tLllillg

Wilh p;llil'lll :-upinl.:. ahl!ul..1 llli~ll Wilh ~nl.:l.: olL'ndl'd (l\Ilrlllal

is 4(0)
Fkx kl\~c ;\llli ;lrdllclion :dl11uld itl~rl..'as.c s.lig.htly

)o;"t !)ysjllt,ctiotl
Hip joinl

'\

M NT ."(rctch: Supinc
PaticlI! Posirioll
Supinc
Leg ;lbduc(cd (knl.:c Ih: . . . cl! or ~Xll.:llllcd to i.'Olall'
mJductu(s., n:spccti\'c1y) until rCs.i~t;\IIl.:C is fdt
Opposite kn~1.: i:- bellI

(Ill\..'

or 1\\'(1 joinl

[)oClOr Po.\-;tio"

Swnding with
Fig. 13.3. Biceps femoris PIA.

on~

leg hl:twcl:n P:JliCIII"s ahduc[l'u thigh and lhl'

table

PariclI! \ Actin! E!fort

AllcmplS to ru~h lhih inlo mlduClion

Effort is resisted by doClor's leI;

[0

keep conlractioll:J~ dos.e to

is(I-

mctric as po;;siblc

Stretch
Doctor lhen takes out slack intn further ;ltldw.:lilll1

MRT Stretch: Side Lying

Parietlf POJirion
Side lying invoh'cd side up
Nontreated leg bent at knee and hip
Thigh abduclcd (knee ncxcd or eXlended 10 i:;olate nile O( l\\"ll joinl
adductors. respectively) lIIuil rcsismnce is felt

()

Fig. 13,4. Hamstring sellstrelch,

Fig, 13.5. Hamstring selfstretch.

\3

vM"~ I eH '"

MANUAL RESISTANCE AND SELF-STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY

.-

.-

_-/... ~ -.: ~rY~~ ,

Fig. 13.6. One and two joint adductor PIA.

Fig. 13.7. One and two joint adductor PIA.

SelfSlrelelles

Doctor Pos;lh",
Standing behind patient
Abducts p:llicl1l's Ihigh. caudal hand hooking 11lldcr patient's kllc~'
Cephalad hand SI<lbilizcs pelvis

Self stretches ilrc shown in Figure 13.8.

ILIOPSOAS (Fig. 13.9)

Referred Paill

"otie"':.. AClin' Effort

Attempts 10 push thigh jilin adduction toward table
Effort is resisted by doctor's caudill arm ((l keep contraction a...
c!(lSC 10

isometric as possihk

Slreleil

Doctor lhl'"

Low back and s'lcroiliac joint. anteriur {high

Clinical He.mlt of t.111scle Shortelling

Poor hip extension
Forward-druwn posture
Difficulty with posterior pelvic till

Activation ()r Perpetuation

lakc~

{lut sl;lck inln further abductiol1

Recenl irllCfvcrtchral

di~k

syndrmnc

261

~ . . . . . . . . "'"

.-.1"\ ..... ,

I ' ,v",~n ~ I'II',...I'IVI-\L

.,. ,
,

'T,'.

''!,

Fig. 13.8. AdduClor self-slrelches.

Correc/il'e Action

SW,ly b,lck (pSO;\$ must act ,IS a checkrein)

Prolonged sitting
Compensation for weak abdominals

Avoid prolollg~d ~ilting

Facilitate ;lIld :-l~ngthen abduminals
Sln:teh cn;Clnr ~rinac

Trigger Points

MRT Stretch: Supine

Anywhere in muscle belly

Evaluation for Overactivity

Pmh'lIt POJir;oll
Sllpine
Lumbar spine Ol.:iy be latemlly flexed away from psoas
Contr.llalcral hip and knee held in full flexion against chest
Involvcd hip frcdy extending off end or side of wble (prefer-lolc
with table height of al le,lst 40 inches)

lmlbility to keep heels on floor during kncc bem sit-up

Eva/ua/ioll for Shortelling

Modified Thomas test
Patient pulls opposite knee to chest
Allow tested Icg to extend off table
Posltivc (cst if hip raises without knee extension (tigtll rcctus
femoris) or abduction (tight TFL)

Doctor PO.'iirirm
Al ~;\lne ~idc of l:Jblc as invulved limb or al end of table
One h'lml IwlJ, cnntral;\tcr:ll knee to chest. thereby stabili1.jn~
pelvis
Oth~r h:llltl t:olll.:in:- proximal to knee or eXh:nded leg

Joint Dysfunction
TIOL1

Pari'1ll \' Actin'

Rai~cs

[:.:flo'"

involq::d thigh up towmd ceiling

Fig. 13.9. Iliopsoas PIA.

Fig. 13.10. Rectus lemoris PIA.

..... ' ,n,' ll::n l~. IVl""~VI"\L nr.:.~l~ If\NLot: f\1\lU ~C:Lt"-~ I He I LoMc~ ~Ur1 lMr'HUV1N(,:i

t-U:XIBILII Y/MUI:UU

263

I Y

::: :hc attempt to tak..:: -.:!lthc

lordosis out of lh~ lumbar spint:o Somelimcs. it i" l\L'n''' ... ~:ry 10
perronn trat.:tillO or PIR mobilizalioll Oil thc \Jppl1sile hlp. 01'
PIR on Ihe ilior'l~:.lS or adduclOrs 10 IOOSClllhl..'llip suflili ... IUly
In allow fur full hlp flexion.
Ot1w,. MRT '\Irt'/t:},cs. Ollter rc1all.:d hip lh.'~or PII{ pm
("l'dures illdlld~' Ihl.' reClus r"':llll11'is (Fig. l~.l(ll alld pI"11i1:.. iliopsoas (Fig. 1::'.11 l. For the prom: iliopsoas. thl.~ hip . . !h11lId
be internally r~llJtl.'J and Ihe spine laterally hl.:llt away. C,tl"l.' i~
needed to avoid :Jbductillg the thigh. This pn1(cdurl' I' Pl'!'haps lhe most :-~cilic iliopsu<ls stretch. but it is a trcllll.'n~hlllS
sll.11n on the doctor without the usc of an elevation tabk. Ifall
elevation t;.\blc i!'ro used, Sti.lrt in elevation ~lIld hold the (hi~h up
while allowing the tablc to lower and silllll!l;Il1Ctlusly . . tr('t(!l
the muscle. A stretching belt may ;\Iso be used.

u;:~!nn ::~ay r;"~lr.;::-;: "b;:;,::';'i;j~ ,~f:"

Self.StretclJes. When performing

self-stretches

((lr

Ih~

hip flexors, the patient should feci the strctl..'!l in the alH('ri(l1'
hip or thigh and not in the low back. For the iliopsoas. better
stretch is accomplished if the patient holds a posterior pcldc
tilt and internally rotates the hip while stretching (Fig. 1,...... 1~).

The reclUS femoris stretch requires some knee nexion t Fig.

13.13) and ;l1so benefits from a posterior pelvic tilt.
To enhance pso:!~ i~olation. patient tolt! to
sistance orfcred by ther<lpist's leg
Efron is resisted isometrically by doctor

~tlpin"tc

fool against n,:.

TENSOR FASCIA LATAE (TFL) (Fig. 13.14)

Referred Pain
L:IICf:11 :1~Pl;'ct C);.

.~,,.~;r(/,

Clinical Rewll of SllOr/cncd i\1uscle

Once patient ha!> fully relaxed. doctor takes up sl;lck by extending

hip to its new cnd point while sl;tbilizing opposite side

Co/llmenl

Knee extensor mechanism disorders

Sacroiliac problems
QL myofasc:ial di"orucrs

Actimthm

Palients orten complain of discomfon in the fully llcxed hip

(the onc not being stretched). which may bt: provoked by the
passivc o\'crprcs~urc rcquired lO nallCn the low back. This sit

Of

.._._

. --_._-_.._.

Perpetuation

Repetitive' strain frum funning

LHeml pelvic ...hi!"1
Forcrunt inslability (ex.ccssive pronation)
Pro!ongeu sittinf wilh hip too ncxcd
Cmnpells:llinn u, :1 wC;lk gllltcu~ l1Ieuius

Fig. 13.12. Iliopsoas self-stretches.

thigh III knee

\)
I.--~~

,i J

,''1:
, ,,'
Fig. 13.13. Rectus femoris self-stretches.
'~

I -'
Trigger Palm
Superior or mid porti(ln of muscle

Observation
Groove presellt in iliotibiJI b~ll1d
Ll1cral dc\'i'Hion of pafdlac

EvaluatiolZ for

I,

MilT Streich

Pot;elll Po.\';r;OI1

Side lying. invoh'cd ~i(.k up

NOlltrc;\tcu leg hem at knee ~lrlcJ hip
Thigh addllctcd behind patient unlil rcsisl~IIU;C is felt

O~'eractil'il)'

Hip flexion during hip :.lbdUClio!l (gIU[Cll~ medius) test

El'aluatioll for Shorteuing

/)oc[or Po.\'ifhm
Sl~lndillg

behind pali~nl
patienl's Ihi~h with caudal hand a!:x)\'c kncc

Ober's (cst

Addll<:l~

Resistance to addllction of thigh

Cephalad hand stahilize, pelvis

10illt Dysfunction
Sacroiliac joint
Patdlofclllor.ti joiut

Corrective Action
"Short fool"

cxcrcisc~

Foot orthotics
racilitatc and strengthen glutclIs medius

Patient\"

Acri\'" 1:.1Iorr

Attcmpl\ tn push Ih;~h ill\o ;lbduClioll 1tl\vard ceiling

i~ n.:sistcd by d<.Klor's c;lmlal !l;l1ld to h:cJl COtltr;lL'tiol1 ;IS
c1(l~C In isollleiric a~ po.."iblc

Eff(.Jr1

'-';

Strctch
Doclor then takes out

~Iack

into further adduction

Other MRT Stretches, The TFL C<tJl also be stretched

with the patient supine (Fig. 13.15). This stretch is felt in the
quadratus lumborum (QL) if the TFL is not light
Self-Stretches. A self-stretch for lhe TFL similm to the
lateral pelvic shift technique that is often used before cngag~
ing in McKenzie extension exercises.
PIRIFORMIS (F!g, 13-161

Referred Paitl
Posterior thigh. buttock. and sacroiliac joint

Clinical Effect of Shortelled Mllscle

Fig. 13,14. Tensor fascia latae PIR.

Sacroiliilc disorders
Entrapmenl neuropathy fst::i;llic ncrve)

CHAPTER 13: MANUAL RESISTANCE AND SELFSTRETCHES FQR IMPROVING FLEXIBILITY/MOBILITY

265
._------'=

:\tNT Stn'tdt
Pp,it;o1/

J'{lf;I'1/i

SUpilll'
llip Ik\,:.! ;.hl'"1 -1;," (lIl:t.\illllllll of ()(J"J
I\.llll' th:\l'd ;11'11111 \)l)"

SI;tllliin,::

)
Fig. 13.15. Tensor fascia [alae PIR.

()

.1Il1ll\tlh .... d :--Id.: ,

f;ll-illg paticn(

CCl'hahtd t"orcann \111 paticll!" thigh SUpplll'h:d hy d{ll({lr~ dlc!'ot

Ccphabll 11;1111.1 pllslws Ihroll~h knce. down shaft or femur
Dnctur [lll,hc... pallcnl's thigh inlO adtlllt..'ti(lll
Caudal !l;llld gra:-.ps paticllt's calf or ankle and produces internal
nllallllll

i
i'

Push.:" thigh outw;ll.. i inhl dodll!"':,> c.:hc.:"l (al"luuIUlli

Also pu\hc\ I(lwcr Iq~ inward in Ilppl)sitc din:c.:ti\lll.lr.... a(in~ an ex

ternal wt;.lti(!/l furce

Stretch
Once p,lliclH has f\llly relaxed. uoclor ;lddllCIS ;lllt! im.. . rnally roo
lates P;lIiCIII'\ thigh iii ,I IWW c.:nu point

Other .HNT ,\/rett:hc.\". PIR can also be performed on the

piriformi:-- supine in adduction (Fig. J 3. J7a), in full flexion
with lhe hip externally rol<:llcd (Fig. 1317b), or prone (Fig_
13.17cl with lh~ knee flexed 90".
Selj-Stn:l<:JH!S. Self-stretches for the piriformis are possible in a \'aricty of positions (Fig. 13.1 R). Figure 13.19 shows
a strong posterior hip capsulc streIch that also addresses piriformis shortcning.

.,
j

Fig. 13.16. Piriformis PIR.

()
)

QUADRICEPS

/\ctiJ'at;oll or Perpetuation
Short leg
Long drive with hip flexed OJnd 'lhductcd
C(lll1pcn~ali(ln for we,lk ~lU1Cll'" medius

, ,..

ObserWllioJJ
fouul lurnc(J

(lUI

in :.I'lIIdinJ; pusture

TrigKer Poim
~'lus<:lc

helly

l\.-lllscul'lf guardillg elicited on light p'llpation over sciatic nOIl;'h

h"wlhwfioll for Overaclil'ily

!-lip c:\lcrrwl rotation or pelvic rOlillion during hip abduction
teus mediu!' tcst

(~Iu

Evaluation for Shortening

(J

Palien! !-upinc. flex hip less ll1an 60, Apply compressive pressure
IhrUll!;h femur tu hip. and mJducl fully: fecI resiliency to internal
wlatiun of hip

')

Joint Dy.~fll"cliall
L4-L5 am! sac.:roiliac joilH

,.....J\

Correct !'ohnrt fOOl

Carrective l\ctiOlI
Improvc chair

F;11:ililalc <llld

l)

:-lrell~lhel1

gltlh:US lllcdiu!'o

Thc quadriccp:-- is morc commonly weak than i( is tight.

Ortell. n:clll . . fl.'llloris tighillC.. . S is mistaken for quadriceps
tightlll'S\. \\'cak ljlladriccp.. . typically kad iO stoop rather than
squat lifting lcchlliquc, which leads III lumbar O\l.'fstrcss.
Squats ;101i lunges arc the most fUllclional exercises for training the quadriceps.
Postborlll:tric I'daxati()ll on the quadriceps is l.'asily perhlrnlcd while PH)ll\.' (Fig. 1.1.2(). Tllis pro<.::cdurc is like the
fcmoral nerve strc{l:h tcst ill that if the ilssol:iatcd nerVe is
compromi\cd. thiS strctch i:-- contraindil:iltcd. Self-stretch can
be aided by the tlSl,; of a belt looped around thl' fOOl (Fig.
13.21). Self-Pm. l:all l:asily be' ac<.:omplishcd with this
mcthod.
GLUTEUS MAXIMUS

Stretching Ihis prim,lry hip extensor is orten 110t necessary. except for those lndividuals in whom this muscle is very
light. The PIR techniClllc is also a good way to facilitate
this muscle for (raining with posterior pelvic tills. bridg~s.
and other strengthening cxcn.:ises. Selfstretching is per
rormed .il"t like (ht: Ir;ulition;a) Williams cxef(:i~l..s (Figs.
I ~.22 ilml I ~.2:\ I.

nCnnl,.Jll-.' Inl IV''1 u r

,nc ,;,rll'lc. n

1IIIUI'lCn,;, IYI ..... I'llVnl..

r n .... v

Fig. 13.17. Piriformis PIA.

Fig. 13.18. Piriformis self-slrelches.

. . _..- ._-------------------------=.

CHAPTER 13: MANUAL RESISTANCE AND SELF,STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY

267

I
!,,

! ,
~ "

0'

Fig. 13.19. Posterior hip capsule and piriformis sell-stretch.

'- .."

I
I

Trigger Polms
Bencath erector ~pin:le l1luscic \;llcr;lIIO tr:.lll$Vcn.c processes
Best to palpate with patient side Iyin~

II ,
-;

Periosteal Poiws

.,

lIi;IC cn:!'l aHachm\:llI

EJ'lIlu(lliml for O,'cractivity

011 hip ;llxlu,;\ioll fn)lll sidt: lying POSillt1ll. monitor for early pelvic
c1cva\ion

;~

fu

EI'(l{U(ltioll for Shortcuing

St:rccllill~ le't:

si\h: I~ in:; patient r.lil'l.'l' tfunk lip \\'itlt hand or foreann tllll.h:r .. hmlllk'r. P\lsitive result i:, ;lhsellCc of smooth COllvexil): of lumhar Spill\.' \\1w;1fl1 down side.

"j

joi"t lJy...ftmc:timt

i';:

'1'111,1.1

~!

Fig. 13.20. Quadriceps PIR.

HIP INTERNAL ROTATORS PRONE

.I

Postisol11ctric relaxation for rC~lric!cd hip external nH,uioll i...

similar to the prone piriformis technique (Fig. 13.24). The
pelvis must be firmly st<.tbili~cd during this procedure.

\.)

,*.',

OUADRATUS LUMBORUM (OL) (Fig. 13.25)

:v
'~

Referred Pain

!! i.J
~

't
~

>

Ctlrrct:t Illlkn:1 pd\ i.. when .. ittiu);

F;lciliw{c (If strl'n~!h\.'11 ghllells medi\l:'
Te;ll.:b proper liflil\~ 1\'l,,'hlliqllC

MRT Strelell
Porie,,' 1'0,\';1;011
Side lying. lnvolwd side down
Pdvis {lH:kcd so 1\1['S\1 is slightly Hl!;\{l,:d hack ward
1lips and knccs 11..':\\.'\.190" wilh ankks \'wsscd

Lah:ral fibers-iliac cresl and laleral hip

Medial fibers-sacroiliac joint. deep in buttock

"'..I

Clinical Result of ShorICllccl/Husc!e

I, ()

Low back pain

Ill.:rpctuatioll or sacroiliac di..,ordcrs
Abnormal hip hiking during ;,tit

'if

.~

Activatioll or Perpetuatioll

Lifling \\'ilh tnmk Iwisled

I \.)

Su:"taincd OVCrlll;\d as in

~
~;

,~

;..

"

I l .,',

Corrective Action
11:);

("iIlTCl,;\ .. hon

g;lrdcll;lI~ Of

working in sl()(lped pusition

Fig, 13.21. Quadriceps self-PIA.

Mt:n .....CILIH\lIVN Ut" I

Ht:

::it-'INt:: A

PRACTITIONER'S MANUAL

Figs. 13.22 and 13.23. Gluteus maximus self-stretch.

Clillical Effect of Shortellcd Mllse/e

Low back pain
Inhibition of abdominals

Activation or Perpetuation
Postuml overstrain (sustained slumping or stooping)
Sudden overload when lifting with hack twisted or Hexed
Compensation for weak or il~hibiled gluteus mllxililllS

Observation
Increased lordosis
Muscle hypcnrophy at 11lIubosacr.11 or Ihurac(llulllbar junction

Trigger Point
Anywhere in muscle belly

Fig. 13.24, Hip inlernal rotators PIA.

Periosteal Points
'Spinous processes of L4-S 1

Doctor Positioll
At side or table. facing patient
Doctor gr~lsps patient"s ankles. raising them
Patienl's thighs rest on doctor's caudal thigh.
Cephalad hand rree 10 palpalc down side ercl.:lllr spinae muscles
for contraction

Evaluation for

O~'eractivity

During hip cl<tcnsion. lumbar ereC!<lr spinae norm:llly follows glutcus maxillllls and hamstring activit)' (conlralalcwl prccedes ipsilalcr<ll)

E,'aluatiolt for Shortclling

F:lilure of lumbar lordosis to n::\'crsc on lingcrtip 10 floor tcst O!" Sit

Patiem:.. Actil'(' Eff0l"t

and Reach lesl

Pushes feci down tow..ml lltl{lr

Arter c(llllr;.tl.:ling QL for :lpproprialc period. is
go" or rdax

cllc()~lragcd

\(I

"let

Stretch

Pelvis in lUckClI position

Hip flexion and degree of pelvic tucking may need to be modi lied
10 isolatc 1m\' back muscles during bOlh colltmclioll ,uld slrelch

Other IHRT Stretches. A light or tense QL cun b~ relaxed

or stretched in a variety of ways. Prone (Fig. 13.26a) and
side-lying tcchniques arc possible (Fig. 13.26b-d). Somctimes, it is diftkult to isolate lhe muscle with PIR, and intcrmiuent cold and stretch (formerly spray <lnd strctch) is <I uscfuloption.
Self-Stretches. A 'standing self-stretch is shown in Figure
13.260.
ERECTOR SPINAE (Fig. 13.27)

Referred Pain
Sacroiliac join!. diffuse area in low hack. hUllock

------.----

Fig, 13.25. Quadratus lumborum PIA.

J.

CH,\PTER 13 : ',IANUAL RESISTANCE AND SELF STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY

269

I
~

..

")

:i

~
i

,I ()

i )
1 -,,
""'.".

\..1

;;;

,
~

.J

'-'-=1

'"

!
-~

J
t
I
,

f,

()
~)

Fig. 13.26. Ouadratus lumborum PIR techniques (ad) and self

streIch (e).

,)

.)
,}

<

! , ..
()

.f.

.~y

I,

......J

~
~

. ""

"

" ~)

I
!f

~,-J

~'

',:;
{

n
.f

,-".

')

-; -::' .-

- : v.~_

Fig. 13.26. (Continued).

'k.<.:t.

_,

~- - .

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

c.,IU

Up side ann h;1n~ill':; olltahk in I r\IlH

Down side k ll~\l.'d at hip and kn..c I'll" s(;lhili:t.;tlitlll
Up side hip in sli,ght cxh:nsi(lll su to hang kg uff (1:n.::k Ill' lahk

DOClOr Posirhm
St;.mding ill fWllllll" hehind p:llit'lil
Fixes pelvis at :lIl1erinr superiur iii:... :-.pinc (ASIS, wilh IIllt.: hand
Other hand (and furcilrln) tlkc:-. hnl:ld \..'0111;\1.:1 uwr up:-.idl.' lumh:ll'
muscles
Pulls ASIS Inward himsdf Ilr hl.'r~dr ;IIllJ rnlah:s lumhar ~pillc
away (Icn rOlation) tu take up shu.:k (i.c.. eng.;lge barrier) ill
muscle

Patient :,. ACli,'e Effotl

Turns upper body backwards against rcsislance while hrc;llhing ill
(may <llso be in~trucled to look inl!ir~ctioll ofturningl

Fig. 13.27. Erector spinae PIR.

Streit"
Fingenip to noor distancc not villid for IUlllbar flcxibility bccausc
of hip motion, hamstring tension. and rcl;ltivc lIiffercncc between
;Unl and torso length versus leg length

joillt Dysfunction
Segmcllt .It corrcsponlling Ievcl. c.~pcciilily L4~L5 and L5-S I

Correc/;w:, "rtim,
Strengthen abdominals
Facilitatc or strengthen gluteus maximu:"
Teach proper lifting tcchnique
Strengthcn <luadriccps
Lumb;.tr support for chair

MRT Stretch
Pllliellf Posilioll
Side lying. inHllvcd side lip
Down side arm back and behind paticlH
Upper torso rowtcd forward

After contracting erector spinae, palic:nt askelllo rdax am.! hreath\..'

out
Whcn doctor feds Illusclc has "leI gu," he or stll.' tal\es 11tH slack
toward new barrier

Otller A/RT Stretches. The ereclOr spinae may he

!oilrctchcd u!oiing a !oiupinc lechnique laught by Jnnd'l l Fig.
13.28). or in the seated position (Fig. 13.29). Care is needed
If stretching in flexion. be
sure to rotate and side bend to the same side. If stretching or
mobilizing in a neutral or extended position. place the patknt
in rotation and siJc bending to opposite sides,
Self-Stretcltes, Self-stretchcs for the low b~lCk lll11sdt:'s
arc abundant (Fig. 13.30). A simple sclf-PIR technique is :llso
an excellent way for <l patient to relax their lower back (Fig.
13.31). h is pragmatic 10 have the patients explore whkh
strclchcs seem more neutral for lhem.
to avoid uncoupled movcmcnts.

.~

, --t>,
" ,]i

Fig. 13.28. Erector spinae PIA.

___ .---10

c;HAPIER 13: MANUAL RESISTANCE AND SELF-STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY

271

f)oC(orl'ositio/l
AI sid..: uf (ahk nn invulved sid..:
Cephalad fllrcarnl pusllcd :;houldcr backward
(';nlll:tl It;IUd ;1Ilt! wrist pull pelvis rorward

l'aJ;t'lIl \- Aelin' qrurl

RUI;I(C~

lorsn t'urwOlrd whik Illoving

ElTon i... rcsi~h..d

.~

hy

p~h'is

hackward

111l\:lol';o kCl:p cotllraeti\ll1 as

dl'''L'

til

ISUllll'\

ric as possibk

Stretch
Once patielll has n.:laxcd fully. 1l0l.:lm 1Il;IY laKe sla..:~ (Ill I IowaI'd
lIew harrier hy pushing should!.:f h:lek",;ml ami pdvi ... f\)rward
POSTERIOR CERVICAL MUSCLES

Referred Paiu
Up (0 suboccipital region
Down 10 upper shoulder girdle
ForchC<ld.
. Fig. 13.29. Erector spinae PIA.

LUMBAR MULTIFIDI (Fig. 13.32)

M lIT Stretch
IJulielll j'lJ\ir;oll

Side

l~

in:;

T(lr~\l nll,tled

ha\:kw.\rd

1'..:1\+, n.lah:d f(1rw;lfjj

Clinical Result of Shortened Atuscle

"Short neck" or ccryicocranial h)'p~rext~nsjon
Cervical headaches
Dizziness of cervical origin
Cervical zyg,tpoph)':-cal joint disordcr~

,\ctimtioll or Perpetllotioll
Susl,lincd neck (h:.:... i,'ii '''':lik. rc.I\lill~ ;1111.1 writing
FOl"wurd-l1rawn or slunpcd pos!lln.'
Trauma (i.e .. whipl;lsh)

Trigger Poillts
Occiput, suboccipilaltri;mglc to C.l-C5

I..

i' )
{i

,)

Fig. 13.30. Erector spinae sell-stretches.

-_.......

_------------_._-------_._--_.,,~-_._---

1"-

Fig. 13.31. Erector spinae self-PIR.

SEMISPINALIS CAPITUS !Fig. 13.33)

.,

MRT Stretch

Pmielff Pos;t;on
Supine

Doctor POSiTio/l
At hC<ld of table
Patient's hcad lIl"y llc ...uppt1rlcd lly dtlCIUf'S cro!>scd arm... whik
doctor's hands arc pl;J\,:cd Oil patil:n(" "llllullkrs
Bring head into forward flexion. stopping as reSiSI;11lCC i:-- fell "I" il"
paticnt percei\'c:-- any ... tretching p;lin

t
~

:,

Fig. 13.32. Multifidi PIA.

Parieflt\' Actil'c E/fort

AnelllplS to gently pu:-;h head hack and hn'::'llhe in while dol'lOl'
fer:-- lllatching resistance
Afler S to 10 seconds. inil!rUl.'teo to "kt );tl"

t\r

Stretch
Whcn doctor pcrccin:!> patient has fully rd:'lxeo. p:.ttiCIlI a...kctl hI
lake deep breath in and out
A!'> p<lticnt exhales :.md continues 10 rd;Jx. dOl.:!ur lakes up <;,lm.:k ill
muscle
New resting length should be achieved thai is ranher into forward
flexioll th:.m before streich
Thcse steps can be repeatcd two or lhree more times

?;

I
~
~

Fig. 13.33. Semispinalis capitus PIA.

Periosteal Poilll.'i
Transverse process of the atlas

il!
~

<

(~'g.

13.34)

I\1RT Stretch, Combine llcxion with rotation ami si<.k

bending to thc samc side (coupled motion). If the patient fl.'ports provocmion of joint pain, an adjustment should be per
formed first. Very gentle forces should be used in this tcch
nique (intermittent cold and stretch is an option).

Joint DysfunctiOlI
CO-Clio midccrvical
LEFT SEMISPINALIS CERVICUS (Fig. t 3.35)

,~

il
.~

LEFT SPLENIUS CAPITUS/CERVICUS

Corrective Action
Tmin propl:r head on ned postur:.l1 set (i.e .. Ah:xaruJcr technique)

Address forward weight-be:'lring pm.Hlre (tight calves. hip nexon;,

and pcctur:'lb;,)
Facilitall.' ;.Int! strenglhcn glulCll\ ma;ximus anti deep lll.'ck
flexors

lHRT Stretch. This maneuver is an ul1l;oupled movcment

for the cervical spinc. Therefore, if joint pain is provoked.
lessen the side bending componcnt. Very gentlc forces should
be used ill this technique (ilHcnniltcnt cold and stn:l(;h is an
option).

!-----------------------------_....
(;'

ii
,'(

1:

GHAeTER 13: MANUAL RESISTANCE AND SELFSTRETCHES FOR IMPROVING FLEXIBILITYIMOBILITY

I!

Pur,,"' 1'1\1 hl';l\ ~ (If should"'l

ClllllPl..'lI:o.:LliHI\ 1\1 short !c~

"tCII'

273

l,', tIll"

SllI}uhkr "k\;ali'Hl wilh rl..'spir"li'lil

Ellltllitlilal :o.lrl'_~"
"\\'ci~ht of th" wurld

011

shouldl'l<'

"

()!JS{'t'I'atiflll
nf I\\'d~:o.hnllltkr lin;: ,,'\'lItOUI" i ,.( ;"1111\.' ;II'P'::::.: :."

Slr:ti;;IHl'llill~

Tri;;;;!..'! !'ai:!!,,,
.\lidhdly,

;llll ... rHlr.

Iatl..'ral

Emilla/hm for O,'cruC/h';ly

Shmtld

110t

ahduct wilh excl..'ssj\'C tlppl'f tr;tpaiH;\ ;tt'liYily

tIl" l'

:rh

"',.';Ipular c!cv;ltioll

Emilla/ioll jor Shortening

Lllcr"Uy hcnd hl'ild .1\\-':1)' and rulal.: hl';lll 1\)\\;11"\1 ;o.id..: III hl'!l'h'.l.

Fig. 13.34. Splenius capiluslcervicus PIR (Iefl).

With nl'd; lle,,"'d. push un shoulda, (>nsili\'I..' limling: i.. Itl'" "T rl"
.. ilicncy (cumpar... hilaterally),

Fig. 13.35. Semispinalis cervicus PIA (left).

LEFT MULTIFIDI AND ROTATORS (Fig. 13.36)

MRT .r;;trefch. Full nll;l\ioll follom:lI by maximal llexion

or the rotated head arc performed. Vcry gCll1lc fol'l.:c,I; should

be llsed in thi~ technique (intermittent (old and ~tn.:tch

IS

;In

Fig. 13,36. Multifidi and rolators PIR (left).

option).
UPPER TRAPEZIUS (Fig. 13.37)

Referred Pain
To mastoid along posteri(1/'. btcralncck alld

llCcipll!

1(1

forehead

Clinical Effect of Shortened Muscle

Hl.:i1t1ach('s
Neck luin
Altered sl"apuluhumcral r11ylhm
Aclil'GtiOIl
Occup,llitmal slress (flllll slIslaint:<.I shoulder .:,,-,';lliuII

Tclcphl1llC 10 car
Chair with ;Inn rcst.~ at \\TOII~ height or ahsell!
Desk. typewriter. or key hoard \00 high
Compensation to weak low.... r lixators of ~t~'lllll~lI.'
HahiHl;d fllrward pnsiliull \11' shoukkr"
Ccr;, ;.... ,i:lllr;lCic kyphosis
IU;tdcqu:th' 'Uppllrt fur IW:I\ ~ hn.:a\\\

Fig. 13.37. Upper lrapezius PIR,

.,

Fig. 13.38. Upper trapezius self-stretches.

Tension releasc shoulder shrugs Jurilll; "'breaks"

Proper support br;l wilh wiJcr strap
Smaller purse with \\ ida slrap
Rc-cdllC<LIC diaphrafnl:.llic hn:athing
F:Jciliwte and slren~lh;:n hnvcr lix;llnr, of sC~lpul;IC

MRT Stretch
Patient Position
Supine

Hc.uJ i~ nes-cd. wl;lll:J tuward ;lI1d lillcrally ncxcd away rrtlm sid...
or,trelch
Arm un illvnlvcLl ,ilk j, n:::laxcd in p<tlkm's side

)
,)

Doclor Position
Stilmling al head of

l;lOlc (Ill

side of ifl\'olvcmcilt

.}

,. ....
}

Fig. 13.39. Levator scapulae PIA.

Joilll Dysfunctional

'1
;,..,J

Atlanto-occipital. any mhcr !l<\stcriur cer.... ical joint including lhc

cervicothoracic junction

Corrective Actions

\...J)<

Improve workstation ergonomics

Make sure elbows arc properly supported by ~mn rests
Correct desk. typewriter. or kcybo;lrd heighl

Shoulders relaxed
Elbows bent at 90
H'lllds rcla:'l:r;d with wrist ill "neutral posilion" on work surfilce

,
.>

u
\
Fig. 13.40. Levator scapulae PIR.

".j"

=~:.-'::.'~.::'-..:.'":::.:n-..:.,J:...:.,.::":.:':.:":.-":.:U:.:".::L:...:.".::":.":.::'' :.:.:'A.:.N:.:.:L::":..A:.::.N::U:...::"::"::L::'_'..:"::.'.::H.::":...:.'L:.':.-H::."::"::.'::.r::.U::.H::.::.'::.M_P_R_O,,-V::.I::.N..:G=-:.-F..:L..:E::.X.::I..:B::.'L::'::.T::.Y::.'::.M::.O::..::B_IL:.::.'T_Y

..:275

II

II
i
,I~~
----~,~

,- ,1

(J

o~ f'

'~

I
!

Crossed or 1I11lTtlS'Ctl arlll C(llllac( wilh Olll.: h'llld gCnll~ on P;tlknl\. slulllkicr ;lIld other h'lIu.! hchind m:lslnid process
"Wind-up" stretch hy laking out slack ill ned llexion ;111(.1 then in
genlly side bending ,l\vay alld roliltio/l tllward illvo!n:d side.
Finally. take \llH :-.ITOllgcst slack in t1in.:ctiol1 of shoullkr lh.:-

pression.

Anernpt." III brin shouldcr ilH(\ ",!l:v;Jtiot\ toward patient', I.:'IT

Common error is for paliclll 10 raise shuulder off l:lbk ralher than
dcvaling il hlward car
Efron is n:sisll.'d hy doctor 10 kcr.:p corllraclioll as t,:llISC 10 i'<JrJlI,:l-

ric as possible

Siretclt
Aflcr cOlllracling upper Ir.lpaim for appruprialc period. patient is
CIlCOUfilgcd t(l "leI 0" or rel;\x
Once rcla:<;llion of muscle is fell. uoctOf m;l)' t:.lke lip shIck hy deprcssing shlluldcr ~l~ far as it will ~lIh1W
SOllle slm:k 1I1a)' ,l!so be taken (Jut by increasing neck flexion,
hut no more in llllCllUplcd side bendin,g away and !'OlatiOll toward
musclc

Self-Stretches. Excclknt .sclr-strclchc~ ar~ shown in

Figure 1.1.~:-\. SclfPIR call c:lsil)' be incorporated into other
self-treatmcnt methods.

I
~

,t ---_......._----------------------------

,}j

Fig. 13.41. Levator s.:apulae self

stretches.

LEVATOR SCAPULAE (Fig, 13,39)

Referred 1>ai"
Vertebral border
Nape
lIeck

or

or scapula

ClilliCll1 Effect of Shartt'"ed iHuscle

Pain 011 sallle ~ide ;lS palielll lllrn~ hcaJ
Torticollis
Altered scapulllhllllleral rhYIIl1\l

ActiwlliOIl
Poslures in \Vlti..:!\ paticHI h;l:, ht,';td lumed li..'f ;';-~'Iullged pcri~ld..;.
e.g.. talking 10 somCllllC sillin~ h' the side
Excessive Iclphnnc wnrk
Working over a desk for pn'!lll11!cl! periods lIt' ;;;,',k Ilexioll

ObJen'atioll

'11' l",.'...'k line <.lpp,,';lr:o

where musde inserts into sl..'apul;l

Wilh shortcnint:. I.:onlour

,!:"

;1 duuhle wan:

Trigger /,(}i"rs
SupcfOlllcdial horder of scapula
Push tr"lpczius lataally to palp;lll.' fulllclll=th l'f nlllsdc

Periosteal /'oints
Later-II surface

Ilr

SpillllUS

Pfll~'l'SS

Ill' C2

Eva{UClrimr for Slwr1l'l/illg

LaWr<111y hend alld rolal\.." Ik\l'd lk'ad away (rl'::~ 1~'SICd sitk~

........ " ...... , .......... ,,,''"'' .. u ..... L

:\pph ~emk prCSSI:r~ to ipsilah:ral :-I\\Julll\,1'

l'o:-i[j\,e,; lest b lack ill' r..."ilic11cy wlll'Jl 1'1I~hitl~

1111

1!'

Otha MRT Strctclu:s. PostisolllCll'ic rclaxalioll may also

he u~~d with rcsistall':~ lltrough the palicnts elbow (Fig,
13.-W1.

:-hl1uhkr

Joim Dysfullcti(Jll
CI-C2 and C2-C', alw l'CJTinllhur:H.'il' jUIKlillll

5jdf-Strelc/w,\. St'if-stn.:tch..:s arc shown without PIR

13.4101) and \\'il!l PIR (Fig, [lAth <lnd cl.

(Fi~.

Correcth'c Actiolls
Using hc'ldsd

,I

Rearr:lIlging C(llllpllh:r
turn head

Fadli[:lle of

slrell~[I\\"ll

ilhlJlilHf

Imn.:r

HI'

r\,:td't1~

lix:llilr~

llIall,.'ri:li .~o

1111

nccd

[II

SUBOCCIPITALS

Rcferretll'ain

Ill' :,clpulae

Sidl' of he'lt!

M liT Slrelcll
Path'lIl Posilioll

C/illica/l:.1fccts of Shortened Muscle

OCl'ipilalllcadadlc

S.L111C as fill' Ir'lp..:ziu:., e.'\n::pl hand is IUnh:d palm up and anehllred

,lllthe way ulllkr hack of lhi~h :lIld lIeek is rotaled away

Doctor Position
AI head of lahh:: Oil side llr involvcment
Arm closest ttl p:lIicnt"s head SllpptlrlS hcad while lhe hand COlllaclS p:llicnt\; supcmllledial horder of shoultler hl:lde
Outer .Ifln crosses in frOll! of olher arm ~{1 OpCll hand C<.Ill COlll,ll':1

nwstoid prm;ess
P;uient\ head lllaXim:llly Ilexed, laterally lIe.'\cd, alltl rulalcd to
w:Jrd siuc opposite of involvl,.'Il\Clll
Takc out ~ll slack in din':'lioll of slwult.ter (!I::prcssiun and minimizc
forces on hC:ld

"Sh~n Ileck"-(;cr\'icncralli~llhYI>cn.::xlcllsion

Acti~'alioll

SUsl;lincd Ilcxinll
r.. 1al;Jdjustcd cycglas:o. (rames
RC<.Lding or writing
Suslained extension

Bil,:y,k riding

J1(Jinl.~

Deep to lr..lpaitls and ...t.'nlispinalis CapiltlS

Era/uatiun for Shortening

?micnr:{ Actit'('

l~ff(}rl

Tries to gently ele"ale shoulder blade

Effon is rcsiqcd by doctor \n kcep (;ontf:lclion

t)

p;

!-lou:.c painting
Forward-drawn P()stllf~
We,ll.: dl,.'cp neck llc.'\of\

Trigger

,fl
}-

",

j
~

-'<

Supine patient drilws chin to chest

Positive finding if gilp of nn..: or l1ll,lrC linger's brc:ldth remains
'IS

close w i"mllt.:t-

ric as possible

)oi"t I>ysfrmctiotla/
C!J-CI

Corrective tlctiolts

Stretch

Improvc
Once palient has fully rclaxcd. dnCl(lr takcs out slack by im:rea:.iog shoulder depression

ft1rw~ml-drawn

posture

'\wmencss trJining of "~hon n~l'k" (i.e .. Alexander leehnique)

Book stand or writing w~dge

,,

Fig. 13,42, Sternocleidomastoid PIA.

--~ .,

277
CUlllPIll\:I m"IlIlo-r ;,; ~'ul",:d Ikl:lll Il..l..'h;~'

nose)
Strengthcn

\\~';l"

,kcp

nc~'"

. .., ...
,..

"~

~ ~

li ... ,Ilh ;111.1

Skqlin~ "II ;\\,. ;'dltlw.. :-ohllrll'n

S('\1

1','..lur;1I

!ll'rt k~1

... 111'''0' ' ...,.mpll\s:lti,lll

lnc,IIT..'I'h',1 i""" ;.:~:.::-igIH
For,,";!rd h,',:,l r,'~IUn.:

Ik\.,\r...

MRT StrCfch

\\'1';11, \kql Il,'~~,

Paricllr Posiriol/

hi

:1.' \01':-

Shnrh'lh.! "'\il-." q;I;tl ..

Supine

OhSC'lTflli1l1l

Chin s1i::htl~ lll'\l'd

\\'ilh "lh1Ihlim;. ,; ... ihl~ prllmilh':lIl in..ertioll (II' d:l\il.'ll1;l1- til' l"'!,'!l

llea.!r"l"\\;ll,;

1',";111'..'

Doctor ('os;r;oll
Tri~~l'r

Al head of lilhk

One hand bdlind neck. ilpplying tral.:lllll\ (~Iiglll)

Heel of nllH:r h;1I1d 011 forehead \\'ilh till~cr~ ptlillling IOwaI'd I,:hill

Anywhen.:

I'oint
illlll\l,~'k, partil.'ul;lrl~

Em(uariOll

hl'IIIW llla:-:lllid pnll:C:-:S

for Ow:racf;l'iry

1h.:;ld Ih.:xilln 11.:'1 ....1 wilh p;llil'lll 'UpIIW

Palicnl ask...'d 1(' ~hl\dy r'li.;<.: Ill,;t..! inll' lIC.\I\ll1 ill :m,,..likl' ra.;hi\'ll
At1Clllrl~

In till h..:al! hadw:ml

Effon is n.:si"lcJ hy dnctor In kct.'p ,,olllr:u.:li(lll as duse II' ismll..:l
ric <IS possil:lk

Once p:ltienl h:l" fully rcla.\cd. dOl'wr illcn:ascs {raclion I'uree will1
haml supporting neck
Doetor lakes Oul .. 1;lCk wilh heel of hamJ till forehead illl(1 f(Jrward
nexioll
Ifpatiellt resi\t .. forward flexion. :I,kcd In :u:ti\"dy Itlck chin in ;Illd
lhen relax: p:lliclll will havc in .;:-ffcCl t:lkcn oul ~Iack thems..:!\"c,'
and ~inHlllalleou ..ly lIsed RI

Referred Pain
Over eyc. frunt;.J! :m:u. 111aslOltl proct:::-:s
Clinical Effect of Shortened Muscle
I-Icad:lChc (o\"cr eyes}
Ei.tmche
Decre:l:-:ed ne;.:k r{llation

Actimt;oll
l'v1cdl;mic;lllI\ l.:rloiltl (execs"i\{: ilt::ck cxlcnsimll
P:liluin~ :1 cl,'iling
\V<llehill~ a lll<"\ ic frUlll lhe froll\ row
Bicycle I'idillg'

Joint 1JY.'ifullctioll
COCI

~lIld C~,C:

Pillow should be lUcked helwccn \IHlllltkr ;1I1d <:hin. NOT unJa

s!ltlllltk'r
Correl'l head-hlr" :lrtl !'nslurc (... hnr!cns SCM)
LlImh:lr pill{l\\ m::y help rc:-Iorc bOlh Itllllh.u ;tnd cervical CUI" ..'~
Cum:;:1 Ilc;lr.. igbh:dness
Limil ovcrhcad '.\ llrk thai (l\"...:rl(I'ld .. chcckn:in fUllclion of SC\ 1
Rt1und-shoulth:r-.:d po,lUr.., (light pt:t.::t<lr:lli~ mu:-:dc:-:) cormihtll-:'; It"
hcat!h1rw;lnl pi.,lufe
SIl"Cnglhcll \\C;l~, Ikcp 1l\'\'1, l\c\(ll''''
Slrclch "IH)n<':l1~'d

Po.\"irioJl

Supine
Shuuldcrs al t::J;;c of lahk, ..u head i.. \UPPorl..d \1111)' al basc

Head wlaled ;:\'.")' frolll ill\"lll\"cd \idc and

...Iightly (()ek'~ Ill'" Il,'''l po\iliOll'
/)OC(OI"

:\1 h.:ad (If lahle

Cephalad hand ih:llld ncah... t III hc;ul.' n;ld\cs h':;Id

Olhn haul! pl<ll:':t..! on p:Il I..:nl.. forehead

()
j

Id

Iu
~

I
~
.~~

Fig. 13.43. Slernocteidmasloid PtA.

c)

Cl

;lll(lWcd

Po,\";/irJlf

;~

\1!.' ,1.....

;.:illUl

c.;

);
~

,uhtll.:l.:il'il;ll,

iHRT Relaxatiolt
PlIli('Jlf

1:!

or 11l\1\\:IIH.:nl

Correcti\'e Actioll.\

Sm!ldr

STERNOCLEIDOMASTOID (SCM) (Fig. 13.42)

Pn:-:ilivc 1...'1 iI' ,:hill pH"''::-: dllrill~ inili;llir'lI

It I c\l,'nJ

MCM/,\DILIIAIIUN Uf THE SPINE: A PRACTITIONER'S MANUAL

Correcti"e Adiolls
;\lh.'l1lPI~ In raj~l'

Effort is

h.. . ad ~Ii~htly. \\ llhllul ally rotatioll

n:sisl .... d by dtl~'lllr hI h'~'p ~(llllra<..lillil <1:- cl(l~t.' to

iSOlll.... l-

I~ '!(I,\'(/ 1iOIl

I)oc\flr tl11..'l'I,:I~ .dhl\\" Iwad \Hl'\h:lld a" 1':\1' :,~ i1 w;1l111l ;ts OWII
Gra\'it)' i~ .. nl~ f",,:\." rcquirl~d Il' lai-.l' up slal'k
:\ lX'rkl'1 ,,~'lrlll;llllll"1l1 111~'llhld ;I' \\'l'11
('nlllr;,indi..:;l1ld if ;,ny ~i~,,~ tlf \ I.'rt<."hr(lha~ilar il1~llfjk;t.'m:y noted

Other 'MilT Strctchc:,\' ((ud Self-Stretches. If the cervical

-"pille is irritahk. lh~ SCM Ill"y still be treated by preposi.
tinning in Ik'-"iOll. thus 'lvoitling provoc;,t1ive cxtcnsion positiolls (Figs. l.l,-t.l and 13.44). These strctches arc ideal inofril~ or self-lfl.:allllclll methods, This ledmiquc is oflcn an
ex('dlcllt prL'thrusl rcl'lxation tcchniquc for .1 patient who
"guards" c.xL'L':-."i\'t.~ly.
SCALENES (FIG. 13.45)

ReJern:d Pain
Peetor"lis

I1lU~(:It;,.

:m~a(hing

pattern

MilT Sfrelc"
PlIlk"t Po.\'ilioll

ric as IXl"sihk

Retrain diaphragmati,
Stress m:ln:tgellk'1I1

upper afln, h;lIlJ. :lllli

rhurnh(lid~

Possible IIUlllbnc .... or t;ngling ill h:mds and/or fingers

Differentia! diilgn('sis
Ulnar di~tfiblltion of symptoms frulll the hrachial plexus or subll1Y(lra~cial

rcfcrr;11

At hC:l(i of 1;lbk
Anterior libers isolated \vith olle hand on mcdial clavicular origin
and other hand ju:q ant..:rior to m;lstnid process
Medi:1I fihers rcquir..: one h;md on midclavictll;u orig.in and other
hand on mastoid process
Posterior libcrs rC\luirc unc hand un later-,I c1:tvieul:tr orig.in and
other twnd just pmilerior IlIl mastoid process

Patielll

Ellorl
10 ~idc

hend b;lck Inward midline

Stretc"
Slack I;lken out into grcater 1;lleral l1exioll
Anterior tiber Ienglhening \"ilh rotation tow;ml involved "idL'
Medial fibc~ require no rot:t1;";j
Posterior fiber lengthening with rotation away

Activation
Forward head pmturc
Par"doxi(: breathing pattern (excc ... ~ive upper chest respiration)
Anxiety
Tension ill nther fix:llors of shoulder girdle

Trigger Paims
Anywhere within anterior. metlial. or posterior divisions of muscle
Palp;\Ie and treat ..calenc~ with c:lution hecause of proximity of extremely sensitive lICllfO ....;lscular li .....uc

If the neck is hypersensitive or any vertcbrobasil;'lf symptOms

are present. this technique is contraindicatcd. Joint manipulation may be nccessary before using this method to cllsur(' the
join.s arc not compressing. especially with respect to the :'1.';1lcne anticus stretch (Fig. 13.4Sa).

Gtl,er MRT Stretches. An alternative w,ly to

<.lddrc,,~ ::l:a-

lene dysfunction involves prcpositioning the patient's ned..: in

Joint Dy,\fullctioll
Flexion li,x;ttion... of cCl'"ical ~pine
First rih blockage

Doclor Posiliol/

Aucmpts

Clinical Effects of Shortened Alusete

cJ:lvian vein
Radial distribution fmm

Supinc, lIead Iak'rall)' helll In oppllsite sitle and slightly extcnJeJ

i\ntcrillr liher~ lllllSI Ill: strl;'ldll'O with hcatl rot;lled t\lW;mJ invol \'cd sidc
Mcdi;L1 libeLS rl.'qllire 11(1 rot,lIion
Postcr;or liher:, n:quire h~ad is rlll:ttcll :1\\';1)'

(antcri(lr

cervical!!!

d stretch position and then contacting the origin of thc I1lu:'l'!c

over the anterior chest. Resistance to inspiration can be :,ufli

"

Fig. 13.44. Sternocleidomastoid PlR.

CHAPTER 13 : MANUAL RESISTANCE AND SELFSTRETCHES FOR IMPROW.~ =LEXIBllITYIMOBllITY

279

Fig. 13.45. S"

~oe

PIA.

c
cienl to achieve posrcontraclion inhibitioll. SI:Kk call he taken
out with the hand over the ante.:rior rcgitm (11' the chest or d~I\
ide to lengthen the shortellcd musdc.
Self-Stretches. S~lf-lr(;atlllcnl is I.'a~y ami ';Ifc. cspl'\':i~lll~
if L'xlCllSion j:, minimized (Fig. 1:\.4(1). Fi~Ul\: 1:;.47 sll<l\\':- ;1
~idc-lying technique for pCrftllming self-PIR \\illl gra\"ily n:,:.

AfIllS il1l1:r:l:"

Sc.:apula

11...1.,;

;.

:IL._ ';\;:nh

J:'m/ualio!l {f)r .r-iltortclJil1g

?ECTORAUS r.AAJOR (Fig. 13.48)

Ann ;Ihdlll;:.;::

Referred Pain

S:tllh' Hill,

inn('f

.,...k l>.'ll~

l'erios((,lIl Foillis
Rib Iwad

or chl:sL bn:'I~1.

~Ill:lk'd

:,-1 alld I'n'll':tc.:H:d

'/i"iggt'l" IJ(li/If'
I\II~ \\

;"iswncc.

Anterior part

ahd~_'

.11'111.

'\Ill.!

}iJ'

and ,"ll'fIl::!I:. rillall'd

\11 l~ll

.\hdUt:li'l1l

t'llr'':;lrI11

Joiu! /).n{uIH:timl

Clillicall:,Jfect oj" 5;/wr(('ued Muscle

P;lill similar lu angi11a
Bn;asl Ilypcr~cn~ili\'iIY
Anterior humer,,1 pt1siliotl

liPPlT nb...

Corn!",i\"(:. \ctim,...
l,;an prolllOh:

11111'l\lVI..' r(lj",'.;~,d Wl'i~111\'~arjJlg P(l~lllrl..'

slwlIldcr impillgc1Il1.:!l1

F:lcililall: i!wj ,'rl:ll~llh.'ll l\lWl:r (Ixalors (If :'l'apulac

syndrome
;\c/iJ,'atioll

Rlllllld-shoukkrcJ. hl';ld!",u"\\ ;ml PI):,Illl"l'

M RT Slretell
I'o.\;li'_,i,

1'1/1it'lIl

ObSerntliml
RIllilld SI'\I\Jldcr"

b - - - - - - - - - --_.__.._. __.....__.
--

Stll'itll'
ArIll ahdul',,;

!i)'

and ,'"ll'rn:lll> nll:tIL,d

...". _ .. _

,- n"

II I lu,"c;:n ;:) M,...I\lUJ\L

I
,

~,,
t

Fig. 13.46. Scalene self-stretch.

,
j

Fig. 13.47. Scalene self-PIA.

Doctur Position

C01lcem

At head of table on involved side

One hand COnl<lcts muscle belly (;,\bdomin:ll or sternal) or opposite
clavicle

If br~lchial plexus syrnplOrns arc encoun[ered PIR. may be

pcrfonned without stretch.

Other hand gr..lsps upper ann

SelfStretches. Self-stretching is casy with doorway or

comer stretches

Parien! S ACli~'e Effort

Attempts 10 raise arm

Effort is resisted by doclor to keep contraction .IS close 10 isomet-

ric as possible

Stretch
Once paticnt has rclaxed fully. doctor may retract shoulder to new
barrier
Must firmly stabilize muscle belly over ribs while !,Iking ~!;' Sl;lCk

PECTORALIS MINOR (Fig. 13.49)

Clinical details arc similar to those for pectoralis major.

Application of PIR can CilUSC nerve entrapment related to thoracic outlet syndrome.

MRT Slrelch
Patie", Positioll
Supine

u' ""

,,

i
!

' .... "

, . ) . 'VI"'~UKL M~~r~

IANCt ANU :;;t:LFSTRETCHES FOA IMPROVING FLEXIBILITY/MOBILlTY

281

)
(")

'. )

t, ..,

!,j

~
.~,

,\
'8
~

I,.,

()

,
i

I,

i
R
N
;,
b

()

()
)

i '. ,

i,

<

..1

,)

'J:,'
t:

Fig. 13.48. Pectoralis major PIA.

Ann abducted :':0" ;llId ~x!::rnally rotated

I~ ( )
i u

f)oC/or

J ,
~

SUPRASPINATUS

Pariellt \' !\cril'(' .qrorl

()

..\llclllp'"

\0

rai:...: ,houkkr III l't.:iling (kccpill,g hand lower Ih,lll

;-.Iululdcr
Efror! i'i resisted hy dUl:l{'; III keep i:oll(ractj{.n
l'l\: <IS pu\'~ihk

"'.'"

:l'i

dt)~c 1(1 i"ornel-

~
~

'\

'\.-'

...

\, -------------~--~-~-_

'"

""
~

lJ

't {

Referred l'a;1I
Ikhoid rq;iun. I:Ilcral upper afln

......

;Illt!

dhm.:

Cliuical J(c.w/t of S/wrtf!"cd IHu.\"cle

Painful ~dxllll'li(\ll (p'lillfu]

.i u
f;

tllli

loward

Other J\tlllT Strctclw.\". ;\ mollified lc<:hniqlk' for prow;

positioning is shown in Figlln.'. 1."50.

Caudal hand gra!'ps ann

I 'J
'!
~

Ouel.: palielH has rda,xed rul1)'. dt1;'ltlr may lake sbd,

lI~W harril:r ny pushing shouldl'r :lway from d<l\'iI,,k

P(J,'j;rirm

AI head (If '"hk' Oil in\"uh;:d ...ide

Ccphal<.td hand I:olllac!'- gkllohtHllcral juint

%...,~

f1
"11

Sfretch

H:tmllwnging hl\\'cr thall ,holildcr

illl"j

..._._

, '

.-- ,

~. ,... rH""'

lllIUNt:H ::i

MANUAL

Trigger Puillis
Supra:-pinatus (os-<;;, decp 10 Ira{'\:zius

Corrccti,'c Actions
Avoid:lllCC of (l\'crhcad work
Crossfihcr m:lss:!gc
Impro\'c scapulnhllllicral rhythm

'.'

MRT Stretch
rmkm PO.'ii:ioll
Prone

Doctor Position
Standing at same side o[ table as involved shoulder
Aml extcndcd behind p;llicnt
With elbow Oexed 90. upper. arm :lddllctcd;l$ far ,IS will

~(Il.:\I111

fonably

Fig. 13.49. Pectoralis minor PIA.

Fig, ,13,51, Infraspinalus PIA.

Fig. 13.50. Pecloralis minor PIR.

Difficulty rC<lchillg above shoulder

ROlator cuff c.Iisordcr$ (i.e .. impingemcnt ~)'llllrome) uften result
from tightness of eXlernal rotators (infraspinatus. teres minor. and
supmspinatus)

Activating Factors
O\'crhc:td work (i,e .. weight lining. throwing. swimming.
Puor :-c:lpu]o!lulTlcral rhythm

ri
f;

-~
%

\,,'[l.'.)

Fig. 13.52. Subscapularis PIA.

._._----_. _ - - - - - - _

.....

CHAPTER 13 : MANUAL RESISTANCE AND SELFSTRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY

1'1;ln: \Jlll' haml ;lgainsl llr~r arm illid g.rasp patient's wrist with
nlh..:r hanll

Gl'lHly pu:-hc.; "rp~r ann out into :lhlluctlOU

Effort is
.1':llil'lll

rc~i"h:d

i:-ullll'tril"ally

.;hotlld follt,w normal orcatbing pror.::cdun:

As paliclH rda\l's. dlll.:lo( takes up slack in adduction

283

COlleem

Although this method is simple to perform. care is nceded if

the shoulder joint is hypersensitive,
Other MRT Stre/cltes. An alternative method that rcduces sirain on the ~houlder joint is accomplished with the
aml brought into ful: internal rotation and adduction across
the front of the chest. To prevent subacromial impingement,
strong traclion is applied to the sh'Juldcr joint. This technique
allows for the contraction and stretch to be felt at the scapular
attachment rather than the shoulder attachment of the infraspinatus.

INFRASPINATUS (Fig. 13.51)

Uefirred Paill
:\lltcriol' ddtnid-shuuldcr. dowl1 ann to hand

Clillical J:.ffect,li of Shortened Mm'cle

Paill whcll sleeping Oil either side
Diflkulty rc..chillg llChind back to unhook br.l
Diflicuhy rcaching b~ICk pocket for wallet
Rotator cuff disorders (i.e .. instability syndrome) often result from
liglullCSS of external rotators (infraspinatus. teres minor. and

supra:-.pinatus)

Activatioll
NcglCl'lcd shoull.kr overose svndrome

:\ltcrcd..scapulohumcral rhythm

Trigger Poiuts
Infruspinatus. fossa (especiilily supcromedial)

Correcth'e Actious
Sleep with involvcd side up .md pillow under involvcd mill

Improve scapulohunleral rhydlnl

MilT Slrelch
Patient Positioll
Supine
Involved shouklcr supported by table

SUBSCAPULARIS (Fig. 13.52)

Referred Pain
Posterior deltoid and posterior ann

Clinical Effects of Shortened Muscle

Difficulty reaching back as in throwing
Involved in "frozen shoulder"
Promotes subacromial impingo:ment m~d rotator cuff syndromes

Activa/ion
Shouldcr ovcruse syndromc
Lack of variety of motion in shoulder area
Forwarddrawn posture. especially tight pectornls

Trigger Points
Vcntral scapula

Joint Dysfunction
Glenohumeral joint

Correcti.'e Actions
When lying on involved side. place pillow between ann and chcst
10 maintJin abduction
When lying on uninvolvcd side. place pillow in from to prevent
excessi .... e abduction

Improve scapulohulllcral rhythm

Slrctch peclor<llis major

MRTStrelch
Patient PQJiliofl

Docror J>osilioJl
Ahduct .Irlll ;Ino flex dbm... to 90"
Allow furearm 10 fall into <IS much internal rotation (forcarm toWilrd Ihigh) as gr'lvity will force il
EnSlife shoulder docs not bcin to lift off table

PatieJ/t:\, Aui\'{,

Elfor!

{JIIC himo <1Il afln abov.,; c1bO\v and other hand on dorsal aspeci of forearm, gently pushes forearm up or backward toward CX~
tcm,L! rotation
Effort isomctric,llIy resisled (.again ensuring shoulder docs not rise
orf t.. hle)

With

Stretch
When paticllt has fully relaxed. lake up slack IOward ncw barrier

in inwfIlal rotation

Supine

Involved shoulder supported by table

DOClor Posilion

Facing patient nn same side as involved shoulder

Abduct arm and nc~ elbow to 90
Allow forearm 10 f;all into as much external rot<llion (forearm 10D

ward head) as gmvity will force it

Ensure shoulder does not begin to lift off table

I'atielll:'i Active Effort

With one hand on ,Inn above elbow and olher hnnd on \"Cnlntl nspecl of forearm, gently pushcs their forearm up or forw3rd loward
inlemal rotation
Effort is isometrically resisted (shoulder should not ri~c sjgnifi~
cami)' uff table)

284

REHAtllLlIAl IUN Vr I HI::

~I-'INt::

A I-'HAl,; 111IUI\lt:.M';:' IVI ...... I\lUAL

Stretch

Stretch
When patient has fully relaxed. take up slack toward

JleW

barrier

in externul rotation
Concern

This technique is contraindicated if :mlcrior instability is pr~

senL It also will provoke extreme pain if 2 "frozen shoulder"
is the problem. In either casco the functional range for PIR
may be limited 10 less than 90 of shoulder abduction.
GASTROCNEMIUS (F;g. 13.53)

Referred Pai"
Calf. posterior knee. and instep

Clillical Result of Shortell cd Muscle

Forw;lrd wcighlbcnring posture

Achilles tendinitis

When pat1cm has fully

in ill\kk dllrsilkxioH

n:l.n.~',1.

take

IIJl

sku.:k 1\lw;lnl

IlI.:W

harrier

Self-Stretchl's. Sdf-slr.. . Il'l,ing tile gilstrocncmius is hest

performed with thc s{andil\~ w;tli lean and it:- lllodilll:;ltiollS
(Fi!.!.. U5-t). It is csscnti;l! lhat the knl~l~ is eXlcnded ;tlld the
hed docs 1101 ri~c up.
SOLEUS (Fig. 13.55)

Referred Pain
Heel. posterior calf

Clinical Result of Shortcned l\1uscle

foorwilrd weight-bearing. pt1slUre

DIfficulty squuning
Acli~'ation

High hcels

Acli~'alioll

Exccssi'iC running

Scat height too high

High heels
Too much driving (pushing on ;leedefinor)

Trigger Points
Superior and inferior musdc belly

Evaluation for Shortening

Trigger POilllS
Medial and lateml border of muscle

Prone with knee bent 9W.

dor~il1ex.

;tI1k\c:

~h()uIJ

have 20"

d(lrsi~

flexion

Evaluatioll for Shortening

Supine dorsiflex ankle without allowing knce to bend. Should have
I0 d()r~iflexioll.

MRT StreIch
Patient Positioll
Prone

MRT Stretch
Patiell1 Positifm
Supine with legs extcnded

Doctor Position
Standing at end of table; gmsps heel of foot with halld
Passively dorsinexes patient's fOOl by le~Ulillg cephalad
Paticnt'!' knee not 'lllowed 10 fle~

Patient imcmpts

Standing at side of table, places patient's leg in 90" knee tlc:-.:ion

Passively dorsiflexcs patient's foot by pUlling up on hed while
pushing down on metatarsals

Resisted Effort

Attempts 10 plantarflcx fOOl {not toc:-)

Effort is isometrically rc~i~tcd

Resisted clfort
Effort is

Doctor Positio1l

10

.f

plantmflcx fool (mu toc!')

isolllelric~lIy resisled

Stretch

'....j

Whcn patient has fully relaxed,

in ankle dorsiflexion

t~lke

,)

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:'

Self-Stretch. Self-stretch is accomplished ,IS for the gastrocnemius. except that knee flexion is allowed (Fig. 13.56).

,;"<

,
~

Postisometric Relaxation Joint t\.1obilization Procedures

HIP JOINT (Fig. 13.57)

tf
~

Patiellt Positiou
Supine
Involved leg flcxed at knee and dr.aped over scaled l!\letnr's
shoulder

Doctor Positioll
Fig. 13.53. Gastrocnemius PIA.

Se;l!cd ;11 s;mlt: sidc or l:.1nk

;IS

"
.:1<

up slack toward lIew barrier

0"

""

..;.$
.~-~

,"

,J
d
,

involvcd hip. (;lcing p;tli...111

-..v)

....

-----_

vnl"\r

I 1:;1"\

loj 1V11"\1-'VI-\L

Mt:~I~IANL;t: ANU ~t:U--ti I RETCHES FOR

IMPROVING FLEXIBILITY/MOBILITY

285

Fig. 13,54, Gastrocnemius self-stretches,

P<.llient's leg draped over doctors shoulder

Cont<.lct m;'dl.: over p<.lticnt's alUcrio( hip with both hand!> and pull:-:
A to P to takl.: out ,Ill available shick in posterior glide

LUMBAR SPINE (EXTENSION MOBILIZATION) (F;g. 13.58)

Patieltt Positioll
Sidl.: lying with hip\ and kth..~:, flexed

Resisted Effort
P<.llient instructed to pull thigh toward abdomcn
Errort should be isornctric:llly resisted by doctor
Patient and doctor shmlld reel contraclion occurring in anterior hip

region

Stretch
Once paticnt has fully rcl<t~cd, doctor takes up SI;lCk by
posterior glid..., hi I1S new end point

incrcasin~

Doctor Positiolt
Facing IUw;m.l patient
P]:Jccs lingers ovcr spinous pr~lccssC!'> (one hanJ over thc other)
Patient's knees in conlact with duclOr's anterior lhigh
Doctor lllust take om <III sbd in lumbar CXICIlSi{ll1 t'l). pushing with
lhigh intu paliern... knecs while "lahilizing vertebral segment
ahuve juilll lixaliun with hand ...(\III.let

nl:;J"lI"1CI'-' IMIIVI'I VI'"

I nl:;; .,:)rll'H:. M

r-hl-',I.J 1 I I I V I ' l C n " IVIKI'lU ..... L

Sdj~Jil..'llfl1l('/lf. Sl'lf'lfC<lIIllCIlI Ill' Ih.: hlln!l:lf spine

in1\\ c.'\l!.:nSitHl l';lll he ;I1.'colllplishl'd hy performing the
:\kKl'IlZic prout.' l'll dhow:-:. proUt.' press-up. and sl:llH.Iillf I.'xh:nsioll \.'\\"'n.:iscs (Fig. 1.1591. If (ill'S": l'xcn:bcs an::

1l1h:tllllfllrtahk. lh\,.' hal..-k 1.:.'\I\.:nsioll . . lrl...\l.:h till 11l1' I..'xt,;rcisl:

h;111 i,.. all lfkdil.\' l'.\lllIsillll 1llllhilil.;ltillll Sl'll"(l'l.:allllI.:111
\:-.\'''; I:ig,urc j ..L'i-i ill Chaph..'r I-n.

1
,

THORACIC SPINE EXTENSION MOBILIZATION (F;g. 13.60)

P<l:'lisoll\etric rda\:llioll l';11\ he lIsl..'d 10 improVl' eXIl.:lIsillll

11l\)bility in lhe I!Hlracil' spille, Thl' seated patient \Hl:-:hl's with
their dhmvs dO\\'Il\\"ard against the practitioller's n,.:sist;lllce.

1
!,
i

,
?

.)
(-""),

RIB MOBILIZATION

PostisOllll'tric rel,nation can be lI~l.'d (0 h~lr mobilize ;111

upper costotr;'lIlsn~rse joint The technique requires that the
doctor COIll:!C( the dysfullctional joilll ;ulli reach (he barrier in

,,

:vll.lbilizing [he thnracil' Spillt,; iHlo l''\(l'llsioll is thel1 ;lCC0111plishe.:d hy raising thl' P;ltil'llt'S dhow" while pressing into the
spine.: with an oppo~ilTg hand,
Self 'li'CallI/fllt, Thl' lhor;lCic region can easily becollll'
kyphotic A simpk slreH:h to incl"ea ....: extension mobility i..;
shown in Figure 1.'.61.

Fig. 13.55. Soleus PIR.

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.~

.<

Fig. 13.57. Hip joint posterior glide PIA mobilization.

.,
j

Fig. 13.56. Soleus self-stretch.

,J
Resisted Effort
Patient attempts 10 push knees inlo doctor's lhigh
Kyphosis or patient's spine should result

,
~

-"

Once patient has rull)' relaxed. doctor extends patient's spine by

10

,)

.,

Stretch
pressing hands anterior

i,
!,

stabilize ~cgmcnl above fixation. while

pushing with thigh ag'lima patiellt's knees in ;\ tlircction Inward

lixctl lumbar SCgllll::.-,1

Fig. 13.58. Lumbar spine extension PIA mobilization.

CHAPTER 13 : MANUAL RESISTANCE AND SELF-STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY

287

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Fig. 13.59. Lumbar spine extension automobilization.

,...",\

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ex.tcnsion by raising the ipsilatcral elbow. Thc patient is in

structed to push his or her elbow downwnrd. Aflcr resistancc
is applied to this movemcnt and the p<Uient relaxes, the joint
may be mobilized (Fig. 13.62).

J~

:1

,~

LOWER FIXATORS OF THE SCAPULAE (LOWER & MIDDLE

TRAPEZIUS) (F;g. '3.63)

,)

Patiellt Positioll
Supine

,"

Doctor Position

""'.7

Standing to side of patient

Grasps paticl1l"s arm with both hands iHH.l pull~ ~hollJdcr blmlc into
protraclion1<lbduclioll

'fi

1'....J,
~

I
I

Resisted Effort
Palicnt pulls should h;\ck towOJrd tJblc ;llld in toward spine. avoilJing hiking shoulder 1(lw;lrd Iheir C;lr or usc of triceps (elbow is
secn to bend)
Effort is isometrically resisted by doctor

\, /

11

{(

Other Facilitatioll Techniques. The PNF DE2 pattern

shown in Figure 13.64 is .lIlother excellent way to facilitate

.~

i~

the lowcr fixiltors of Ihe scapulae.

,* ,
~

i,
,~

A wcll-known PNF technique for the shoulder inyolvcs resisting contractions by the intcrnal and external rotators in
various degrees of abduction (Figures 13.65 and 13.66).

Facilitation Techniques

I,~{

RHYTHMIC STABILIZATION OF SHOULDER JOINT

...-J

<;,.;>

Fig. 13.60. Thoracic spine extension PIA mobilization.

n.C."Mt:llLIIAI 'UN UF THE SPINE: A PRACTITIONER'S MANUAL

-"J
Fig. 13.61. Thoracic spine extension selfstretch.

MIDDLE TRAPEZIUS (F;g. 13.67)

Palienl I'mi;lioll
Pnllle wilh

,lflllS

al ... id~,

Ooelor Pm,iliotl
SI;llldin~ ;11

side nr 1;lhk'

/>Cllienl's ,\clil'(,t EJJorl

into CX(Cn.. iOll with

R;lise~ ,lflllS

c.\ICrn;1! rnl.lliOll
Auempts 10 pull shouldcr hl.ll,h:s logether without shrllggin~
SIHlUldcrs
Rcsist;mcc lIlay he .. ppli~d (0 mcdial hnnJcr or SL';qllll;u:
H,lIllJ wcights mldel1 for pro~ressi\'c training.

Fig. 13.62. Upper rib PIR mobilization.

Grc<Jtcr challenge will result from performing this same

movement with lhe arm~ parLially 'Ibducted. abducted 901>.
;lIld fully 'Ibductcu. A bench or exercise ball may be used.
None ofthcse cxerci~es :-hould be performcd. howcver, unless
the (laticllt can avoid shoulder shrugging (upper trapezius activation) during thc 1ll0\'Clllcnl.
Other Faci/italiol/ Techlliques. This arca llJay also be
exercised with the dbows bellt by simply squeezing the
shoulder blades logelher (Fig. 13.(8), Rcsistam..'c to the medial horder ()f the sC<.lpul<Jc will facilitate the 11litldlc trapezius
(Fig.. IJJ)t).

LOWER FIXATORS OF THE SCAPULAE (LOWER AND MIDDLE

TRAPEZIUS) (Fig. 13.70)

I'alitilll 1'0.\;lioll
Side lying
Involved ,o;idc up
Ann fully abducll.:d

Doclor I'ositioll
Silling hchind p:lIicnt
PI,ICcs thumh or linger ctmtacl ,It
l'atiell/~'i Acti~'e

Fig. 13.63. Lower fixators of the scapulae facilitation (contracl

relax),

infcf{~mcdi:tl

hon!cr uf sC,lpUIa\'"

'".oJ/arl

Pulls shnulder hbdc h<.lck Inward spine while :I\'t1iding .. ny tcndt:l\cy to shrug shoulul.:f\

CHAPTER 13: MANUAL RESISTANCE AND SELFSTRETCHES FOR IMPROVING FLEXIBILlTY'MOBILlTY

Fig. 13.64. DE2 proprioceptive neuromuscular facilitalion paltern.

Fig. 13.65. Rhythmic stabilization lor the shoulder.

Fig. 13.66. Rhythmic stabilization tor the shoulder (90" obduction)

289

.. _

, ."', ''-'I'' ,-,r 1 nt:: '=It'''INt:,: A

PRACTITIONER'S MANUAL

~~1~~]~}-:
;S{J

Fig. 13.67.

~,,1jdd'e

-.~

trapezius facilitation exercise .

Hand weigh I

lllily

be added

If p;ltiellt Icnt.ls 10 hypcrc.'(tt:nd lhe Illw hack. j1laec.: ;1 pillow unda

;Ihdmnc,~

GLUTEUS MEDIUS FACILITATION (F;g. 13.71)

PatieJIt Po.. . itioll

Side lying Wilh lower hip

~ltIU

knee lk.\l'u

Doctor Positioll
St;uHJing hchinJ palienl
Contacts glutr.:us medius insertion OJlIO gn:;Jter trochanter
Grasps p,lticllI'S kg around kllL'l,"

Facilitation
Fig. 13.68, Middle trapezius facilitation exercise (elbows bent).
Effort should be isometric,llly n,:si~(cu ny dt}('l<lf ;\1 inferomcdial
border of sc;qmlm: (or po,tcrior SIHlllluI,"rl
Palient may iSlllllctri<:~lIy huld ;lddlJl,:ted ;Hld l1qm:ssed rb;lCk ,lIlli
down) posilion uf sc... pul~e tlnd perform:
.
Shoulder ~ldduc(ioll!~bJuCli(lll
Shoulder Ih:.\ion/e.\lt.,t1 .. inn

Rapid mobilization into abduction \vhilc ;lpplyillg "goading" stitllulation to tendinous insertion
Each mobilization should incrementally incn:ase range into hip
abduction (may be performed in f.ISI. ratchet)' manner four It) eigllt
I!mes)
After Illobiliz:ltioll, leg placed inlo abduction. internal rotatiol1.
and slight extension: paticnI Iwlds leg. up as doctor suddenly let ...
leg drop
Muscle should he !-ccn 10 i.(uic.:kiy contract so leg ducs nut dwp

';1;"

"

,
}

Fig. 13.69. Middle trapezius contract-relax facilitation.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _----A_

.'>

"V '; !PH,) r-Lt:All;11111 Y i....1VOILII Y

_----=-'-

,,~

'~".

"

,,
Fig. 13.70. Lower and middle

trapeZll~s

contract-relax facilitation.

Fig. 13.71. Gluteus medius lacilitation.

CONCLUSIOS
The MRT arc invaluable lools when sofl tissue lesIons are
considered primary or significant in the patient's functional
pathology. If chiropractic ~\dju~illt1ents are unsuccessful in relaxin" contracted musculature. MRT should be applied. High
velocity adjustments arc still the most potent tool available.

especially when;] joint lesion is primary. In patients with significant guarding. however. MRT relax the pJlient and inhibil
muscle tension. thereby making the adjustment easier to perform and longer lasting.
Generally. tense muscles should be relaxed <:.nd shortened
rnyofascial tissue stretched before weak muscles are exercised. Therefore, MRT should be used allhe beginning of any
rehabilitation program before initiating a strengthening program.
M~lIlual resistance techniques are simple and allow a
patient to learn self-treatment. Their usc enhances the doctor
patient relationship, encouraging the patient to become morc
tlclively involvcd in their own health carc. Well-prepared patients arc be ncr ablc to manage minor aggravations of their
symptoms on their own. Self-treatment docs not replace chiropractic or manual medicine treatmcnt, but it is increasingly
valuable in an era of diminishing third~party reimbursement.
ACKNOWLEDGEMENTS

I thank Joanne Larricq. Jerry Hyman. Vladimir Janda. and

Karel Lewit for their suggestions and contributions to th;:~
chapter.
REFERENCES
1. Kabot H: Studies on neuromuscular dysfunction. XIII: New concepts
and leehniques of neuromuscular reeducation for p-,ralysis. Pcnnanente
Found Med Bull 8:121, 1950.
2. Le,'ine MG. Kabat H. Knott M. et 01.1: Relaxation of spa.<;ticity by physiological techniques. Arch Phys Med Rehabil 35:214. 1954.
J. Mitchell Jr F. Moran PS. Prouo NA: .m Evaluation of Osteop;Hhic
Musclc Energy Procedurcs. Valley Park. Prouo. 1979.
4. GaY'mms E Lewit K: MobiliZ<ltion techniqucs using prc..<;sure (pull) and
m\l~cu1ar facilitation and inhibition. In Lewis K. Gutmann G (Eds):
Funclional Pathology of lhc Motor .Systcm. Rchabilitacia Supplemcntum. 10-11. Bratislava. Obzor, 1975. flP 47-52.
5. Lewit K: Postisomelnc relaxalion in combination with other methods of
muscular facilitation and inhibilion. Manucllc Med 2:101. 1986.
6. Robinson KL. McComas AJ, Belanger AY: Control of soleus motoneu
ron excitability during musclc streIch in man. J Ncural Neurosurg
Psychiatl')' 45:699. 1982.

7. Guissard N. Duchalc;llI J. Ihinaut K: Mu.~clc strctching .1IId motoncuron

excitability. Eur J Appl Ph)'si\ll 58:47. 1988.
S. SehieppJti M. Crcntl.1 P: From activity 10 rest: Gating of excil:nor) 'Ill,
togenctic affcrences from the relaxing muscle in m:ln. Exp Brolin Res
56:448. 1984.
9. Willi:tms PE. Goldspink G: Longitudinal growth or striatcd lllusck Ii
brcs. J Cell Sci 9:751. 1971.
10. Tarbal')'
Tarhary C. T:lrdicu C. Cl 'II: Physiologic;11 :md structural
changes in ca(s soleus lll\lsck due ttl illllllobili7.atiou;lt diffcrellt lengths
hy plastcr cam. J Physiol P"ris 224:2:\ I. 1972.
II. Williams PE. Catanese T. Luce)' EG. ct al: 11lc illlportam:c
strctch and
contrnctile activity in thc prevention of conneclive tissue acculllUlalioll in
muscle. J All.1t 158:109. 1988.
12. lakei M. Robson LG: lllixotrophie changes in human musclc stiffnl::ss
and thc errecL~ of fatigue. Q J Exp Physiol 73:487. 1988.
13. Habarth KE. Hagglund JV. Nordin M. e~ al: Thixotrophic behaviour of
human finger flcxor muscles wilh accompanying changes in spindle :md
rcflex responses to stretch. J Physiol (Land) 368:323. 1985.
14. Hagbarth KE: Evaluation of and melhods to ch.mge muscle lone. SC;ll1d

Je.

or

J R,habil M,d Suppl 30: 19.

199~.

15. HUllon. RS: Neuromuscularb3.<;is of stretching excrcises. In COllli P (cd):

Strength and Powcr in Spon: The Encyclopcdi;L of Sports l\-1cdicillC
Scries. London. Blackwell Scientific. 1992..
16. Voss DE, IOnia MK. Myers BJ: Propriocepti\'e Neuromuscular
Facilitation. Pattems and Tcchniques. 3rd Ed. Philadelphia. Harper &
Row. 1985.
17. Janda V: Seminar notes. LosAngcles Collegc ofChiropraclic. May 1988.
18. E,'jenth O. Hamberg J: Muscle Strctching in Manual Thcmpy. A C1inic:11
Manual. Vol. I. Alfta Rchab, 1984.
19. Holt LE: Scientific Stretching for Sport. Halifax. D:llhousic Uni"crsity
Prcss, 1976.
20. Cailliet R: Shoulder Pain. 2nd Ed. Philadelphia. EA. Da\is. 198 I.
21. Liebcnson CL: Acti~'e muscle relaxalion techniqucs. Part I: B'1Sic princi
pIes and mcthods. J Manipuhllivc Physio! Ther 12:446, 1989.
22. Liebenson CL: Activc musclc relax:nion techniques. Part II: Clinical application. J Manipulative Physiol Thcr 13:2, 1989.
23. Janda V: Musclc spasm-a proposed procedure for differcntial diagno-sis. J Manual Med 6: 136. 1991.
24. Lewil K. Simons 00: Myofascial pain: Relief by post-isomctric relax
:lIion. Arch Phys Med Reh:lbil 65:452, 1984.
25. Travel! J, Simons 0: Myofa...cial Pain and Dysfunction: Th..: Trigger
Point Manual. Vol. 2. Baltimore. Williams & Wilkins. 1992.
26. Grcenm:;1.n PE: PrincipleS of Manual Medicinc. Baltimorc. WilJiall1.~ &
Wilkins. 1991.
27. Spilzcr WOo LeBJance It. Dupuis M. el :II: Seienlific arrro;u;h to the :ISsessment and management of acti,ityrcl:llcd spinal disorders: A monogr:lph for clinicians. Report of the Quebee Task Forcc Oil Spin:,l
DiSQrders. Spinc 12 (SuppI7):SI. 1987.
28. Bigos S. Bowyer O. Bmen G. t:t al: Acute Low Uad: Problems ill Adults.
Clinical Practicc Guidclinc. Rockvillc, U.S. Departmcnt of Hcalth and
Human Scnic!::s. Puhlic HC'llth Servicc. Agl::ncy for Health Cme Policy
and Research. Dccembc:r 1994.
29. Lmricq J: Lecture. Los Angeles Collegc of Chiropr-,lctic, April 1994.

----.----.

-~

J.

14 Spinal Stabilization Exercise Program

JERRY HYMAN and CRAIG lIEBENSON

,,

Repetitive strain is the 1110S( <:ommon fl"aSOn pcopic dC\"l:lnp

pain. Improving load handling ability is instrumental in preventing chronic or rccurrCll! pain. Ironically, by redirecting
the patient's (ocus from chronic pain 10 functional integrity.
the pain is more likely to "go aw'ly: The result of controlJing
.~

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'/

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;
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loads in .1 more biomcchanically effective manner is less tissue strain 'll1d. therefore. fewer pi.linful.cpisotlcs. StabilizOltion
exercises twin a patient to coruml posturally destabilizing
forces. These exercises may start by requiring isometric pos
tural slabili7.alion of a key area. such as lh~ lumbopelvic june
lion during trunk or cxtremity movcments. and progressing to
involve control of lumbopclvk po~ture during functional ae
tivitics such as sitting. Iifling. ~qll:llting. lunging. etc. Such
exercises are Ihf?rapew;c in that they teilch the patient how to
maintilin postural control in activities of daily living. By focusing primarily on reducing lumbar overstress during func
tional exercises. the quadriceps. glutci.lls. ~lIld abdominals arc
trained without increasing back or hip pain. With this program, it is possible to achieve strength and endurance gains
because the back is not stressed. thus the individual can train
muscles to the point of exhaustion. Postexercise muscle soreness without symptom eX41cerb.uion is one of the essential
stepping stones to returning to full p'lrticipation in the <lctivj
tics of daily living.
Physical training addresses key functional deficits of
strength. mobility. or motor control (endurance. coordination.
balance). Functional stabilization (FS) exercises begin with
identification of a functional range. especially of lumbopelvic
movcment. This is the range of movcment that is both safe
and appropri:ltc for the task at Imnd. Pathoanatomic diagnosis
is of secondary imponance in these paticnts. Assessment of
functional deficits or palhology (specific joint or muscular
dysfunction and abnonnal movement patterns) and identification of a safe training range (neutral spine position and functional range) are of primary importance in successful physical
training of the patient with back pain.
Functional stabilization achieves muscular reconditioning
without aggravating presenting symptoms by focusing on
control of the lumbopelvic junction (maintaining'l functiOlwl
range) while exercising the "weak link" with the lIeceSS.lry intensity to achieve a training effcct. Neuromuscular control.
mobility. pain-free range. endurance. and willingness afe all
assessed during this process. Basic exercises such a.~ pelvic
tilts. bridges. trunk curls. lunges. and othcrs are included. II is
necessary for the pr:lclitioncr to experience their own abilities
through active ICilrning during such a training rcgimen 10

elicit proper responses from the patient. Maintaining proper

lurnbopclvic stability requires limiting and controlling exces~
sivr;: or undesired lumbopelvic movelllcnt strategies: e.g., performing a lunge with too much anterior pelvic tilt and resultant lumbar hypcrlordosis.
Patient education about the importance of good function
for preventing pain recurrencc.s is esscnti;'Jlto motivate the patient to work on creating a healthier back. Explaining that fitter backs have fewer symptoms is helpful. Therefore, it is
wise for patients to remediate function r..Hher than just to seek
pain relief. Learning to stabilize their back and gain self-rnan.Igement skills i.~ th~ key 10 preventing recurrences. Educating
our patients about the importance of this process and seeking
a commitment from them is one of our most crucial functions.

STAIlILIZATION I'ROGRAM AND OVERALL

PATIENT CARE
The stabilization program starts by identifying the training or
"functional range" in which movement can be performed in a
biomechanically correct and painless manner. Staying within
this range may initially require performing isometric stabilization exercises by co-contracting (he gluteal and abdominal
muscles (i.c;.. posterior pelvic lilt)_ If a patient is asked to hold
a posterior pelvic tilt and then move either anns or legs or
both ("dead bug"), they find thai holding the pelvic tilt
"burns" the abdominals. Kinesthetic awareness. coordination.
strength. and endurance are all trained in the process. A simple trunk curl is another example of an exercise that requires
proper lumbopelvic control. During a trunk curl. the patient
must control the 11<1lural tendency to recruit hip flexors that
would tilt the pelvis anteriorly. Floor. pulley. machine. and
gymnastic ball roUtines'may all be used 10 increase the stabilizing demands. The stabilization routine can begin in nonweight~bearing positions and thus achieves intense training
.effects. such as postexercise muscle soreness in failed back
surgery. postsurgical. subacute. and chronic pain patients
without causing harm.
The main go;)1 of this program is reconditioning key
spinal stabilizers through building ~treng(h and endurance
while insisting on proper neuromuscular control and coordination. The program also is of value as a mobilization approach that gently shows the path to movement exploration
and reeducation. In (his case. the de~ircd end result is less a
conditioning effcci (postexercise sorencss) and more increa~
iug patient confidence. muscle relaxation. circulation. and
293

nc;nf\DII.. II""IIUN VI- I He ::;PtNE: A

PRACTITIONER'S MANUAL

f
~"

joint movement. In addition, while pcrfomling stabilization

exercises, struclUral limitations ~lrc clearly identificd (Le.., inability to pcrfonn a posterior ~iil during a bridge as an indicator of tight anterior hip struclUres) that may require remcdiution thr;ugh stretching tedmiqucs.
This exercise progression is oncn facilitated by the <tddition of manipulative Iherapy to improve joint or muscle function. Sometimes an exercise th;lt is painful al first becomes
painless after an ~ldjustmcnt or muscle inhibition technique.
The combination of passive and active care is ideally suited to
enhance the effects of either alone. Adjustments should last
longer and pain recurrcnces diminish in frequency as a patient
begins to gain greater lumbopelvic camral and thus improved
spinal stability.
This exercise program was first formulated for patients
wilh low back pain by Vollowitz and Mo,gan, and is called
functional stabilization or spinal stabilization.l.2 It has been
adapted [0< usc by orthopedists and has ,educed the need [0<
surgery.~.4lts integration with other rehabilitation methods in a
chiropractic setting has been discus~ed previously.s In a study
of various treatments for chronic low back pain following un~
successful L5 laminectomy, stabilization exercises along with
McKenzie-type exercises were the most effective. 6 These lowtechnologic exercises were found to be superior when com
pared with passive methods, joint mobilization, and hightechnologic exercise experimental groups_ Alltreatmenls werc
administered three times per week for 8 weeks, Specifically. increased function as measured by lumbar range of motion (mod
ified-modified Schober fo< flexion and extension), spinal muscle st,ength du,ing lifting (Cybex Liftask), and self-report of
disability (the Oswestry Low Back Pain Disability Questionnaire) showed greater improvement with the active approaches
than with passive methods. Flnally. the mean intcrval for pain
relief was highest in the low-technologic exercise group (91.4
weeks)compa<ed t,52.8 weeks forthe high-technologic gmup
and less.than 10 weeks for Ihe othe, gmups.
FUNCTIONAL OR TRAINING RANGE
Many chronic pain, subacute, postsurgical. or failed back
surgery patients arc fearful that exercise will incrcase their
pain. Some simple concepts can be applied that enable nearly
anyone to begin to stabilize their spine. Training an area requires first that the range of motion (ROM) for the particular
movement is defined. The goal is to find a range in which the
patient can exercise without eliciting symptoms other th<ln
physiologic SOreness (postexercise soreness). This range m.lY
be narrow, leading initially to only isometric exercise (i.e., a
pelvic tilt). Some patients demonstrate a nexion or extension
"bias" that must be respected. Some patients may not tolerate
sagittal motions. but arc fine with rotary or side-bending active movements. Wilen the painfree range or "bias" 'W.f bee"
delermined 10 be biomechanicllily safe or .wable. if ... 1wuld be
llsed in progressive exercise Iherap)~ This range milY changc
depending on the position the patient assumes or the movement being tested. This tf'lining mnge has been labeled the

"functional rangc" for the particular task at hand. Idt'1l'ij)'ilfg

Ihe tmilling rauge is impOrlll1ll for petiorm;".': therapcutic ex
ercise ill (lily part oflhe body. \Vilh resfJccllO spillal prohlems.
IWIi'cI'er, Ihe lttmboprll'ic Illolion i... of grealc.<;{ \allu'. The
beaut)' of this exercise approach is that the patient !c..lfIlS lhat
it is possible to exercise without p;tin. As a rcsuh the p<.nicnt
gains confidcncc that some control over symptoms Gill be
achieved with the usc of spccilic sclftrcatmcilt procedures.

RULE FOR TRAINING THE "FAILEO"BACK

Find the painfree range of mOl ion or functional mnge

Identifying the training range involves uncovering postural, movement, and weight-bearing sensitivitics. 7 individuals with postural sensitivities usually must sit or stand a spccific way (Q "void pain. For instance, an individual with a
flexion bias is nOI able (0 stand for prolonged periods because
of an inability to tolerate lumbar extension. They must preposition their spine in some flexion, c.g.. using a fOOl stool.
Patients with mOVfment sensitivities may have pain dur~
ing certain activities. An individual who experiences pain
when bending forward to tie shoes or put on pants may have
an eXlcnsion bias. The functional range of such a patient may
not include flexion of the lumbar spine. A weight-bearing sensitivity or gravity intolerance may be revealed by a history of
pain Ihat OCCUfS during sitting or standing and is relievcd
when resting. Compression usually aggravatcs these symptOrrlS, as does coughing, sneezing, or any strong muscular
contractions. This situation is common in patients with acute
disk syndromes, who may have no functional range when up
right, but can train effectively whcn recumbent. Another option for the weight-bearing sensitive patient is water cxer
ciscs. Exercise performed in water should not mimic
land-based exercises because mO[Qr progwmming may be inappropriately altered by the combined effects of water contact
on the skin and reduced weight bcaring.
Finding the training range is somewhat like a provocative
examination used in the McKenzie system (sec Chapter 12).
The goal is 1O detennine what movements and positions rcIieve, aggravate, or ha\'c no effect on symptoms. Those move
melHs and positions in which symptoms arc relieved or arc
unchanged can be used as pari of a training program.
Activity within (he training. range is best tolerated by the
paticnt when attempting repetitive and prolonged exercise
training. The pain-free range is nol always one and the same
with the most stable or biomechanically. correct movernenl.
For cxample, ~l posterior pelvic tilt during (runk flexion is biomechanically efficient. because ~10 anterior tilt C,IO overstrain
the lumbar spine and encourages substitution of the hip ncxor
muscles (i.e., iliopsoas) for the abdominal muscles (see
Chapters 6 and 18). Many patients, however. report more pilin
with this positioning than with the anferior tilt of the pelvis.
In cases in which the less stable or biomechanically inefti
cicnt movement is more painrree, the joints and related soft
tissucs should be analyzed for dysfunction, with ..1 focus on
poor mobility or flexibility because of adnpti\'c shortening or
poor soft tissue extcnsibility.

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BI.',::Il1"1.." of the indiYit.luality of ~;\I..'h p~llicnl's fUllctional

ranJ;t'.lhIW llHH.:h antcrior nr posterior !ll'h'jc tilt is. feasible will
vary (~lr 1..'\-1..'1)'0111..'. hnding the p:linlcs.s range. '1long with asSl..'ssill:: (til" s!l(}I1111tlS(,:k" .llld capsular rt.':'triClions and diagnos.ing slru..:lur;d patho)ol!Y Ii. t . spondylolisthesis) will !c.ld tOlh::
IL'rtllillill~ [he functional or training ran,gl' for each palit'll!.
Th\.' hl'id~c c.\cl\:is,l' provides :'lllothcr example of whell :11

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h.:rl'd IIh:..-h;lI1ics hct.;llIsc of poor mobility or Ocxibility can n:suit in thl." cxcn:isc being leSs. painful when pcrfomlcd incorr..:t.:II~ Ih~1Il wh..:n il i~ pcrform":d com:clly. Biomechanically.
the bridgL'i~ most ~table and efficient when a sufficient posterior lill i~ used. thus r~ducing lumbar stress :ll1d increasing
glutcal ;lCti\'ity. If. howcver.)he patient has tight hip flexors,
shorh::ning of tile hip joint cap~ulc. andlor tightness of (he
lo\\'cr lumbar cr~ctor spinae musclcs. little if any posterior
pdviL' till will be wlemted by the patient. This case is one in
whit'h muscle relaxation "ltd/or ~tretching and joint mobilization allJJm aujuslillciH would be required before the bridge
L'ould he used as a stabilization cxercise.

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I'ROGRESSIVE S1;\BILIZATION
EXERCISE TRAINli'\G

Exercise therapy should be simple and painless to promoie

patient confidence. lnilial rcactinuion c.xcrciscs arc dcsincd
spccilically for a paliclll cmcrging from an acule episode or
for it p~Hicnt with chronic pain \\"ith fear of movement ("kinesiophobia") and symptom magnificalion (0 allow them 10
exercise \",,'ithout cxacerbating their symptolTls. The pmienr
shol/ld leam 10 explore b(lsic IWII!Jope!I'ic IIw\'cmenrs. slu.:h
liS IIIl' pc!I'ic lill. lIlUl perform g('",le .wrelches a"d ligltl ca,.diomscular ('xen.:i.'\(:. Weight be~tring or gravity strcss can be
minimized by focusing on supint:. prone. and siHing positions
during exercise. The stress may be greater during upright activilics of d'lily living.
Initial c~erciscs whereil1the patient c~plores movement;:ll
the lumbosacral junclion ill a variety of postures demonstratcs
the patient's neuromuscular control (or kinesthetic awareness). These exercises also fcn;:ll any structural limitation.
Such a Iimiwtion may be prcs~nl as a result of viscoelastic
stitTTlt::ss. elevated ncurol11UScul.lr tonc. bony abnonnality. or
struclural palhology.
When acute pain is <lc<:omp;'lnicd by inflammation. (he patient will have p;'lin with most or all movclllcnts. "Rclalive
rcst" and physical agents arc Il~cessilry for this "chemical"
pain. As innamlllmion sl,Ibsides. symptoms will begin to behave "mechanically:' meaning certain movcments will provoke .symptolll~ whereas other movements will relieve symptoms. As symptoms become mechanical. active exercise is
indicated.
The staning point for the exercise is determincd by appropriate histOi"y and cxamination. The answers one receives arc
determined by the questions onc asks. Movcments and positions that provoke symptoms an: best avoidcd. and those that
relieve symptoms should be indudcd in an exercise regimen.
PO.\"I.traillirlg check.\" of /m;,,/,ro,okillJ.: IIIm'ell/eHlS or poxi-

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IABILIZATION EXERCISE PROGRAM

tiOtI.\". alallg WillI olher additional (1u/{.:ome measures (i.e., lim;Ied range of /1/0(ioll. areas of lel/{I(~mess). should be per-

IOl'lI/ctJ. This poslcheck is a crucial step in increasing patient

conlidencc abolit the positive benefits of exercise. It can allay
fe;lr and .IIlXicly ahout p;'lin and convert Ihe patient from a p;'lin<lvoidcr In a pain Ill,mager. Also. showing the paticnt thallhcy
C;1ll1ll0W casier :ll1d with less pain aftcr the exercises have bccn
performed enhances pmicllt compliance and motivation.
Evaluation or the prospective slabilizalion rchabilit<.ltion
p;'ltient is summarized in Table 14.1.

STABILIZATION CONCEI'TS
imponant conccpts that pcrtain to this therapeutic exercise philosophy arc defined as follows.

TI1C

FunctiOlml or training range: P;linfrcc ;lTld stublc joint runge '1f lllOtion (USU:lUy wilh respect to hllnbopclvic motion) and appropriate for the task nt hand
Passive prepositioning: Using body position and/or suppons to passively place joints within the functiOilal range (i.e . lumbar roll to

preposition lumbar spine in extension during sining)

Active prcpositioning: Patient actively pUiS his or her lumbopclvie
joint into (he functional runge nnd holds it isometrically during
the course of an exercise (i.e. postcrior pelVic tilt as a prelude to
a "dead bug")
Dynamic Slabiliz<.Ilion: Gradual tnovcmcOl of the lumbopclvic junc~
tion into the functional nmgc during c~crcisc (grJ.dually changing a pelvic tilt from squalling to standing)
F:lcililation: Process of :l<;tiv3ting ("waking up") <t Illu~I..'iC iil<ti is
inhibited
Labile surfaces: Support surfaces that arc unstable. such as styro
foam rolls. bahmce or wobble boards. and "gymnastic" balls
Functional tasks: Tasks which one would pcrfann during the nor
mal course of daily work. recreational. or spans activity.
Perfamling these lasks with stabililY i.\nd coordimltion is the final
goal of thcmpcutic exercise.
The purpose of stabili7..<ltion c:ltcrciscs is to train proper
coordin;;nion during posture. movement, and exercises of progressing levels of difficulty. The stabilization program teachcs
an individual to: identify correct posture, find their training
r.mge. maintain postural comrol while perfonning intensive
excrcises. and nlHomatizc coordinated, stable movements and
postures during activitics of daily living (Table 1~.2).
When training a palient with back pain. improving stability involves more th~n just "dding resistance and repetitions.
Table 14.3 lists important v'lriables to consider as patients
progress through a routine.
In the office setting. stabilization c:ltcrcises can be used
like olher conditioning programs by increasing repetitions
.lOd resistancc according to standardized protocols (i.e.. goal
of 3 sets/IS rcps). According to Morgan, it is customarily no-

Table 14.1. IdentifyIng the TrainIng Range

History of static, dynamic and weightbearing intolerance
Identification of the movements thai provoke ar relieve symptoms
Identification of the positions that provoke or relieve symptoms

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Staoilil-alion cxcn;isc:-. 'IIC uftcn pi.linful if extcnsibility is

Table 14.2. Trunk Stabilization Routine
poor. \Vhcn this situalion is identified. it must bc addressed be1. Identify and explore training ~r function~l range.
.
fore the p::ltiCIH (.111 successfully pcrform stabilization cxer
2. Train lumbopelvic control dunng dynamic exerCise uSing
cise~i. For in.';;(allcc. difficulty in activating the g.luIC:J1 muscles
Passive prepositioning
Active prepositioning
is oftcn rcl::ltcd to "lower crossed syndromc" with light anterior
Other facilitation methods
.
.
.
hip
struclures. Any attcmpt at hip extension exercises typically
3. Automatize coordinated posture and movement In dally skills
results in lumbar overstress and It,unstring ;,md cn:ctor spinae
ovcractivatiun. In Ihis example. the first line of In~"IlHent
would be flexibility training. followed by gluteus maxillltls
Table 14.3. Increasing Factors that Progress Training
muscle facilitation and then exercise (sec Chapters 2 and IR).
Often during therapeutic exercise training. a muscle is
Gravitt load
Movement complexity
hard to activate. The Illuscle Illay not be weak from loss of inBalance requirement
nervation. or disuse atrophy, bUI Ill"'y only be inhibited. Rene:\.
Repetitions
inhibition from related joints and reciprocal inhibition from
Resistance
antagonist .muscles arc both potential therapeutic targets that
should be addressed (sec Chapters 2 and 18):Such relics therapy can facilitate a "donnant" muscle. Oth~r lllet~lOcis to wake
vantageous to perform stabilization exercises to a point of exup such an inhibited muscle include (echlllqucs trom the pro
haustion independent of repctitions,~ the end point being
prioceptive neuromuscular facilitation philosophy. s~ch. as
when the patient can no longer maintain lh~ spine in the funcoptimum patient positioning, verbal cOlllmand. tone 01 vOice.
tiunal range during movements. Even then. the palient may be
irradiation. and proprioceptive contacts. The value of these
instructed to perfonn a similar exercise in an easier position
methods in facilitating':In apparemly weak muscle should not
("peel back") so they can continue to exercise thc muscles tobe undercstimatcd.
ward greater physiologic exhaustion. Gaining kinesthetic
\Vhen the muscle is adequately facilitated so thm percep~
awareness oj the functional range and [hen exercising to fa~
tion or awareness is present, volition alonc can enable the patigue is the best way to deril'e full benefit from this program.
tient to train the muscle therapeutically. With practice and
It is the quality alld lIot the quantity ofmOl'emell1 tilm is mo.'"
repetitions, the muscle can be strengthened and its incl~sion
sif!llifiaUlt.
in everyday or cven stressful activities can be 3Ulomallzed.
~ Peeling back is an important consideration as a patient
Such "reprogramming" is the ultimate goal of FS cxercise~.
progresses through a therapeutic exercise program. In this
Depending on the level of deconditioning or structural
process. an exercise in the patient's training range is identified
pai.hology, patients may present with a gravity intolcrilnce.
dunn a which the individual can feci a "bum." Aftcr exhaustThese patients can still be trained using non weight-bearing
ing th~ muscle over a minimum of 2 minutcs of training, the
positions. Gradually, they can move from supine and prone
patient then "peels back" to another exercise in which the
loading to quadruped and kneeling and eventually to slandfunctional range can be maintained. The end result is a more
ing. Slide board or shuttle apparatuses (i.e.. Total Gym) with
intense conditioning effcct while maintaining stability of the
incremental adjustments from horizontal to vertical can facilspine.
itate the transition from nonweight bearing to \veight bearing.
Achieving post-exercise muscle soreness requires a cerIndividuals with low motivation often arc noncompliant
tain minimum intensity of exercise. From 30 to 40 minutcs or
with active care regimens. These patients can be "converled"
hundreds of repetitions arc needed to attain such a training efor problems can be avoidcd by determining mutually acceptfect in just a handful of lumbopelvic musclcs (e.g.. abdomiable functional goals and creating simple. painless exercises
oals, gluteals, quadriceps, hamstrings). These same exercisc
tailored to their individual needs. Additionally, postexercise
principles, however, can be used in a lcss intense fashion to
checks of functional outcomes provide the palient with evi
help promote better neuromuscular control without actually
dence demonstraling the benefits of self-treatment. If they se,e.
accomplishing a muscle conditioning effect. Such an applicaprogress. they will be motivated to a greater extent than at
tion may be successful for certain pi.Hients. but it may fall
asked 10 proceed on the doctor's word alone.
short of the mark for a patient with lumbar instability or
Treating failed back surgery, lumbar instability. or highly
chronic pain.
anxious paticnlli represents the most difficult challenge to the
physician. These patients have nearly. invisible "f~nctional
CLINICAL APPLICATION
ranges:' but they may initiate training In the follo\Vmg manner. After identifying and exploring their functional range.
Therapeutic intervention with stabilization exercises requires
they may begin by performing isometric floor stabilization
a clinical problem-solving approach. Typical problems efl~
exercises in the recumbent (nonwcight bearing) position with
cmmtered n.hen progressing patients through a stabilization
traction assistance (see Figure 14.56). The patient may
routiue are ,mor flexibility, muscle i"I,ibition, weight-bearing
progress with or without traclion assist;,mcc to other mo.re dcimolerallce. or low motivation. Addressing these situations as
mallJing positions, sut:h as quadruped. se.ned. or standlng. if
one encounters [hem is essential.

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I.;HAe I loti 14 : ~elNAL STABILIZATION EXERCISE PROGRAM

Table 14.4. Lunge Test as a Functional Screen

Trunk drills forward during lunge: tight hip flexors. weak gluteal
muscles
Increased hyperlordosis during lunge: tight erector spinae, weak

abdomina Is
Front leg's heelliHs aU floor: tighl soleus
Excessive knee shaking: weak qual'is, poor balance
Front knee in Iront of foot: too short of a stride or torso moves too
far for.vard

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Ihe p;,lticnt has difficulty mainlaining their function'.l1 range

through activc prepositioning. Ihey may usc passivc prcposilioning. For instance, supine hook lying with a cushion under
the knees kceps the spine in a posterior pelvic tilt and allows
easier stabiliz31ion training with either trunk (sit up) or extremity movements (respecting any flexion orextcnsion bias).
The exact progressions chosen depend on Ihe patient's rc
sponse to training and the individual work or activity demands to which they must return safely.
Training c::tn also pr~gress by increasing the movement complexity. For instance, movements may begin in cardinal planes (sagillal or coronal) and advance lO include torsional. coupled, and functional movements. Once a paticnt
has learned to explore lumbopclvic motion and to identify
their asymptomatic and stable functional range. they can perform various exercises while isometrically holding their
spine within this range. Adding extremity movcmcnts to b;'lsie
trunk exercises further challenges Ihc palit.:lJl~ lurnbopclvic
control.
The goal of FS exercises is 10 perfonn skilled funclional
movements with the spine stabilized as the p::ttient moves
from one position to another. Examples include moving from
sitting to standing, standing to knceling, and quadruped to
standing. At limes, the functional range may change during .1
movernc'1l. A classic example of a transitional siabilization
exercise is performing a lift from a squat position l() st<lnding
with overhead rcaching. In the squat position, an anterior
pelvic tilt is held. and in the standing. overhead reaching position, a relative posterior tilt is maintained, This change is necessitated by the tendency of the lumbar spine to hypcrlordosis when rcaching overhead.
Another type of progression involves increasing the balance requirement during exercise. Progressing from noor to
gymnastic ball or balance board cxercises heighlens the balance demands. This increase allows for a training effect th,lt
simuhaneously improves strength, coordination. and balance.
The freedom of movement provided by a labile surface allows
subcortical training of renexes that helps the patient to automatize bcttcr spinal stability. Improved rcflcx. automatic
control of lumbopelvic motion during activities of daily living is the final goal of spinal siabilization training. When the
patient has automatized this behavior, they can be considered
re-educated.
Two types of functional lesling are described. One Iypc
provides baselinc infonnation that shows overall progress.
ntis fonu of ic:tiiug can be used to motivate the patient and to

infonn third pal1y payers of the patient's st<ltus. if titis type IS

quanlifiablc. it is an id~al oulcomcs assessment tool. Another
type of functional testing seeks to identify functional dclkits
that arc cnlTccwblc with specific prescribed illlcrvclllions. For
the purpose of spinal siabilil.ation training. such pn:scripti"c
fUl\ctiollaltcSliug would assess the patient's ability to perform
anterior ami posterior pelvic tilts in a variety of positions
(hook lying. quadruped, sCilted. standing). lunges. squats.
trunk curls. sit backs, single leg balances. and bridges. Other
tests could be singled out, but.1 few sin1plc tesui, such .IS those
listed, can provide infonnation about coordination. slrength.
and flexibility. Table 14.4 shows how the lunge can be used .IS
a screening tesl.
STABILIZATION EXERCISE TRACKS
Stabilil.ation training as described in Ihis chapter deals with it
progressive program of exercises designed to reverse the effects of deconditioning or to maximize performance potcmial.
Exercises are' organized into various "tracks," each one e1mllenging the patient's ability to stabilize their spine in a different way. Within each track. the exercises arc ordered so that
they progress from simple to more complex movements. Each
track is in effect a progress chart of a patient's spinal stability.
The patient who C.1n successfully perform only the first few
exercises in a specific track is more dccondilioned than the
patient who can execute all the exercises in that track. It is
best to find the exercise within each track where "breakdown"
occurs, and then "peel back" to the one in which control is regained, Finding the palient's limit and peeling back is the art
of spinal stabilization.
Progressing through a stabilization program docs not
mean maslcring one track before moving on the next. \Vhcn
difficulty or weakness is encountered in one track. switching
to another is often a catalyst to progress. Progress can be
monitored by using a checklist (Appendix 14, I).
One key clement to stabiliz.llion exercises is the emphasis
on maintaining the spine in a functional range during training.
often incolTeclly termed Ihe "neutral spine rosilion:' Most
abdominal and gluteal exercises require a posterior pelvic tilt.
Just how much flexion c,leh patient needs should be determined individually. Most individu.lls do not have a "neutral
spine posture" but ff.uher lmve a functional range. Each patient, with the help of their clinician. must learn how 10 control exccss motion to avoid exc~eding Ihe boundaries of their
functional range. Some p,uierns indeed hi.iVe a "bins" toward
more eXlcnsion or flcxion of the lumbar spine. ;:Igain cmphasizing the need for individualized training. Similarly. ccrti..lin
universal biornechanical principles dictate that when sitting,
standing, or lifting, the spine shnuld be upright (lordotic).
How much lordosis will v<lry. Some people tend to be
"slumpers," whereas others arc more "swayback," Each
group of individuals needs to develop reflex. automatic conlrol of their lumbopclvic junction a lillie differently 10 avoid
excessive loading. 111is fine tuning is what FS excrcises arc
all about. Training may sl;,trt with illL:reasillg awareness

lIuuugII facilitation lllcthuu,..,. i;ll.::ll pr(1gr~ss to l'xl1allslill~ ~x

crciscs and daily hypcr\'igihuu:e (for ahmll 6 \\cck:,). put it
will ultimately fail lInlc~s norlllal 1Il0\ clll~lH p;Hlcrns arlO uot
reprogrammed so ,that the illdivitlu;l! "C;lll:!lcs l!lcllbdn:s
doing it right.
The following spc~ifk exercise.. . ;11\.' Jcsi~lled as dirf~I\:l\1
avenues to travd wilh a patient. I-:;Idl palicllt will pnll..Lcd al
i\ different rate. Sessiolls lIl;ly vary fH111I I () minutes HI mOl\'''
than I hour depending Illi the ll....eJs (If thl.: patil.:1I1. and Ilol
those or the pr.lCtitiona. In gCllcr;l1. each regimen carries the
pOlcntinl for patient frustratioll bc(au_,>c a gn.::ll de;1I or coordination is required by thc patiem. Ckar g()als must be laid
out and the prilclitioncr must be p,,{icll( and cmp:uhctic. ;\
6-wcek course of Slabilizatioll session", is often atk::qLlille to
begin the process of reprogr:.l11uning hetter neurolllllS(lIlar
control ilnd spinal stability.

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Ofril'l..' scssiol1s ShtHdd OCcLlr no more; than three to four

times pl.'f week. At IIr'1. {he patient is simply trying 10 led a
'"hum" ill the '"bi{' Illu:,eks whik feeling no stfain in lhe;
spinal ;11'1..';1:'. EXel\:isl' inlensity is inl.;"rcascd until pos(cxercise
SO..l..'llI.......... is ;\chicn:d \\ ithout s)'mpllllU eX:Kcrbatiou. A few
_'C~Si()ll' lIlay he rl.'qllirl..'d 10 lind Ihl..' training range and
achiL""c this rcsull. OIll"I. this lask i., ilCl':lllllplished. the pro
gr;IlH qllit:kly ~:l1hL'r" Ilh)llll..'niUm. :\, Illllg ;IS ;Ul cxcn.:isc
r..::tUSI..'", poslexl..'n:ise Il1thL"k sorcllcss. il ,11OUld nO{ bc repented
daily. WilhoUllhc il1h:lbily of lraining re4uircd to achiL:\'c this
dfcc!. the 1110tor 1.;"0111rol lh;r..:essary to achievc spin:.tl swbility
in Jaily lifc is 1l00likcly 10 result. Once a patient is discharged
from the prog.ram, intensity and rrcqucnl.y may be decreased
to a IlWimCllallce It;ycl.

1. Floor Slilhllii'.ation Excrdscs

A. LUMBOPELVIC FUNCTIONAL RANGE EXPLORATION

Lumbopdvic range of lllUlioll

terior and ant~rior pel\'ie tilts.

i~ ~xplorcd

by performing pos-

Hmlk lying (f-i!;. I-U I

Supin.: Icg~ cxlenlkd I..:n..ure unly millin.I:!1 duwllw;m.l heel

pre~

sllre) (Fig. 14.2)

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Fig. 14.1. Anlerior <al and poslerior (b) pelvic till (hook lying).

Fig, 14.2. Posterior pelvic tilt (supine).

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<;HAPTER 14 : SPINAL STABILIZATION EXERCISE PROGRAM

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Fig. 14.4. Anterior (a) and posterior (b) pelvic tilt (standing).

fl.

B
Fig. 14.6. Posterior (a) and anterior (b) pelvic lilt (kneeling with
buttocks on heels) .

"

i,
~

)l

'.)

}
Scated (Fig. 14.31
Standing (Fig. 14.4)

.)

Quadruped (Fig. 14.5)

Kneeling with bUt\UCKs \111 hccb (Fig. 14.6)
Kneeling with thighs vcrti("011 (Fig. 14.7)
Silting on 110m with feCi \s(llc~) logether (Fig. 14.8J
Prone

:g

.;s

li ()

~ u
i
t

L)

if: >,
,;
i ,,,}
.

,J

Fig. 14.5. POSlerior (3), anterior (b), and parti3.1 (c) pelvic till
(quadruped).

,..
v

,.;

r,

r
'l'"
~

1.

Difticulty performing pelvic lilt~ often is <.I result of poor

neuromuscular control. Appropriate verbal commands. r~\{:ilip
tative cues, passive prepositioning, and <lpproprkncly dirL"l.'tcd
rcsist<lnce arc all helpful aids in achieving the ability 1(1 pcr
form these basic movements.
Adjustment or l11obili1..a tion to the lumbar spine in I.'ithcr
ncxion or cxtcn\ion is often helpful. as is relaxation (If ('1\"('[.
active erector spirwc ll1Llscies.

n,-, ,"u, .... , ' ' ' '

' V ' " VI

"'I... ..,,- ""I....

" r n ........... I I I I V ' ' ' l : ; n

IVIJ-\'''';UJ-\l.

B. "DEAD BUG" TRACK (ABDOMINALS)

For each exercise in this track, ensure that the patiellt maintain:-: the posterior pclvic tilt not only at
lh~ heginning
the movcmcnt, but also to the end of the cxen.:isL'.

or

I. Hook lying. activc prcpositioll in posterior tilt, rJise one ann at

a time ovcrhead
2. Hook lying. active pn:posilioll ill posterior tilt. raisc both arms

ovcrhcad
3. Hook lying. activc preposition in postcrior tilt, raise onc foot.\
few inchcs off thc noor at a timc. switching to thc other [oat so
as 10 "march"
4. Hook lying. activc preposition in posterior tilt. bring onc knee to
chest at a lime.
5. Hook lying. active prcposilion in postcrior tilt. bring one knee to
chest at a time while raising opposite arm. return foot 10 noor
(Fig. 14.9)
6. Hook lying, activc preposition in posterior tilt, perform alternating kicks without letting feet touch the floor (the lower the legs,
the harder the exercise) (Fig. 14.10)
7. Dcud bug (Fig. 14.11)
8. Add ankle and wrist weights

"

:1

;
I,
;,

..

~
,

.,

When a patient has developcd the neuromuscular skill to

pcrform exercise 6 properly, then they have an exercise that.
if perfoffi1cd repetitively. will bring about the required training effect to condition the muscles.
Difficulty with the "dead bug" track is usually associated
with poor neuromuscular control or weak abdominals.
Shortened psoas and/or erector spinae (hip flexors) muscles
may also be a factor.
C. BRIDGE TRACK (GLUTEALS AND QUADRICEPS)

I. Supine, hook lying. with active prepositioning in posterior

Fig. 14.7. Posterior (a) and anterior (b) pelvic tilt (kneeling with
thighs vertical).

pelvic rilt bridge. slowly raising the pelvis and lumbar spine one
segment at a time and then lowering one seglllcnt at a time
(keeping kyphosis of lumbar spinc throughout) (Fig. 14.12)
2. Bridge up. alternate hecllifts while holding bridge
3. Pcrfonn bridge. then "march" with only one foot on the floor
(shift weight before marching) (Fig. 14.13)

8
Fig. 14.8. Posterior (a) and anterior (b) pelvic tilt (sitting with soles together).

-----j.

CHAPTER 14: SPINAL STABILIZATION EXERCISE PROGRAM

301

Fig. 14.9. Posterior pelvic tilt with opposite arm and leg raised.

Fig. 14.10. Posterior pelvic tilt with alternating leg kicks.

B
Fig. 14.14. One leg bridge ("dips").

Fig. 14.11. "Dead Bug."

Fig. 14.15. Opposite arm and leg raise.

4. Bridge up. extend one knee, keeping both thighs paralic-I. perform one-leg bridges or "dips" (Fig. 14.14)
5. Holding bridge with straight leg. lower and raise leg

Fig. 14.12. Bridge.

A training effect is possible with application of exercises

from exercise 2 on. Difficulty with the bridge track is often
associated with a shortened psoas muscle or ovenKlivity in
the lumbar erector spinae muscles. The one-leg bridge exercise involves use oflhe gluteal medius, and its difficulty may
be associated with piriformis or thigh adductor tighlness/
ovcractivity. Additionally, lumbar segments may have decreased flexion motion. Sacroiliac and thoracolumbar joint
dysfunction should also be considered.
D. PRONE TRACK (GLUTEAL MAXIMUS)

I. Single arm raise with pillow

2. Arm and opposite leg raise wilh pillow (Fig. 14.15)
Fig. 14.13. Bridge with "marching."

3. Without pillow

~-----------------------

nc.n .... o ..... 1 11"\1 IVI\l Vr- I Nt:.

::.... INt:

PHACTlTIONEH'S MANUAL

Diniculty ort~n arises because of decreased spinal and hip

lighl psoas (hip flexor) muscle or hip capsule
may be il1\'ohed. Decreascd lumbi.lr spine mobility in extension (lixed kyphosis) is also a faclor.

~xl~nsihilily. :\

E. QUADRUPED TRACK (GLUTEUS MAXIMUS, MEDIUS)

Preposilion in ncutral position anti faise one aflll (Fig. 14.16a)

R~lis~ one kg (Fig. 14.lJlb)
R"ise oppusilc ann tlIl1J It:g (fig.. 14.1()c) (may add wrist and
ankh: wcighbl
Add cxterrw] rcsistanc~ with doctor pushes <Fig. 14.17)
With 0111.' :lflll r:lised. perform trunk rot;\tion (Fig. 14.18n)
Support arlll on balance board. pcrfonn trunk rotation
(Fig. 14.181

()

()

:)
Fig. 14.16. Quadruped progression.

Fig. 14.17. Quadruped with extern~1 resislance.

'. ,)
)

I
!.

II
B

A
Fig. 14.18. Quadruped with trunk rotation (a) and on balance board (b).

___-:--

,)

I
~

~- __--i~
<. i'

._.

,---- .....

,,

,
j

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~

,!

1,

"

A
Fig. 14.19. Kneeling hip extension.

I,

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,~"

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)
1

i,,

I, )

I,

t,

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tI

)
)

Fig. 14.20. Kneeling to semi kneeling progression.

Difficulty with the quadruped track is encountered when

lhe prone track is not mastered. Also. gluteus medius weakness/inhibition on the supPol1lcg side may be present bCl:l.\uSC
of adductor, piriformis tensor fascia 1,.11<.1, or quadratus lUll1bo~
rum hyperactivity/tightness.

!-~

" J

I
l';~

G. ABDOMINALS

F, KNEELING TRACK (QUADRICEPS, GLUTEUS MAXIMUSj

-~

iJ{!

,.,1

.~

.~

t"li
~

1a. Siuin on heels. trunk and hips Ocxed. poslerior pelvic tilt.
r;lisc torso by extending hip... (abdominals and gluteus max
imus) (Fig. 14.19)
lb. Silting on heels. trunk upright, posterior pelvic tilt. r.:lise IUrsn
by extending hips (Fig. 14.20 a illld b)
2. Sallie position as shown in Figure 14.20B with arms raised

\.>

(Fig. 14.20e)

',,-J

f:o

~"")

I,,

3. Wilh weights (Fig. 14.21)

4. Hold rOtiscd pnsilic... while Ilcxing ;llld extending
14.21C)

...l...-

;~
:\

&
~
j;
f
~

Kneeling may be difficult beC<llIsc of knee problc!-.lS or

tightness in the erector spinae or n,~ClUs femoris. Erector
spinae shol1cning or decreased lumbar flexion mol ion is also
a factor.

j
"-,'"

{ }

;lrlllS

(Pig.

Crunch with pa:-sivc pn:positiolling (hips ;llld knees positiol1t"u ;11

90" llcxioll a" Oil :1 chair)
Crunch wilh ;lclive pr~positi()nin (Fig. 1~.22)
Trunk curl (willi knc...s h~nt ;md partiully ..::\tcndcd) (Figs. I.L~J
and 14.24)
Posterior pel vic' tilt
Keep chin tucked. raise head then uppcr back until should..:r
bhtdcs arc off Ooor
Feel shnululIlll lift up

~'
;];:;

.,

Fig. 14.21. Kneeling to semi-kneeling progression with hand weights.

.'"

'!t
j

,
.,

Fig. 14.22. "Crunch" abdomina!s (active prepositioning).

B
Fig. 14.24. Trunk curl with legs extended.

Sit back
Posterior pelvic tilt and lower trunk one segment ilt a time,
then raise back up without lordosis (Fig. 14.25)
Lower abdominal hip thrust with back nat and hips and knees

ftexed 90' (Fig. 14.26)

Oblique

Fig. 14.23. Trunk curl with knees bent.

Difficulty is often encountered when the erector spinae or

hip flexors arc overactive/light. Lumbar spine joint dysfunction may also be prescnt.

...
.:;:

-----------------

H. LUNGE (OUADRICEPS\ (FIG

1.1 ?7)

Fl'l'1 should hl' ~h(ltlltkr width ap;H'l

~I;\illl:lill slight lumhar lordosis lllr')llfhnlli llll\~l'
Ik",iol\)

(1'1"1111\

knl'l'

Slight pllsleri(lf pL'lvic lilt lllay (ll' lll'e,kd Ill';ll' ,'<llllpkti'lll

descelll
Stride should he long cnough S() kn<.'e is jUq (J\"I.:r (,1,'\
Lungc forward until back knee touches !loo!" (Fig, 1-1.27B)
Add hand weighb. lIledicinc ball. (\r wl'ighl bar
Adt! resistance fmm behind with pulley or exercise tubing
hooked Ollto patient's belt
Backward lunge
Sideways lunge

lJ{)"

Ill"

Difficulty can be encountered when hip flexors (back leg)

or hamstrings (front leg) are tight. Observe balance en'ors, in-

Fig. 14.25. Sit back.

A
B
Fig. 14.27. Lunge.

appropriate neck/shoulder movements (i.e.. chin poke, shoulder shrug), and slllall jerky- transitional movcmcnts.
I.

SQUATS

With feci shoulder width apart, actively preposition in pal1ial anterior pelvic tilt and pcrfonn partial squat (no more than 90 knee
flexion) (Fig. 14.28)
Progress to lcaning forward 10 touch noor with hands without
losing anterior pelvic lil!

Fig. 14.26. Lower abdominal hlp thrust.

Difficulty can be encountered if adductors arc shortcned.

will lift lip if soleus is tight.

I-feels

Note: Tllesl' lI\O\,CIllCIHs ;m: Ill\lrl' difficult (lll circular-tuhular (O,llIl

Altcrn:lh:ly lifl onc fOOl sli1;llIly \ll'l" l100r (f:i~, 1-l.~9hl
Prngrcss tn lJO" hip I1cxitlll
Rep-:;ll ,lh(l\'C with anll:' o\'Crhl',1l1 (Fig. J.L29d
Repeal ah\I\'\. with hoth hands ahovc chesl Wi,g. 1~.:!9dl
On drdc wcd,ge. hands (11\ t,-hl'sl. onc knec tn l.:ht'~l

2. Styrofoam, ;"ledicine Ball. Stick. Exercise 'nlhil1~

Stahilization Exercises
A. ON STYROFOAM

Pcrfllrlll posterior pC!\'ic lilt with hands on l1uOf (I/~ l'irch;) (Ii:l'l
closcr together is h;mkr) (Fig. 1-l.::!9a)

.-1;,

B. ISOMETRIC ABOOMINALS (WITH DOCTOR

OR THERAPIST)

Actin: prep\lsil;Ull ill cnlllch l'klsitjoll wilh loam held bCtW1;'l'lI

klh.'t'S

Patiellt rt'sists movcmcnt of foam whcn doctor Jlushes or pulls

foam (fig. 14.30)
Active preposition in cnlllch po~ililln (90/90 hiplkllt'C Ikxjon)
with mcdicine b,lll or liglH ohjcct helJ bl.:1WCl.:i\ fecI
Doctor Ihrows ball to patienl overhead lFig, I-lJ 1)
Al.:lj\c preposition ill cnlllch PO~ili~\ll wilh hall held helwecn floel
ill1d gymna~tic hall un ahdml1cn
Pati~nt rc~i~(s movcmcnt (If gymnastic hall hy Ihc uoctor ill
diffcrclll Jin:ctiollS ~l(lwl)'

.,
,~

3. Gymnastic Uall Exercises

To increase pmicllt confidence. gYl11n~ls(ic h.J11 cxcn.:ise:-o call
be done between two chairs for b~lI ..mcc suppon. The ball is or
the proper heig.ht if the hips and knees of the patient silting on
the ball arc at 90 '-Ingles.

'";
,
A

"

c
Fig. 14.29. Styroloam progression.

Fig. 14.28. Squat. A. Correct. B. Incorrect.

..

._._._ ... .. _.,_ ..

,~

~.~-

... ..., .... , ...... ,..

;;UI

I
1,"
I

1]

Ii

Fig. 14,30. Isometric abdominal "crunch" position with resistance. .

l
~
J

Be careful that the head docs not shift forward (+ Z) or lhM the
chin pokes OUI causing ecrvicocranial hyperextcnsion
Scated, posterior tilt. and roll down ball part way until abdOluinals begin "working" (Fig. 14.35)
Hold position and slowly lift one fo('~ ~t :~ tim,: {gh!!("us
medius)
Shoulders on ball, active preposition in posterior pelvic tilt anu
bridge up (Fig. 14.36)
Hold bridge and fk~ onc leg with knee bent (Fig. 14.37)
Keep postcrior till and prcvcnt oppositc hip from f<llling and/or
hiking
Hold bridge and flcx onc leg with knce eXlcnded (Fig. 14.38)
Bridge up and down with one leg on floor

Ii

I~

I
"

.~

C. ABDQMINALS

II
!
I,
~,~

{ J
! _--"'J..

~
'R

i! " ,
"

Middle of back on ball. trunk curls

Stall low on b'lll (passively prcpositioned in flexion) :Illd
progress higher on ball until exercising ill extended position
(Figs. 14.39 nnd 14.40)
Middle of back 011 ball. perform partial trunk curl. l'llCh bnll
thrown by doctl1r (Fig. 14.41)
Progress to harder positions on ball
Middle of b<.lck Oil ball. pcrfoml partiallrUllk curl. ptlll (miley or
exercise lubing in rotary directioll (elbow:" should :"lay extended.
movement occurs from waist muJ IInl shoulders ()I" ,U"lHS)
Progres~ by adding. rcsisl,lI1CC
All fOUf!'., front roll (feet off the gnmml) (rig. 14.421
D. HAMSTRINGS

With legs extended ,100 feet on b.l!1. bridge up .Illd roll lK11I toward bUllocks by Hcxing knees, then roll ball away (Fig.. 14.43)
With hips and knees .It 90/90 nc~i(ln. pCrfUnll bridges (Fig.
14.44)

,)

Perform anteriDr and po~\crior pelvic tilt on ball (Fig, 14.32)

Active prepOsiliol1, in nculr:ll position, perform single leg raise
(Fig. 14.33;1)
Sillgle leg raise and rull back (maintain slight lumbar lordosl:-J
(Fig. 14..11h)

Sealed, perform posterior pelvic lilt and roli down b.llllO bridge
(Fig. 14.34)
Return to sitting position with pusterior or antcrior tilt (small
steps do nUl stup)

A. SEATED

B. BRIDGE (QUADRICEPS. GLUTEALS)

'1

Ij

Fig. 14.31. Isometric abdominal "crunch" position wilh medicine

ball.

.. _

..,

, n.-.

J"

'v'lIcn

.::> IVlf\l\JUJ\L

.-""i

Fig. 14.32. Sealed anterior and posterior pelvic lill.

i}
B
Fig. 14.33. Single leg raise and roll back.

309

CHAPTER 14 : SPINAL STABILIZATION EXERCISE PROGRAM

Fig. 14.34. Seated to bridge.

Roll ball from extended position (0 kncc flexion position with

single leg (Fig. 14.45)
90/90 bridge with single leg (Fig. 14.46)
Raising the umlS vertically increases Ihe stabilization dt'mands
on the trunk
E. SUPERMAN

Prone on ball with fc:ct against the wall. perform postcrii.1f pelvic
tilt and then extend Ihe trunk by pushing off from w,llI and
straightening the back. Make sure to maintain some gltltcal and
'lbdominal co-contmction throughollt movement (Fig. \-t ..P a
and h)
In extended position. swing one ':lfln up overhead whik holding
posterior pelvic tilt tFig. 14.47c)
Fig. 14.35. Half sit-up with alternating leg raise (progress to partial bridge).

If this exercise is Jinicult to perform. retrcat to till;.' knceling (rack exercise :,hown in Figun: 1...J..19.

MCMROlLiIAllUN Ut- THE SPINE: A PRACTITIONER'S fl.o1ANUAL

----------~==~

\
~

I,

Fig. 14.36. Posterior pelvic lilt and bridge up.

Ii
1
\

I
I,

A
Fig. 14.37. Hold bridge and flex benlleg.

I
t'-- -

I
I
I

8
Fig. 14.38. Hold bridge and flex straight leg.

Fig. 14.39. Trunk cur! lower on ball (easierl.

CHAPTER 14 : SPINAL STABILIZATION EXERCISE PROGRAM

311

,,
~

J
{
~

B
Fig. 14.42. All fours front roll.

B
Fig. 14.40. Trunk curl higher on ball (harder).

>-~

"

B
Fig. 14.41. Trunk curl and catch medicine ball.

F. SEESAW

AllIerior thighs llll 11:111. hands un lloor. active prCp{l~ilitlll in ncutrod pusitiun. r<lise ;Ill'" lo\'..cr upp~r :lnd lower body alternately
(sec-saw) (Fig. I-lASl.1 am! h)
Raise nne leg ttl perform the scis:"or Wi,g. 1-1.4Rc)

Difficulty c:m be cncoul1(crl.'d if erector spina(' or hip flexors arc light

c
Fig. 14.43. BridQp. and roll ball in and Oul.

B
Fig. 14.44. 90190 bddge.

Fig. 14.45. One leg bridge with roll.

-j
)
:'"

.~)
!

Fig. 14.46. One leg bridge 90/90.

'--j'

,)

J
J
G
~J

C}
B
,~'"

oJ

Fig. 14.47. Supr;:man progression.

CHAtJ I t:H 14 : ::it-'INAL :::i IAt;ILlLA I IUN t:Xt:H\,JI:::it: tJHUl:iHAM

jlj

G. SQUATS

Wall ~lilk wilh !llwL'r b;IL"~ again:-;t wall and :-;ligllt anIL'rill!" pl..'h-iL'
lilt (Fig, I--L49)
Perform wilh a weight in !Jamb: a:-; legs L'xlellll. gradually rai~L'
the wL'ighl overhead
When lhe arllls reaeh horizontal. transition rmlll ;Ill ;1I1tcrillr til
a p\l~IL'rill!" pelvic till
I'l'l'rorlll a ~qllal wilh olle roo! 011 11(1(lr (Fi~~. 11.)(}) \(1nlk~~Ld
squab \~ilh the h;llllllay llol he as deep)
H. KNEE ON BALL FRONT ROLL

Knees on hall 'lIld hand.. . 011 noor, c.:irl'lllllduet plClvis

(Fig. 14.51)

B
B
Fig. 14.49. Squat.

t.

Prone on hall back extensioll (Fig. 14.52)

Prone on ball upper back CXllCliSioll (Fig. 14.5.'1
:\dJuct :-;hl\ulder hladcs and l1ll'n lift sterTIUllI ll(( b;111

Kecp chin lud,cd in

Fig. 14.48. See-S3\!J progression.

OTHER BALL EXERCISES

B;

~k,(rt:tL"1l (111

h,dl

(Fi:~,

11.:'1)

. _

...... "

,""'.........

I I ....

-.I' " .. c.

"'1"11-'0.\..1 1IIIVI\ll::N ~ MANUAL

1f
,

i,
t
~

I
,

Ii

J
Fig. 14.50. One leg squat.

B
Fig. 14.52. Lumbar extension.

A
Fig. 14.51. Knees on ball circumduction.

B
Fig, 14.53. Dorsal extenSion.

315

CHAPTER 14: SPINAL STABILIZATION EXERCISE PROGRAM

Fig. 14.54. Back stretch.

Fig. 14.55. Shoulder rotation with trunk stabilization.

4. Pulleys and Bicycle

A. TRUNK TWISTS
l..,nmelrk slahililalillll with ahd\11llin~:lIgl11tcal co-contraction,
perform trunk {wi\! ,-lgainsl resistanti-' (hold elbows in c\lcmlcd
po\itioll) (Fi~. 14.55)
8. GRAVITY-ASSISTED PULL DOWNS

Pcrl"orm push:rior pdvk lill ag'lin\t rc..,i..,lalKt' while bringing

h:lnds

hz

t(l

;lhdplllcn

'l;.;ainst

1\'sisl,IlKT;

Fig. 1,,+.)(1)

Fig. 14.56. Pelvic tilt and pull downs with traction.

.... _ .. _.

I
I

" . _ _ , ... _ , , . "..... " . , ..... , ... ,. v

,v,nl'lvr-.l..

C. RECUMBENT BICYCLE

Supine 011 floor or lay h:l..:k 011 large hall whik riding stational;;
bicycle (r:ig. 14.57)
REFERENCES

1,
l

I~

l. Mon.::1Il D: C(lIlC':l't~ in fIllKH''lI;11 tr:lining ;ll1d Jl<hIUr:11 l'lahili7~lliol\ fur

the I;Jw.h:Il'j.;.injurl'll. Tllp . \ltH..: C;m,: Traul\1a R..:hahil 2:8, 19HH.

2. ~h1H~:1I1 D: $..:rnil1ar. 1.11.';' All":l'k.l Colkgc ofChin1praclic. 1992.

J. Sa:II~J:\, Sa:.l IS: Nnllup.:r:lli,..: Ir"::lllll..:nl ,If hl'rni:lkd lumbar illlc('\l'rte
br:t1l1i~c wilh r:llliculop;llhy. Spin..: 1... :-01. 1~)H9.
J,\: l)~'I1:11llic muscu!;" ,,1:lhili/.:l1iuli in lhe nOIl0pt.:rali\,,: IrC:IIIll.:n1 (If
lumll:tr p:tin syndromes. Onllo Rc\' 19:691. 1990.
5. Liebells~111 CL: Rch;jhilil:llioll Oflhc chnlllic had; p:lln patient: FUl1l:llonal
r,:sltlraliolllcchni4u,:s. Cal Chir J 16:26. 1991.
J.:. Timm KE: A randomilcdcontrol ~lud)' of acti\'e "nd passh'e IfCa\lllt:nls
for chrnnlc low b,lCk p:lin following l:lIllincclomy. J Onhop SportS Phys
TII.:r :m:27(1. 11)<)4.
4. S:I;J1

I.
~

7. Vollowil/. E: Furniture prcscriptinn for the cOllscr..:ui\'c l1l:IIl;lgclIlcnt of

i
I

I
I
\\:

I,
Ii
~
i
!

I~

I
I

I,
I

lowhad p:Lill. T(I[l/\cUlc Clr..: Traullla Reh:lhil 1: IS, 1988.

ACKNOWLEDGMENTS

We arc grateful for the example and guidance of Dennis

JO.IIlIlC Llrricq in the completion of this ch:lptcr.

Morgan and

APPENDIX 14.1 Exercise Checklist:

B

I. FLOOR STAllILiZATION EXERCISES

a. Lumbopeh'ic functional range exploration

-Flg. 1<1.57. Recumbent bicycle.

__ Hook lying

_ _ Supine legs extended

Scaled
_ _ Sl:mding
_ _Quadruped
_ _ ~neeling with buttocks on heels
_ _ Kneeling with thighs verticul
_ _ Sitting on floor with fcct (solcs) togcther

b. "Dead hug" Track (abdomina Is)

_ _ Raise I arm at a lime overhc<ld
_ _ Raise both arms ()verhc.ld
_ _ "March"
_ _ Bring

I knee to chest al a time

_ _ Bring I knee to chest at a time while raising opp_ arm

_ _ Alternating kicks
_ _ Dead bug
_ _ Ankle and wrist weights

c. Bridge Truck (glutcals and quadriceps)

_ _ Bridge
_ _ Bridge wI heel lifts
_ _ Bridge wI "march"
__ I leg bridge
_ _ Bridge and lower and raise leg

-~

d. Prone Tmck (gluleus maximus)

II

_ _ Single ..Irm raise wI pillo\v

__ Arm/opp. leg raise wI pillow
_ _ W/nut pillow

e. Quadruped Track (gluteal maximus, medius)

Raise I arm
_ _ Raise I leg
_ _ Raise opposite ann and leg
_ _ Wrist and ankle weights

External resistance
_ _ 1 arm raised perform trunk rotation
_ _ Balance board perform trunk rotation
f. Kneeling Track (quadriceps, glute.al maxim us)
_ _ Silting on heels mise torso

_ _ Silting on heels. trunk upright raise torso

_ _ Sitting on heels. trunk upright raise torso wI r.liscd arms
__WI weights
_ _ Flexing and extending arllls
g, Abdominals
_ _Crunch
Trunk curl
Sit b.lck
_ _ Hip lhrust
_ _ Obliques

h. Lunge (quadriceps)
_ _ Lunge
__ WI weight
__ WI pulley or exercise tubing
Backward lunge
_ _ Sideways lunge

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2. STYIWFOA'I. '1EIHCINE 11,\1.1., STICK. EXERCISE

TUIIIN!; ST,\BILIZATlO;-; EXERCISES
a. 011 st)THr(l~1ll
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MI.'I..h<.tlIl.' tJ,llI held hct\\cl.'lI fl.'l't/"tlcb

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3. GYMNASTIC BAI.L EXERCISES

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.1. SC::lted
_ _ Anterior

_ _ Single leg raise and roll back

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b, Bridge (quadriceps.
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__ Return to sitting position

__ Y~ sit up and nmn:h'
_ _ Bridge up/down
__ Bridge and flex! leg wI knee bent
__ Progress 10 only upper b~lck and he.\d ()II ball
_ _ Bridge ,lOd flcx I Icg wI knee extl.'llded
_ _ Bridgc up ;lnd down wI I leg on noor

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Sec-s:!w
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g, Squats

Wall slide

WI <:omcthtng in h:.lmt<:

Isometric St,lhiliz::ltiol1

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pu"hcs ur

pulls

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90/90 \\1 "mg.!l' kg

h. Ismuctric ..\ hdominllts (w/doctor or thcnlJlisl1

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___ I I\l1l.'l' III

balllnlllk curls
and c;Hch ball thrown by dncUlr
_ _ l'rugA'SS hI harl.ll,,'r positions on b~ll
_ _ Trull" lurl/pulky or exercise tubing in Wl.. tliol)
All !"tlur" fnllli rnll
d. H:lIlls{rin~s
FI,,'l'1 1111 hall hridt:1,,' w/mll in
t)O/IJO hIIUgl''''
~_ Roll 11:111 w/ singk kg

~_Trul\k cml

\VI l'Ilr\\.lhi r.\.II,1

WI I loot on nOOl
h. Knec on Imll front roll
Front roll
i. Other b:lll exercises
B'lck extension
___ Uppcr back cxtension

Stretch

4. PULLEYS A;-;n IIICYCLE

Trunk twists
__ Gravity-assisted pull downs
I{CCltlllh(,,'llt bicycle

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IJ ::,ensory lVlotor ::)ttmulatton

VLADIMIR JANDA and MARIE VAVROVA'

Tht:rapelllic~lpproaches have (hanged along with our in

creasing kllO\\'h:dgc and underslanding of physiology. In the
original approach to therapy, we viewed the motor system as
an effector only. and did not C:lltlsidcr its rok with the alTcren! system as one functional unit. The conclusion was drawn
[hat motor performIll1cc is a result of isolated and separate. although coorJinatcd. activation of individual muscles. The
focus of these techniques was activation of individual muscles or llluscle groups in the hope that the new motor pattern

would develop automatically. Examples of such thinking arc

exercises prescribed according to muscle testing or the progressive resistance exercise program.
The next qCP in thc evolution of therapcutic approaches
accepted Ihat a movement cannot be accomplished without
coordination of the afferent pathways and centers. Along with
this knowledge came the realization that the motor system
and the afferent system were closely linked,

VARIETY OF THERAPEUTIC APPROACHES

Kabat developed and introduced into practice the concept of
activation of afferent patlmtays as an approach to movement
re-education. ' In therapy, this concept is the basis of the
Proprioceptive Neuromuscular Facilit':ltion (PNF) technique.
This approach. as well as others such as those developed by
Temple Fay. the Bobaths, Vojta, and Brunnstrom, systematically stresses muscle coordination and the importance of proprioceptive information. At present, it is understood that the
afferent system not only has an informative role. but also par~
ticipates substantially in motor programming and motor system regulation. Therefore. proprioceptive stimulation is
stressed more and more.
The term proprioception was used for the first time in
1907 by Sherrington to describe the sense of position. posture. and movement.) This term has since been defined in a
broader way. and today. although not quite correctly. it is used
to describe the function of the entire afferent system.
It is now underslOod that to split the function and/or dysfunction of the rnyo-ostco-al1icular system from central regulatory nervous mechanisms is wrong. Both parts function as
one inseparable functional unit and cannot be separated.
Thus. any lesion or impaired function of any pall of the peripheral motor system leads to adaptive mechanisms in the
ccntral nervous system and vice versa.
Kurtz was probably thc 11rstto notice, from a clinical
point of viev.... the relatiollship betwcen the lesion (injury) of

the foot joints and incoordinated muscle function of the lower

leg ..' Apart from fundamental experimental work, such as that
by Wykc~ and Skoglund,~ it was Freeman and co-workers
(1964, 1965, 1967) who, in Ihe clinical selling, systematically
considered some aspects of joint traumatology and the importance of impaired afference in the genesis of an unstable
ankle joint,(}R Freeman and colleagues also introduced, in
non-neurologic cases, a detailed evaluation of coordination.
and stressed the importance of muscle inhibition as an integral part of the clinical picture. Since the publication of this
initial report by Freeman and Wyke, interest in tillS problem
has increased. One of the most extensive works on this topic
is by Hervcou and Messcan.')
In 1970. we started to work out our program for clinical
use, based to some extent on the published reports just mentioned. To avoid problems in terminology and/or confusion
with terms such as PNF, we named our technique "sensory
motor stimulation" with the hope of stressi!~g th~ !.!!"'),ity between the afferent and efferent system without implicating
any specific structure or function.

BASIC CONCEPTS OF MOTOR LEARNING

The principle of sensory motor stimulation is based on the
concept of two stages of motor learning.l\l The first stage is
characterized as an attempt to achieve new movement performance and to work Ollt the basic motor program. The brain
cortex (predominantly the frontal and parietal lobes) arc
strongly involved in this process. This type of motor regulation has some advantages as well as disadvantages. It enables
the individual to achieve new skills, although it is rather slow
as it passes several synapses, and it is tiring given [he necessary conscious participation of the cortex. Therefore. the
brain tries to minimize the pathways and to simplify the regulatory circuits. This mechanism has been named as the seconel stage of motor learning. It enables a reduction of cortical
participation, and thus is less tiring and much faster. If such a
motor program has become fixed once. however. it is difficult. if not impossible. to change it. Therefore. in motor reeducation, the goal is to achieve a quality of movement patterns that is as close to normal as possible.
To prevent injury. and microinjury in particular. fast reflex muscle contraction is needed to protect lhe joints. The
second stage of molOr learning enables such a faster response.
which may, in fact, play a decisi\"(:: role in prt:vcntion.
Bullock-Saxton and colkagucs" reportcd it is po:,siblc to
319

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". _ . _ ........ ~ ..... ,... rn/"\\.,.l II lVNt:H"ti MANUAL

Fig. 15.1. Rocker board.

accelerate muscle contmction approximately twofold with increased propriol:cptivc flow and balance excrciscs. in scnsory
motor stimulation. an attempt is made to facilitate the proprioceptive system and those circlIils and pathw<.lys thai play an
important role in regulation of equilibrium and posture.
From the point of vicw of affercncc. reccptors in Ihe sole
of the 1'001. 7 from the neck l~lllSclcs.'~ and in (he sacroiliac
arcal.l have the Ill<lin proprioceptive influcnce.
Receptors from the sole can be f<lcilitmed in different
ways. e.g.. by stimulation of the skin receptors or. more
effectively. by active contraction of the intrinsic muscles of
the foot by forming the so-called "short or slllall fOOL"
Clinical experience has revealed that isolated activation of the
imrinsic muscles wirhout activation of Ihe long loe flexors is
most effective. Therefore, it is diffieu"illo agree wilh Ihara and
Nakayama. who recommended the "fOOl fist" (0 :Jetivatc proprioeeptors. I~
The deep neck muscles contain m,my more proprioceptors
th'lIl 'Ire found in other striated mllscles.l~ Abwhams has
shown Ihat these muscles should be considered for maintain
ing posturc and equilibrium rather than for producing dynamic movc'ncnl. It should be menlioned that deep tonic neck
reflexes arc thc result of muscle activation and do not involve
the neck join!.",.IS was described originally.
In c1inic:d practice, the sacral region is now recognized as
an important area in the control of posture and equilibriulll.
This observation was conrinncd by I-linoki and UshioY At
present. however. it is not possiblc 10 differentiate whether it
is the sacrum itself and its position or the sacroiliac joints that
pl<lY the decisive role.
A special role has been recognized for the cerebellum and
the whole spinovestibulocercbcllm regulatory circuit

M:lI1Y exercise aids of varioLls types arc llsed. llH.:luoing

wobble and rocker boards. rolls from plastic material. bal:llH.:e
shoes. various lypes of twisters and trampolines. and the
Filter. Wooden wohhlc and rocker boards arc preferable to
lhose Ilwue of plasti.. . matcriaL h~causc woou.stimul<.ltes Ihe
receptors to a gre:ller extcnL For the s<lmc re"soI1S. IOYS Illade
or wooumon..' readily slilllU!:lIC propriocepliotl ill children.
The an;r.,~e dimcllsi:lIIs (lenglh X width X height) Illr
the rockcr board arc .15 elll X 15 elll X 15 em. II> The radills
of the wobble board is 35 1.:111 on :m..:ragc <llld the height is
15 cm. Exercises 011 thc rocker hoard arc easier than on the
wobble board. ;'lnd therefore it is <Id\"is'lble 10 sian wilh its lise

".",

(Figs. 15.1 and 15.2).

The size of balance shoes (Fig. IS.3) depends 011 the size
of the foot. Sand'lls Illust have ;,1 linll. innexiblc ~olc that is
modeled and 'HIS metatarsal support: these fe:Hurcs help 10
configure lhe small fool. There should be just one str;'lp O\"(.r
the forefoot and the heel should rem~lin free. again to help III
:'Ictiv;ttc the intrir.l:-;ic muscles of the foot. The hemispheres arc
of solid mhbcr. 5 10 7 em in diallleler. and arc placed in the
center of gravity.
The twister enables ~\l.:tivati()n of the trunk .1Ilt! huth.ll..k
mllscles. Exercising before <t mirror helps to visu:Jlii'.e any
aSYlllmetry in muscle strength and/or asymilletrically p~r
formed cxercise. Wc prefer to usc a flat twister that is 40 l'(l\
in diameter.
The Fillcr. likc the {\\listcr.. is strictly speaking not a de\"jcc
for proprioceptive training. 'Ilthough it helps to improve coordination. Scveral devices with similar function arc currcntly
av'lilablc. We usc onc developed by Fitter Intcrn<ltional from

"

Canada (Fig. 15.4).

A minitrampoline (Fig. 15.5) is an excellent device f\lr
stimulating the proprioceptors of the entire body. Unfollu
nately. the material lIsed for most trampolines is not suffi
ciently resilient. The stimulalory effect is thus redulcl,.L
Springs that arc 15 to 18 e111 in lenglh provide a suilllbly un
stable base: springs of less than 7 em do not provide cllou~h
proprioceptive stimulation.
Other devices include b:dancc b.dls th.u "<lfy in size fl\llll
60 to 120 cm in diameter. They 'tfe efficient for kincsthcti ....
stimulation and balance training. Rolls frolll polyester ;Ire
widely used in the United States and help to activ.ltc the trunk
muscles ill general. Because these rolls <lrc used mos!ly whil-.'
the patient is supine. they do not overstn.:ss lhe spine ;\nd

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SENSORY MOTOR DEVICES AND AIDS

The sensory motor approach is not a rigid program or system. It can be used in all cases .md can be tailored to each
p:Jtienl. V;lriolis b<llancc exercises ;'Ire used. Any equipmcnt
required is simple and inexpensive. The principlcs arc not
new and wen.~ introduccd by Bobath and Bob.lth for motor
re-education of childrcn with cerebral pals)'. 1.\ The npplicatioll
of this approach to patients with chronic back pain patients.
however. was intruJt.i..:~d only recently.

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Fig. 15.4. The Fitter.

Fig. 15.5. Minitrampoline.

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lhcrcforc can be used by individuals with ~Ul "cute low back

p~\in syndrome.

thus help in prcventing falls. This tcchniquc C~1Ilt10[ be rt:L'olluncndcd. however. for patients with ..tCll{e pain syndromes.

INDICATIONS FOR USE

METHODOLOGY

Sensory motor stimulation is bendlcial when used as a part

of any exercise program in that it helps to 'improve muscle
coordination and motor programming or regulation and in~
crc..\ses the speed of activation of a muscle. Used originally lO
ithprove the unstable ankle after an injury. sensory molor
:,timulation C"Ul be of value to individuals with it variety of
conditions (Table 15.1). Chronic back pain syndromes reprc:,cnt onc of the most important indications. Better cOlllrol of
the (runk. improved activation of the gluteal muscles...md
thus better stability of the pelvis arc achieved. There is a
broad indic:ltioll for its application for sensory defects of neurologic origin. Carefully (to avoid injury). the method can
help to compensate proprioceptivc loss in aged subjecls <lnd

In this chapler. we describe only th~ main Illl;thodologic prill

ciples. A detailed dcst:riptioll is 'I\'ailablc clscwll(("c. l ;
One of the most important ~ldvalltagcs or this progr<llll is
that it helps to improve not only muscle imbalalll.'(' blu. ill par-

Table 15.1. Indications for Sensory Motor Stimulation

Unstable knee
Sprained or unstable ankle

ldiopalhic scoliosis
Faulty posture
Postural defects in general

Chronic back or neck p<lin

Prevention or treatment 01 ataxia

 ._ ..._._.....

ticular, the most important motor 'lctivili~s, such 'IS sWllding.

i.e., posture and gait. Then.:forc, the most important cxadst:s
art~ those performed in lhe upright position.
Respecting the appro;lch of motor leanting :.JlHJ motor rq::uhltion, <iny dysfullction in the periphery should be nor11lalized Hrst. bcc.ltlo.;e allY p.\tlmlngic or ul1wamcd proprinct:pli\"c
information from lhc paiphery results in fllllt,;lion;!l ad;lptati\'c processes
the cntire t.:entr..llncrvous systcm. Thcrdort.'.
attention is lirst paid to thc skin, joinls. and their adjal't:nt
SlruclUrcs, followcd by IlHlsdes and thcir fasci.1. Thc lrig~er
IKlint..;. either .Icti\,c or btent, should he trc;llcd.Illd ll1u~(1c
imbalancc, which is ;tlways present to ."ollle degree. is improved by .1 rc.\son:lhk slrcldling prugr'IIH.
To illCrc:Jsc proprioceptive Ilow, special .ltlcntiol\ is paid
w fonning the small (short) foot, lhe Int.:king mechanism of
th~ knee. stabilization of the pelvis, and the position of the
hend and shouldcr girdles.
The excn:isc progr:lI11 in the upright position follows :-L'\'cr.ll rules:

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1111UNt:.H:::; MANUAL

The tam "smail (shtl!"u 1'001" lhg. 1:'./lJ Is II:-L:'d II'

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snit'll.: Iht: slml1ening and n:lrrowing llf Iht: fll{l( whik till' 11ll'S
;Ire rda\l.'d :IS llHH.. . ll a~ possible. The :-1\1:111 rllllt hdps [\\ in(fC;lSt,; aff..:rent input. mainly from thl' ~ok. h impHl\'l':- lht.'

pnsillon Ill' lltt.: hody sl.'gmt:llts and till.' ~[:lbility of tilL:' hlld~ ill
lilt.: upright positio1l. and hl'lps ttl illlprmc til... rcquirlt! spril1~'
ing mOWiHl'll( Ill' till' fOOl during walkill~.

or

I. Currcctlun lJI,;~ill~ ill di"l<ti ;lIca:- alld gradually t:olllitltlCS prl)\'

illlally. tVfoddin,g. tlf the foot (l'el'l) mlllC.. lirsl. rolJow.. . J by
l'orreCIIUIl ot' Ihe position of the knec. thl'll lhl' pelvis. :llld lln:llly
lhe hC;It! ~lIld shlluldcr~.
~

Excrcbcs an: pcrfonnr.:u in b:lrl' k..:l. \\ hidl incn:;lscs pmpriil'

ceplivc Miumlatioll and forces the thcrapi" HI pay attentioll til
oeHer cmllrnl. List but nUl least. while u~in~ lhe hal;mcc ;liJ:,. il
helps tn decrease [he pOlenti;Jl d:1l1~cr of in.iuries .
.". Exercise shuull.i i,~ IlU llll.:all .. 11111\0.....: pain and should IlIlt lead to
physic:ll hOIl1:ltil') futiguc.
-L From the beginnil1~. lhe aw;m:nt:ss of po,ture W;lffants special
;ltIcll1ion.
:;. Excrci~cs SlllHlld hegin Oil st;lhk surf"":,,,. :md lhell pwgrc", In
more I"hile ~tJrr;\Ccs.

Exercises Gill be divided inw lhosc that focus on training

lhe transfer of weighl or the center of gradty <Illel those that
f~lt.'llS more on b.i1ancc and lllusl'ie coordination in general.

Fig. 15.6. The short foOl.

Fig. 15.7. Passive modeling of the short loot.

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:st:N::iUHY MOTOR STIMULATION

323
When the patient achieves suffkient skill. similar exercises on the rocker board and later on the wobble board arc
"dded. Thc dcmands can be increased by <tdditional variations. such as maintaining the balance in one leg stance Of in
a scmi~(luat with a slight external rotation in the hip joint:-.
This position is rcconnnemkrJ especially for patients with all
unstable knee joint. Almost speciflc;'llIy. the .Ictiv:ltioll
th~
vaslus medialis is incrc<lsed.
Another step is the performance of lunges (Fig. 15.9). first
on the linn noor. then on the rocker. and finally Oil thc.: wohble board. Fast lunges accelerate reaction and control and arc
Ihus effeclive for preventing knee injuries and. in panicular.
falls resulting from incoordination.
The program continues with jumps (Fig. 15.10). ag~lin on
both legs on a firm noor. Progressions include performing on
onc leg. on labile boards, and/or on the trampoline.
Pushes toward the pelvis. trunk. shoulder girdles in different directions. combined with perpendicular pushes toward
lhe labile boards (Fig. 15.11). significantly increase the proprioceptive flow to the central nervous system. which facilitates the spinovestibulocercbellar circuits. This activalion
brings sometimes quite surprising and fast therapeutic effects.
This technique has been introduced into therapeutic practice
only recently. Its application for diagnostic purposes wns described by the French neurologist Foix in 1903 and has since
been used clinically in the diagnosis of cerebellar lesions. l~
Balance shoes (Fig. 15.12) are exceptionalIy useful. and
most patienls like them more than most other exercises.
Balance shoes increase thc dcmands on the entire postural
mechanism and automatically. without a conscious effort.
help to correct posturc. Because this exercise docs not require
special control and can be used throughout Ihe day. it is usually easy to milintain the patient's motivation to cooperate, In
general. the improved posture becomes evident \vithin <.I few
weeks of training. Better <.:oordination and increased speed of
muscle contraction can be noticed within I week of (raining.
attributable to improved activation of the gluteal Illu:,dc~. \I In
all unpublished study. we demonstrated that the abdominal
recti. if hypotonic or inhibited. were better _Icti\,atcd after
lIsing the shoes for I week. This improvement could be rclated to both thc speed of muscle contraction as well .IS the
total amount of elcctromyographic activity during. a ,,:url up.
When using balance shoes. sevcral important aspects
must be considercd:

or

Fig. 15.8. Short feet and half slep !orward stance.

Initially, the formation of the small fOOl is difficult to

perform in erect posture. Therefore, it is advisable to sian

the fonnation while silting. usually in three steps: (I) sitting.
with passive modeling by the therapist: (2) scmiactivc (pas-

sive modeling by the therapist in combination with active

palient effort): and (3) aClive self-formation (Fig. 15.7).

Proprioceptive stimulation can be increased by additional

prC5surc applied toward lhe knee ~md thus via the shin to the
fool.
In standing. Oll~ tf'lining exercise begins with the small
feet parallcl and slig.htly apart. Then. the body sways slowly
forward and back. the heels remain fixed toward the floor. and
(he lower extrcmiti~s and the tfunk arc in alignment. The
range of motion must be controlled to prevent falls. The ther
::lpist controls the ~ways by touching the chest from thc front
and the buttocks from the back.
In another v'lri:uion the knees arc bellllO 20 to 30. The
hips nrc slightly abducted so that the knees arc slightly apart.
Both positions and ,idditional swaying movemClHs help to in
crease the body awareness and the feeling of a well-b~llanccd
and controlled posture.
The next steps arc body control in a IIalf SIC!, lonvard
slaTlce. the corrected stance on both legs. and in one
leg stance. To iu(:reasc proprioccptive flow. slow pushes
and then even strokes in different directions tow;.m! the
pelvis. shouldcrs. and hoth areas arc added by the therapist
(Fig. 15.8)

The small feet mus! be. maintained if po!isihlc. Jurill~ Ih..: whole
gait cycle.
The subject should Ir)' to control the posture. in particular the po
sition of the pelvis. shoulder g.irdles. ~1I1l1 hem!.
The sleps should be short but quick.

The reel should he held

L~lter<ll

p:lr~1I1el.

;lnd verliC_11 shirt or the pd .... i:- :-hnuld he a"'oidt'd.

G_lil should be trained in place lirst. jf necessary with

some support lO avoid inslilhility and falls. At the beginning
of the training program, it is advisable 10 control th~ gail in
balance shoes hcfore: :I mirror. According to our dini(iI\ cx~

nc:.nr\Oll... I 1"1 IVI" vr I hr;: ::>I""INt: A

PHACTITIONER'S MANUAL

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CHAPTER 15

SENSORY MOTOR STIMULATION

325

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pcricnce. it is more efi.:ctivc 10 walk in the h"lam.:c shoes for

a ~hon time. just sc\'e-D.l steps may be ...uflkicnt. (1 10 2 minutes). several times p;:r day.
The [\I'iSla help :0 impw\"c the 'Ktiv<ltioll or the tnlnk
and buttock l1lu:-oclc In addition. till.:" twi;-;tin~ 11100'cmcnt;-;
:-opccifkally ..lCtiv.lleth-: deep intrill'>il: .. pinal IlllISdc..... Durillf
its usc. it is easy to .::ontrol the !-ynullclry of lhc cxcn:isc.
This device is v..J1uablt bccaliSC it help... ('tll"l'CL't ;Isymmctrics
that develop in patient:' with hal:k pain as'1 rule ;1Ilt! arc SOIllC
times difficuh to recognize. The twi,ter docs not specilic<lUy
increase proprioception. but il impro\'c\ coordin"ltion amI all
lOmatizcs trunk .md ptlvic cOlllrol.
The "';lI('rT~1 functions in a similar way as the twister. although the cstinli.ltiQn of body asymrnetrit:s is kss rccogni/able. It also cl1lphasjz~.. the ghlleus medius lHusdc and its Ialeral stabilizing functions (Fig. 15.13,.
The usc of rollers lIl/(/ bllltll/c(' halls in Ill\..' treatment 01'
back pain h;'IS gained popularity. although (h~y wcre used fl'r
decades III the treatment or children with cerebral palsy. Olh.'
adv:'llllagc in using balis is th:tl they arc safl2'. minimize lill'
danger
an injury almost to nil. .Uld help to ill"tivatc proprioception. balance, and equilibriulll control. Till' il1l"rediblc \';1riety of possible exercises. \..'spcciaJly with rc~ard to the pl'lential positit1llS, h~lps 10 l':,wbli<;h impn1\"cd kinestheti . . .
aW'lrcness. :,pin:l! ~t,~bility. :1I1d l1ew 1ll0VCIlll'1lI palterns.

.)

or

Fig. 15,11. Therapist pushes.

..

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Fig. 15.12. Standing on balance shoes.

1-

it-

Fig. 15.13. Training tile gluteus medius on the Fitter.

Fig. 15,14. Walkin9 on a rninilrampoline.

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Fig. 15.15. =:;.:r point kneeling on the

L~

~inilr(lmpohne.

.l
Tht.: IJlillitr:;/II/mlill(' i:-. :t paninllarly lJ~~ful devil.:c.
Jogging or jUIH;,ing :u.:ti\";llCS proprioceptors 1110(1.' dTcclivcly
l!l;lll il simil:lI' ~.\~rci.'ic pcrt'Ol"lnl'U on ;J lil"ll1 none In addi
{ion, it prole<.:t, lhe joints l1CGlU.. . C il rlllH:lioll~ ;I" a shock ;Ib
sorhcr. Excrl'j,;.:-, on"l trampolilh..' do lUll nccu lO k performed
in ;lll upright position only. Ex~n.:iscs pcrform~J while sitling. afC particularly dTcctive in strengthening the abdominal llHlsclcs.:ilL! fOllr point kneeling is n.Tolllllh.:ndcu for cIucrly women '.'.-ith kyphosis rd'llcd to ostcnpt,rosis (Figs.
15.1..J.;lIld 15.:"1,

CONCLUSIO:\

The sensory motor stilllul;ltioll approadl rcprc~t:nl' all essential p;lrl of till: IhcmpclItic progr.un fur p~lIicnt;" with chronic
back pain .1~ "ell as for indi,'idtlals with pO~!llral lkkcl.S.
such as idiop~lthic scoliosis or faully poslUre. and for <.Ill situations in which Jde!.:ls in affercncc .Ife presumed. Such a
progr;ll11 C:I1l ~d"o be llsed effccii,'c1y to imprn"c the ability of
the "hc;lhhy" motor system 10 rc\polld Illore quickly. Givcn
that the speed or muscle l:ontraction is one of the most illlport:llll lllean" to protect the joints. it seems propriol:cptive
facilililtion can cOl1lribUle substantially to the prevention of
recurrences or acule pain. The sensory motor \tilllulation
progr<l11l is not a fixed or rigid program: rJihcr. it must be
adapted to the individual problems of the indi,'idual patient.
The need to I..timulatc proprioceptors is even greater thall a
fe'.. . decades ilgO: our lifestyle ha... d1<lllgcd slJb~lantially .Illtl
is assol:iatcd ,':itll a gcneral decrease in scnsory (propril1t:cptive) stimulation.

t
T

REFERENCES
1. Kah:u II: C..:mr;,1 m..:..::hanisl1ls fur r..:co\"cry (If lU:urunlu""'ul:tr rlln~'tl"ll
Scicncc J 12:2.'.1950.
Shcrril1~lol1 CS: On r<.'..:ipr,x:aJ il111<.'r\':rliol1 of alll;lgo11i:-<li.. l1lu~ck,. Pr' ...
R Su..:: L'llllJ iBlt'1l7lJB:J:n. 11)07.
Kun7. ..\l): Chwm..: "prail1<.'d ;mkk.Am J Surg ,U:I~S, )I).W.
..l. Wyk..: B)): The neurology of joinl:-. Ann R Coli Surg Ell~1 -l I:25. 1')('-_
". Skogbnd S: AIl:llOlI\ic.,l and phys;o!ogi"'al sludil's ot' klll'<.' jllinl iUlla';\
liol1 in Ihl' GIl. :\.:Ia Physiol SC:lIld ~6 (SUpp! I 2..l'J: I. 195(1.
(1. h..::el1l:111 MAR, Dean MRE. Hanh:llll IWF: 11\\: l'liol,,!,:y :llld rr," <'1\.
tion (If fun..::t!l.n:s! in,whility of tit..: f(lol. J Bllll\.' JI1;1lI SUfF Inri ..l-.t'-~.
1%:".
Fr..::..::m;lII MAJ{. Wykc no: Articular ..::nutril1llti"u, to limh llltlH'k r...
lle,..::s. J I'hysiol 'Londl 171 :201'. IWH.
,"i. Frcl.'lIlall MAR. Wykc no: Ani"::lliar r<.'tIc"l.'.S al Ill..:: anklc joint.:\n d,-'~'
tWlllyl'grOlphic "tudy of nunnal ;llld ahnorm:lt inlluell"'-":::- of :lIlkk .I,'tnt
rmdl'LI1\lrl.'''::Cr[(lr~ upun rcllc:o.: Ol":li,,!ty in kg lllu~dl.'s. Br J Surg :"J:'h)tl.
1967.
9, l-!<.'ncllL! C. \h;"C,11l L: Tcdllliquc tk rcedw.:atioJl l.'t d crJlII.:alilll1 pr,'!~ri.
()((plive. Pari". .\laloin. 1976.
Ill, GUYh>n AC: B;:~lC Ncurm:dcn..::c.l'hil:l\Jclphi:l. WB S~Ul.Jcrs. 1%-,
II, Bu\lu..::k-Sa~\lln JE. Janda V, Bullock "II: Rdkx :u;ti"i1lillll uf ::hlll,';lt
llIUSI,.h:,,, in \,;lIking. Spinc 18:71).1, J91"J~.
i:. Ahrahalll' VC: Th.: physilliogy of nCl;k Ulus...-ks. nl<.'ir ruh: ill h~.l,1
1111\\'l'111.:nt and m;:inICn;l1\l;":: of pmlurc. Can J Physilll Jlh;lnnanll 55:.~.'~,
1977.
I). Hillllki M. L'"hlll:-':: Lumhllsacral propriu..::cpliw rd1c:o.:c" ill hl'd~ ....Iui
lihriulll. Acla Ololaryngol 33()~SupplJ: 197. 1975.
It Ih:lr.l H, Nak:l~:illla A: Dynamic join! CUllIWllr:lilling fur kn..::<.' li::.llll;.lll
iniurics, Am J Sports t-.kd t4:309. Infl.
15. B~lbalh K, Ihlbalh B: Thl.' f:1CiliWlion of normal postural rC:I(til'Il" ,~nd
l\)1l\',;:lIlelll in tr'.:J.lmCIll ()f cercbral p:tlsy. Physil'lh..:rapy 5U:"2-l(>. t'}t~.
16. Umhll1 AK: Trullk musck activity induced hy 1lH">.'1: size" uf wI.ht>k ,ro.ll
anl,'d hO:lrd,. J Onhop Spurts Phy.. Thcr R:70. \98(1.
17, J:llld:l V. V;l"W\:t .\1: SellS""")' MOlor Slimul:llil'll: i\ Vidcll.l'r<.'s..::l11...,: t-~
JE B\I!hx:k-S;I.\I~)fl. Brishanc, AU\lr:.dia. Body C\lIIlrol Syslems. 1')':'_\

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16 Postural Disorders of the Body Axis

PIERRE-MARIE GAGEY and RENE GENTAZ

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POWEll OF THE POSTUIlOLOGIST

Input into the Fine Postural System

\Vhen posturologists undertook the study of postural control.

they did not suspect how much power would fall into their
hands. I Slowly. year af[er year, they discovered their ability to
manipulate muscle tone by manipulating the input into the
postural system. Preceding generations of neurologists had
conducted studies of muscle lOne and th<ll ended in failure. In
1948. Thomas and de Ajuriagucrra wrote. "Lc tonus varie ~t
toul moment. il est continucllemcnt en jeu ... Toutcs Ics excitalions pCriphcriqucs. de quclque nature qu' cllcs soienl.
sont capables de provoqucr des reactions toniques" (The tone
varies at every tum. it is continuously at work. Any peripheral
excitation of whatever kind can bring aboUl tonic reactions).:
At present. posturologists arc fInding that they do know how
to manipulate tone. and this knowledge empowers them. This
power is indeed extraordinary in its novelty. but not always in
its reliability; posturologists arc reminded from time to time
that they do not yet know everything ahout manipulating
muscle tonc. The basis of this new knowledge is worth ex-

EXTEROCEPTIVE INPUT

plaining.
BASIS OF POSTUIlOLOGY

-'

,)

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Ever since BelP askcd how a pcrson maintains an upright or

inclined posture when facing into the wind. physiologists
have asked the same difficuh question. Over many years. the
contributions of various types of sensory input (0 the control
of upright posture were discovered one by one: vision~ and
signals from the legs and feet,~ the vestibular apparatus.~
paraspinal muscles,to and oculomotor system.' Not until the
concept of (he system appeared w....s it possible to understand
hawaII these different senses work together to control posture. Researchers could not observe and record the subtle phenomenon of upright posture!l.~1S adequately until (he resources
of clectronics l6 and computers were availablc to allow them
to make recordings that do not modify the phenomenon and
can be interpreted by signal analysis.
Today. after many years of study, Bell's question can be
answered in terms of a simple and consistent model of the
mechanisms participating in the control of orthostatic posture:
the model of the fine postural systcm. The term 5)'slem is used
here in accordance with control system theory. i.e.. we do not
need a detailed underst<lnding of thc nervous centers and
pathways participating in Ihis control in order to study Ihe
input and the output of this black box and to analyze its transfer functioll.

To remain upright and slCady in their surroundings. people

usc all tbe information about lheir position provided by their
st:l1sory org.ans in relation Wilh the surroundings. including the
dectromagnctic ficld,~IfHI" the gravitalional ficld,20-2! and the
pressure Hcld underfoot. ~.\A~'Thrcc outwardly directed sensors.
or cXlcroceptors-vision. vcstibular apparatus. and baroreceptors from plantar soles-provide information; we do not
know of any others apart from these three captors (Fig. 16.1).
PROPRIOCEPTIVE INPUTS

The cye moyco;, about in the socket. while the vestibular apparatus is enclosed in <I bOlly mas.s. The system cannot integrate positional information from these two sensors unless it
knows their relative pm,itiollS. which are given by the oculomotor system. :'-.'0 Thus arises the idea of another kind of sensor, inwardly directcd. a proprioceptor. which has no direct
relation to the surroundings but is nevertheless indispensable
to a steady posture within them. Likewise. the feet can move
by many degrees in relation to the head. but postural informatioll from the feet and the head cannot be used together unless the system knows the relative positions of the head and
{he soles. This type of information is assessed by proprioception of the whole body axis:II - 36
Cenlntl Integration
NECESSARY BUT PRECARIOUS INTEGRATION

Retinal. otolithic. ,lOd plantar exteroceptivc information,

combined with proprioceptive infonnation from the 12 oculomotor muscles. all the paras pinal muscles. and the muscles of
the legs and feet. unite to give the relative positions of skeletal elements from the occiput-atlas to Lisfranc's joint. This
combination generates il considerable amount of information
that the system must integrate, in real time. if the posture is
not to waver. Therefore. problems with the control of orthostatic posture do not necessarily indicate that a sensor has
failed. Rather. it may involve faulty integration,:" which may
OCf.ur for many reasons.
DISORDERS OF INTEGRATION OF VISUAL INPUT

Faulty integration of visuJI input is easier to analyze than thilt

relating to other types of input. bcc.llIsc it is easy to record a
329

.~..

HI=HAt1ILIIAIIUN OF THE ~PINE: A PRACTITIONER'S MANUAL

stcildine~s of stance with and withoUI the help of vision. and

to reckon the cOlltribution of the vi:-:llal input using the

so-called "Romberg's quoticnt:'-I Postural sway is oneil mea
sured on a stalokincsigram. a record of the successive posi-

or

tions of the subject':; center

gravity projected onto the sur~
face beneath the feet. and Ihe Romberg's quotient is the ratio
of the ":In~a" or the slatokillcsigram with the eyes closed to
the area with lhe eyes open. llIultiplied by 100. \Vilh this simple [cst, some patients arc roulld to be just as steady with their
eyes dosed as w:ilh them open. They miglll as well be blind

as fm as their standing posture is concerned. Such "postural

blindness" is a frcquclH finding, occurring in association with
many disorders. including vcstil!:-il;'lf neuritis (Fig. 16.2);lK
strabislllu's."1 and low back pain.~11
Deficicncies of integration of visu;.d input arc so frcquent
in clinical pmctkc that \'isual input despite its powerful effect (usually postun!l steadincss is 150% bctlcr whcn thc eycs
arc open~l J. seems <llso to be cnsily disrupted. Its integration
is thought to depend on the nonn;'ll funclioning of the other
sensors. By itself, the signal of retinal slip is ambiguous; it
may be related to movcment of the body. or the surroundings.
OJ" of the eyes. Its postural significance.: must .be dctcmlined
by comparison with signals from other sensors: oculomotor
inplH (is it lhe rcsuh of mOVC1l1elll of lhe eyes"!) or vestibular
or plantar input. in the lalter case combined with proprioceptive input concerning the body axis (is it the result of body
movement?). One mighl predict that integrntion of visual
input is poor when olher input in[o the fine posturdl system is
malfullctioning. and that situation is precisely what is observed clinically.

Fig. 16.2. Histogram of the distribution of Romberg's quotient in

182 patients with vestibular neuritis. The gaussian curve shows
the theoretic normal distribution of Romberg's quotient in a normal
popUlation. logarithmic scale. 253, mean for normal subjects;
152, mean for patients with vestibular neuritis; CL 95% confidence
limits; p < 0.001. Student's Hest.

Output of the Fine Postural System: Muscle TOIle

Few would argue that maintaining an upright position IS
achieved by mcans other than muscle-postural tonc. At lhe
beginning of the last cenlury. Bell noted that it is only by the
lise of muscles that thc limbs stiffen and the body is firmly
balanced and kept upright.) \Vhat is new is the knowlcdge that
postural tone is controlled by a postural system. Th~rcJore, hy
manipulating the input into the postulJ,l system. one can manipulate postural tone almost at will.

Observations Relaling to the Fine Postural System

\I\~

Fig. 16.1. The postural man.

The most striking fea[urt~ of the control of onhostatic posture

is its fineness; every normal person keeps his or her gmvitational axis inside a cyl:nder less than J em! in cross section:u """"" We know that the fine stretching of the neuromuscular spindles is accurately control1ed.t~; that the stretching
of oculomotor muscles acts on postural tone only if it is
fine 2K ; and that the fineness of poslUral sway is below the lheoretic threshold of the semicircular canals..t/> Clinically. we
observe that. standing upright with their eyes closed. paticnts
with vcstibular neuritis are as stcildy as normal subjects
(Fig. 16.3).3& Only when postural sway becomes abnormally
great (area of the st<.ltokincsigram is more than 2000 111m!) do
the semicircular canals perceive it. A clear break exists between the neurophysiologic comrol of fine movcments and
the control of wider movemcnts. Theoretically. in posturology. this break would be at a slalokincsigram area of about
2000 mm!. and clinical findings confirm [he theory: a group
of 800 dizzy patients comprised two subpopulatiol1s. divided
al precisely ,hal breaking point (Fig. 16.4)."
It is important to <l\"oid confusing behaviors controlled by
differcnt neurophysiologic mechanisms; such confusioll leads
to difficulty in interpreting data ..t7 It is to prevent such confusion that the sct of mcchanism~ controlling orthost;.ttic posture
is called the fine postural system.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~u

CHAPTER 16 : POSTURAL DISORDERS OF THE BODY AXIS

The Postural Patient

; \ subject

- r-\

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225

31

5 056

Fig. 16.3. Hislogram of the distribution of statokinesigram arEas

in 182 patients with vestibular neuritis (eyes closed). The gaussian curve shows the lheoretic normal dislribution 01 the parameler
of statokinesigram area in a normal population (eyes closed).
Logarithmic scale. CL. 95% confider1ce limits; 225. mean for normal SUbjects: 282. mean for patients with vestibular neuritis.
(From Gagey PM. Toupel M: Onhostalic postural control in
vestibular neuritis. A stabilometric analysis. Ann Otol Rhinal
La<yngoI100:971,1991.)

/1\
10 subjects

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/
91

210

493

1691

4024

820J

Fig. 16,4. Histogram of the distribution of stalokinesigram areas

for 800 unstable patients (eyes open). The gaussian curve (Iefl.
heavy line) shows the theorelic distribution 01 this parameter in a
normal population. The fine curves have been superimposed
merely to emphasize the bimodal aspect of the distribution.
Logarilhmic scale. 91. mean lor normal subjects: 210. upper 95%
confidence limit.

Limit"i of Posturology

~~

To consider thc centml ncrvous system as a "black box" is

certainly an 4Ivowal of weakncss. Until ncuroanatomy can ex
plain where and how the multimod'll information ttwt helps
people stand upright is integrated. however. we have no
other choicc. We cannot prctcnd to know enough abollt the
nervous centers and pathways controlling posture to be able
to propose a neuroanatomic model useful in clinical practice.
The scientific way forward is 10 establish what linb we can
obscrve between tlte input of the fine postural system .and its
output.
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POSTUIlAL DISOIlDEIlS OF THE SPINE

II

The subject that panicularly interests the therapist is how posturology can help the p~rson for whom standing upright is difficult or painful.

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The person \vhose spine hurts for a postural reason is said

to have a functional disorder. Radiographic and laboratory
l~sls !l:\ve diminatcd rheumatic disc;.\sc. orthopedic illness.
:md ohviotls nucleus pulposus herniation. but pain continues
for unknown rc;\sons. Onen. [he patient feels bener after manlIal therapy. hut lhe pain keeps coming b'lck. Such recurrences likdy h;I\'(: a cause that the manual therapy has not ad
dressed. In fact. Olle can obscrve in these patients abnonnal
asymmetry of postural tonc. Is this the mysterious cause of
the rccurrences'~'}
Identifying Postural Tonic Asymmctr:y
PHYSIOLOGIC ASYMMETRY

A human being docs not have the perfect symmetry of a

Greek statue: rather. the statistical norm is postural asymmetry. Not only have we seen asymmetry of orthostatic posture
in tens of thousands of "!lonnal" subjects, but also we have
established Ihat such asymmetry is not random (I' < O.(XH on
the X:! test).~J Therefore, it is reasonable to think that such
asymmetry is characterized by laws. The practitioner must not
conclude that every type of postural asymmctry is abnom1al.
PATHOLOGIC ASYMMETRY

To distinguish pathologic from physiologic asymmetry. the

gains of neck reflcxes are measurcd during a stepping test. Fukuda-Unterberger Stepping Test. A nonnal subject
stepping in place blindfoldcd rotates up to. but not more than,
20/30 after 50 stcps.~'-"! This finding is easy 10 verify. but
several technical points must be considered. Testing conditions should includc no sound or light source that could indicatc a direction. The Ihighs should be raised neither 100 far
nor too little at each step (about 45 0 :s right). The pace should
be neither too slow nor .too fast (1.4 Hz is goOd).H \Vhen
putting on the blindfold. the eyes should be in the "primary
position" (looking straight ahcad).~~ The head should be neither rolated nor tilted,~~ and the anns should bc stretched forward. horizontal and parallel.~l.~l
Although this simple test, with the head in a neutral position, provides useful information. we prefer a more rigorous
test that makes usc of the postural neck reflex.
Measuring the Gain of Neck Reflexes. \Vhen a nomml
subject keeps his or her head turned to the right. the tone of
the extensor muscles of thc right leg increases. and vice versa
for the left sidc.~,~7 When a nannal subject pcrfomts (he
Fukud<l-Untcrberger stepping test with the head turned to lhe
right. he or she rotates farther leftward than if the test is per-

fonned with the head facing forward (Fig, 16.5). Thc difference between thcse two angles of rotation is a measure of lhe
gain of the right neck rcnex. The sante applics. mutatis mulandis. if the head is turned lefl.~~
The test must be carried out methodically to avoid confusion. The results arc tabulaled, following clearly defined conventions. Angles of rot~ltion are denoted r+" if rightward

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HtHAtllLlTATION OF THE SPINE: A PRACTITIONER'S MANUAL

.,'

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Fig. 16.5. Fukuda-Unterberger's slepping lest with head rotation.

When the subject performs the lest with the head rotaled to the
right rather than straight ahead. he or she rotates farther leftward
and vice versa.

and "-" if leftward; + 10 means the patient had turned 10

to the right al the end of the lest and - 30 means the patient
turned 30 to the left), Calculating the absolute value of the
gain of the neck renex requires paying attention to the signs:
+ 10Q and - 30 make 40 of difference. not 20! It is impor~
tant to adopt new conventions for the gain of the neck rcf1cx~
for inst<lllcc. a gain in the "normal" (predicted) direction as
just dc'scribed is denoted "+," otherwise "-."
An example of how [0 calculate the predominance of neck
reflexes is provided in Table 16.1. The following explanation
relates 10 this sample.
HL. +50~: Head lUmed left: the patient rotated 50 rightward
HA. -10: Head straight; {he patient rotated 10 leftward
HR. + 20~: Head turned right: the patient rotated 20 rightward
LG. +60": Absolute value of the gain of the left neck reflcJC. is 60.
noted with a "+" because it is in the nonnal direction
RG, - 30~; Absolute value of the gain of the right neck reflex is 30.
noted "-," because it is not in [he nonnal direction
Left predominance 90: The best gain is the gain of the left neck rcflex because it is in the nonnal direclion; the difference between
the t\\'o gains is 90. (If both gains arc in the nonnal direction. the
larger is considered best. If neither gain is in the nomlaI direction.
the smaller is considered bcst.)
This mel hod allows testing of the muscle. tone as it varies
in accordance wilh a postural tonic reflex. Although it is accepted that .1 predominance of more than 50 is surely pathologic. the risk of error in <.lccepting this limit is not yet known.
Table 16.1. How to Calculate the Predominance of
Neck Reflexes
HL

HA

HR

RG

Predominance

+50"

-10"

+20~

_30"

Left 90"

HL, +50: Head turned lelt: the palient rotated 50 rightward. HA, -10:
Head straight: Ihe palient rotated 10 leftward. HR, +20: Head turned right;
the patient rotaled 20 rightward. lG. +60: The absolute value of the gain of
the left neck re!lex is 60. noted wilh a + sign, because it is in the normal direction. AG. - 30: Tho absolute value oltha gain ollhe right neck reflex ;s
30', noted -. because it is not in the normal dircclion_
Lell predominance 90': The best gain is the gain of the left neck reflex because it is in tho normat direclion; and the dillercnco between the two gains is
90'. (II both gains are in the normal diroction. the larger is considered best. il
neither gain is in the norma! direction, the smaller is considered best).

HO.,,", to Manipulate Input into lhe Fine Postural System

If the patient shows abnomlal asymmetry of postural tone,
the posturologist must try to restore symmetry by modifying
the input into the syslem that controls orthostatic posture.
The system is dclicme. however. ::tIld must be manipulated
carefully. with gC1H1e stimulations: otherwise. it does not
rcspond_:j;.
Three types of input arc accessible tu the clinician: spinal.
oculomotor, and plantar.
SPINAL INPUT

Manual therapy of the spine is well known. and for the pa~
tients considered in this chapter, it is assumed that clinical
success is only temporary. That assumption does not always
apply to other postural patients. such as those labeled unstable and the squinter. The practitioner should consider the possibility of acting on the fine postural system through this sensory roule.
OCULOMOTOR INPUT

Oculomotor (and possibly viSUitl) input can be manipulated

by putting a weak prism. of I to 4 prism diopters. in front of
the patient's eyc.~~ An optical prism de .... iates light rays toward
its base. For pedagogic purposes. think of a weak prism put in
from of a normal eye as moving t'le eyeball by e.liciting the
fusion reflex opposing diplopia_ This movement stretches various oculomotor muscles in accordance with the various positions of the base of the prism. (In fact. this cannot be the true
explanation of the action of such prisms because they act even
in the absence of binocular vision.)
Conventiolls of Notatioll, Imagine an optical prism. base
down in front of a subject's eye and with one of its dioptric
faces perpendicular to the subjcct's visual axis. If the prism is
rotated around this axis. its base describes successive tangents
on a trigonometric circle centered on the subject's visual axis.
By convention. degrees on this circle are counted counterclockwise from the observer's viewpoint. Regarding the subject's left eye. 0 is tOward the subject's temple. 90 at the
zenith. and 180 toward the nose. where<.ls for the subjccl's
right eye. 0 is toward the nose. 90 at the zenith. and so on.
(Fig. 16.6).
Strabismologists consider that each of the six oculomotor
muscles has a main direction of action (ar 0. 55. 125. 180:".
235<>. or 3050).~9 Because a prism deviates light rays toward
its base, the main oculomotor muscle it forces to work is the
one with the main direclion of action thm is opposite the base
of the prism (sec Fig. 16.6). Table 16.2 illuslrates 'he correlations between prism positioning and activation of oculomotor
muscles. The formula RLR 3 refers to a prism of 3 diopters.
in front of the right eye. base tangent at OQ, activating the right
lateral rectus.
lAw oftlJe Semicircular Calla/s. Even when considering
only the main direction of action of each oculomotor muscle.

",re =_"

-,

,y

,,==..OO~ ~"."" ="=' o"~.~

.._-------

lCHAt>IER 16: POSTURAL DISORDERS OFTHE BODY AXIS

55'

0'

Fig. 16.6. Main directions of action 01 the oculomotor muscles

and positions of prism bases.

Table 16.2. Relations Between the Positions of the Base

of Prism and Oculomotor Muscles
Stlelched Muscle
Base 01 Prism At

Right Eye

loti Eye

0'
55'
125"
180"
235'
305"

RLR
RIR
ROS
RMR
ROI
RSR

LMR
LOS
L1R
LLR
LSR
LOI

LA: lalctal r{!Clus; MR: medial rectus; IR: in/crior ractus; SA: superior reclus;
SO: superior obliquus: 10: inferior obUquus.

Six oculomotor muscles increase the gain of the left neck rc~
flex. and the other six increase that of the right neck reflex. It
is bcucr to decide in advance which oculomotor muscles may
bring about better balance of the muscle tone than to proceed
solely by trial and error. The law of the semicircutar canals
can help in the decision.
According to the law of the semicircular canals (Table
16.3). deviation of light rays away from the main direction of
aC'ion of an oculomotor muscle acts on the tone of the c;lttensor muscles of the legs in the same way as deviation of the endolymph stimulating the cupula of the semicircular canal governing the rencx activity of this oculomotor musclc.)...(,4 If you
know on which side you wish to increase the gain of the neck
reflc;lt. six oculomotor muscles can be eliminated' immediately
by referring to law summarized in Table 16.3.

333
po.se new tenninology to describe these new plantar orthoses.
Any construction crossing the foot transversally is called a
bar. and any marc circumscribed constnaction is called a Spot.
The front-to-back position of bars can be designated as
follows:
Infracapilal. under thc metJtarsal heads
Amerior. behind the metatarsal hC:lds
M~Jial1. allh,~ kvd or the sC:Jphoid and cuboid bOlles
Posterior. under the distal pan of the calcaneus
Infratubcrous. under lhe calcancallubcrosity

For spots. side-to-side positioning is also specified:

Medial infracapital and lateral infracapital. under the heads of.
respectively. the first and second and the fourth and finh
metalarsals
Anlcrornedial and anterolatcral, behind the he:Jds of tht: corresponding metatarsals: and so forth (1l1ediomcdial. rncdiol:Ueral: posteromedial. postcrol;]teral; and medial and latcr.ll infratubcrous)

Any CO!1struct:C!1 must be positioned in accordance with

the podographic footprint. with due attention to dysmorphisms of the fect. The footprint can be achieved by using a
light layer of ink under the foot and then having the subject
place that foot onto white paper.
Fool Paiu. The effectiveness of these exteroceptive stimulntions mny be limited by any pain in the foot of which the
patient r:nay not even be aware. ~herefore. we recommend
both questioning the patient and pressing with the thumb on
various regions of the soles to discover any painful area that
the patient had not not;ced. In such cases. antalgic elements
should be provided in addition to the element for postural
stimulation.
Proprioceptive Disorders of the Legs alld Feet. \Vhcn
free movement of the joints of the legs and feet is impaired to
'he extent that proprioception is affected greatly. plantar postural stimulntions are less effective. Such disorders must be,
corrected before stimulatory wedges arc used.

Identifying the Right Input

In principle. Ihe therapist can modify ;Jny input discusscd in
this chapler. In practice. however. there may be only one thnt

PLANTAR INPUT

Plantar input can be modified with microwedges under the

soles. The mcchanorcceplors of thc sales are accurate to
within I g.. and the wedges used to stimulate them must
be correspondingly thin (about 1 mOl in thickness). Thick
wedges do not alter postural-tone.
Microwedges act on plantar baroreceptors. They may also
stimulate deeper proprioceptive sensors. such as capsular or
ligamentous Pacini's and Ruffini's corpuscles. Golgi tendon
organs, and neuromuscular spindles. Microwedges placed
under cenain regions of the sole modify the sensory input into
the fine postural system.
Because the technology of conventional orthopedic shoes
does not correspond to that for postural stimulation. we pro~

I
~

,.

f.......

-~

"

Table 16.3. Law of the Semicircular Canals

Increases the gain of the neck rellex

"0
~

>~

a:'"

1ii

"
0

>-

'"
~

-'

Righi

Left

RMR
RSR
RIR

RLR
RIO
RSO

LLR
L10
LSO

LMR
LSR
L1R

LA: lateral rectus; MR: medial reclUS; IA: inlerior rectus; SA: superior recluS:
SO: superior obliquus: 10: inferior obliquus.

I-'.>-'..

----,-------------------_.

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

I
.1

will cffcC'tively alter the patient's postural tone, and the prac-

"I

titioner must look for it Then, the quickest and most adaptable clinical test is the rotators test.
ROTATORS TEST

OUf tcam has lIsed this clinic'.li tcst of tht.: tone of the hip ro-

I
i
g
f,

I
,

Ii
I

I
I
I

I~
,.

I
I
,

I
~
~

I
'

tator muscles since the work of Conslantincsco and Autct."~

This lest has the great advantage that the patient is lying down
and does not gCllircd. and that the effectiveness of each Illa
nipulation is known within seconds. Seen for the first time, it
looks like a conjuring trick, so before explaining how to do it,
we explain the underlying ideas.
Clinical Investigation of Muscle TOile. Clinical investi
galion of muscle IOIlC is a delicate subjcc~ indeed. Despite the
longstanding agreement, going back to Galen, 10 define
"tonc" as muscular activity that does not bring about any
movement, most authorities agree that the tenn is ambiguolls.
The idea of "light tcnsion thal any muscle at rest is usually.
subject to," or som~ :~uch usual definition confuses the effects
of the viscoelastic properties of muscle tissue with the effects
of contractile processes originating in the nervous system.(o(>
Therefore, tone is a trap, representing one of those words the
meaning of which may unconsciously be distorted, to the
great detriment of clarity of discussion.
Because the concept of tonc is so elusivc. criteria for its
clinical investigation must be all the marc rigorous. This need
is panicularly great when we manipulate tone to test it. for
what is observed then is not "tone." but ruther certain tonic reactions to ccnain changes imposed by the clinician. In the unavoidilble "action-reaction" pair. [he reaction will have epi
stemologic value only insofar as [he action is known. \Ve
must know what we are doing before we can understand what
we arc observing.
Sherrington led the way in the rigorous study of muscle
tone by quantifying the lone of a muscle by its resistance to
passive stretching in tcnus of the physical quanti tics Icngth.
time, and force applied. It is reasonable to continue strctching
muscles to tcst their resistance to stretching. and thus their
"tone:' but each maneuver must be defined in physical tcons.
Regarding stretching movement. the amplitude. speed. acceleration. time elapsed since the prcvious movement. and applied force must be specificd. Each parametcr matters: ampli
tude for the properties of elasticity and for secondary spindle
endings: speed for the properties of viscosity: speed and acceleration for primary spindle endings: nnd time elapsed be
tween two successive strctchings for muscular Ihixotropy.('7
We cannot adequately stress the limitations of the clinical
examination of tone. In such a moving world, the posturologist must be wary and accept only those excitation-reaction
sequences that are repeatable and uncontaminated.
Performing the Test. The subject is supine. in a strictly
controlled posture: arms lying loosely bcside the body. head
facing straight up, eyes in the primary position, jaw relaxed
(lhe teeth should not touch). Sland at the end of lhe lable, facing the patient's feet, and take the heels in your palms. with
your hypothenar eminences and linlc fingers resting at the

edge of the soks wilhout touching them. and the mcdial edge
of your thenar eminenccs pressing 011 the anterior edge or the
pnticnt's external malleoli (Fig. 16.7).
Lift the subject's (eel JUS! 2 or 3 cm from the wbh::: your
;,nns should be extended and your body should be s!raiglll
and leaning slightly back. so that you arc pulling gClltly 011 thL'
patient's Icgs. With the subjc,.:1 relaxed with feet slightly
;!rart. pl'rftmll llvc or six succcssivc medial rotations of both
feet at once to tcst the p;\ssivc rCSiSl<lllCC of the external thigh
rolators to these movements. Nine out of lCIl timcs. the exh::rnal rotators of the right thigh offer the stronger resistance. \Ve
say they arc hypertonic relativc to the symmetric muscles.
This tcst is not as easy to carry out as it may seem. Your
pronation movements to rotate Ihe feCI should be supple. n:::laxed, and fairly fast-at a frequency of abolJt 2 Hz. which is
the resonant frequency of the hip joint in such axial rotation
movements (Walsh EG. personal communication). Thus. this
rapid test mainly investigates the viscous componcllt of mcchanical propcnics and the primary spindle endings: it eliminates the effects of muscle thixotropy. (\Ve recolllmend practicing with volunteers: after nbout 100 exercises. you will
start doing it casily.)
Preparing to Perform the Test. The amplitude of Ionic
responses to manipulations of the postural system varies
among subjects. Therefore, it is important to take some time
at first to become acquainted with lhe amplitude of each patient's own reactions, to feel how the rotators respond when
the head. eyes. or arms are turned.
Usually. the tone drops in the rotators on the side to which
lhe head is turned (or increases in the other side-the test fundamentally is a comparison). The same holds true when
the eyes are turned. but for unknown reasons the eyes must
be closed. Medial rotation of the aml (as when the right
hand is placed on the left shoulder) brings about a decrease
of the lonc of the ipsilateral rOlators. and lateral rotation of
lhe arm (as when the lefl hand is placed under lhe neck)
bring~ about a decrease of the tone of the contrahucral
rOlators.
Once the practitioner can accur;.1tcly detect the patient's
responses. the next step is [0 climinate any interference rclated to malocclusion.

()

Fig. 16.7. Rotators lest.

~-----,---------------------------------

jG

335

"""... , oK 16 : POSTURAL DISORDERS OF THE BODY AXIS

-,
;

MANDIBULAR INTERFERENCE

Why or how m;,mdibular disorders can change lhe rules of lhe

galllt:: of postural lone is unknown. This still mysterious phenomenon must be borne in mind from the outset when examining any postur..11 patient. for experience has taught us tll;]t it
;s a wash: of time to put prisms in front of the eyes or minowctlgcs under the feel of a palicnl whose pos(ur..Il lone is
altcn.:d hy a mandibular disorder. Only after Ilwntlibu1:.lf uis-

,
J

orders have been cured. so that they no longer interfere with

postural tone. is it reasonable to usc prisms or microwcdgcs.

if the palien! still needs them.

The back teelh-molars and premolars-have protrusions
or cusps that engage the cusps of the opposite teeth during
closing movements or occlusion of the jaw. for instance.
during swallowing. The positioning of cusps makes great
demands on precision, with which occlusodontists are famil~
iar. The posturologist need know only how to be sure that
some modiliciltion of lhis "imercuspidation" is not ahcring
postural tone.
Testing Procedure. The principle of lhe lest ior imcricrencc by rnillocclusion is simple: the tone of the rotators must
not alter when the intercuspidation is modified.
To begin. tcst the rot:HorS with lhe subject's teeth in lhe
usual intercuspidation position. Ask the patient to swallow
spittle and keep the teeth in contact-the usual intercuspidation position; now. test the rotators.
Next. put a small piece of Bristolboard. cc~ to :.:zc, b~
twecn the back tecth and have thc patient walk around and
swallow spittle several times before testing the rotators again.
with the modified intercuspidation.
If the results of lhe two tests are not the same. modification of the intercuspidation has altered the tone. To verify this
finding. use other tests (such as the Fukuda-Umerbcrger stepping test or the thumbs test) and refer the patient to an ocdusodontist.
The bitc planes can be more sophisticated and more effective than the piece of BrislOlboard rccommended here. but
how to make them and fit [hem is beyond the scope of this
c!wp[cr. Even if bctter options arc not 3vailable. this crude
method is useful.
After establishing that mandibular input is not playing
havoc with the patient's postural tone. the practitioner then
considers which of two types of input into the fine postural
system to modify to effect treatmcnt.

adapt to the new visual surrou!\ding::: by IUming his or her

eyes to look around in all directions.) If one or two muscles
bring about tonic reactions, this information is noted for a
possible prescription. If none of them produces ~\ response.
we recommend testing the other six Illuscks anyway before
going on to the next stcp~ the practitioner need not be a slave
of the law of the canals.
LOOKING FOR AN EFFECTIVE PLANTAR AREA

Manipulating plantar input is easy: tcst the rotators in thc

standard conditions. stimulate the sole at a particular spot. and
immediately test rotators again. The stimulation is done simply by applying light pressure with a finger. just enough to
stimulate the baroreccplOrs in ttle soles-2oo g at most. If the
resuhs of lhese IWO leslS differ. the plantar spot stimulated
may be able to modify postural tone, and is wonh keeping in
mind for a possible prescription.
The entire area of both soles. onc after the other and spot
by spot. may be tested, but spots under the scaphoid at the top
of the arch and under the cuboid at the lateral edge of the foot
should be tested firsl. followed by spots in bars under and just
behind the heads of the metatarsal bones and then spots in
bars under the anterior part of calcaneum.

Prescribing
Tonicitj' is such an elusive phenomenon that measuring the
gains of neck reflexes and testing rolators is. not sufficient to
ensure that the correct manipulation has been identified.
Faced with 'his uncertainty. the practitioner has various
choices. depending on the circumstances.
If the piltient can be re-examined promptly. c.g. within a
fortnight. it is acceptable to lry lhe simplest and most efficient
modification (a press-on prism aflixed to the- patient's glasses
or wedges made quickly). A therapeutic trial is one way of
making de.lr determinations.
If. however. the patient cannot be rc-e.x:lmincd soon. the
prescription must be based on the convergence of several
tests. From the billtCry of possible tests-po5-turologic. chiropractic. osteopathic. kincsiologic-each pra.:ritioncr chooses
lhe ones with which he or she is most comf~)nable. Nonnally.
we usc the stepping test and the test of Ba.rrFs vcrtical (sec
subsequent discussion). \vhich we consider fairly reliable. and

LOOKING FOR AN EFFECTIVE PRISM

Measuring the gains of the neck reflex reveals which side has
the stronger tone. left or right; the law of the semicircuh\r
canals identifies which of six oculomotor muscles have the
best chance of modifying postural tone in the desired direction. The next step is to test those six muscles. one after the
other, using the rotators test. The patient puts on trial spccta~
des with a 4 dioptcr prism. \Vith the base of the prism positioned successively at each of the six orientations associated
with these muscles, the rotators arc tested for altered tone.
(Before testing the tone of the rotators. the patient should

Fig. 16.8. Device for Barre's test. Heels are 2 em apart and
blocked behind. Feet are fanned out at 30.

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

the thumbs' tcst (see following section), which is sensitive.

None of these tests, howevcr. is absolutely necessary. \Vhat is
necessary is (0 base the prescription on morc than one tcsl.
BARRE'S TEST

For this test, Barre observed his patients in relation to a vcrti

cal plane, the intcrmallcolar median sagiual pbnc. Each adjective matters. The unclothed pmicllt is posilloncd between

two motionless plumb tines that arc aligned with the main
medial axis of his or her suppon basco Positioning the feel is
accomplished most easily by using a simple arrangement such
as a block behind the heels and a block with a 30' angle between the feet, with the heels 2 em apan for the sake of steadiness (Fig, 16.8), The subject must stand still, relaxed,looking
forward at eye level, with the arms hanging beside the body.
The observer, behind the patient. aligns his or her eye with the
two plumb lines and notcs the me;J1l positions, at the midpoint
of postural oscillations, of the glUlcal cleft. the spinal
processes of L3 and C7. and the vertex relative to the plumb
lines.
The observation is repeated with and without the corrective device-the prism or plantar insert-that is being evaluated (Fig. 16.9)63. Often, the result of this tcst 1S not immediately altered by a manipulation thnt later proves to be
effective. Therefore, we consider the tcst to be fairly reliable.
T: tUMOS TEST

The patient stands upright, with feet apan by the width of the
pelvis. The practitioner, from behind. puts his or her thumbs
gently on the patient's skin. without pressing (<1 pressure of
about 10 g is appropriate), making sure they are positioned
symmctrically relative to the patient's body axis, starting at
the level of the posterior superior iliac spine. The patient is
then asked to roll downward slowly, i.e.. to start by dropping

-,

Fig. 16.9. Barre's test. A. Try the plantar input first. B. Try the
oculomotor input first C. Try both of them. D, Be careful. do not
try either oculomotor input or plantar input without looking at the
spine, the mandible, and joints of the feel. E, A whiplash injury is
a possibility. (From Guillaume P: L'Examen clinique postural.

Agressologie 29:687,1988.)

fig. 16.10. Thumbs test.

the head completely. then letting lhe.shoulders fall. and tin~l!ly

the trunk. as if attempting to touch the fect with the hands.
without bending the knees (Fig 16.10).""
The practitioner. meanwhile. notes whether his or her
thumbs arc dragged symmetrically. or if one is dragged higher
than the other. The tcst is rcpeated with the thumbs al variolls
levels of the spine. for instancc L3, 012, D7. D4. C7. ~lnd the
occiput. The rcsuhs obtained with ;md without manipul~lting
an input into the system arc written in a table for comparison.
Using a test thc mechanism of which is not fully understood has its dangers. but with this reservation. we can say
that the thumbs test is sensitive. revealing slight differences
that other tests miss-the results of the thumbs test arc altered
by a change of only one diopter of the prism. This sensitivity
is the reason we include it in our battery of tests.
Just which tests are used-Barre's venic;.I!. the thumbs
test, or some other test-maners less than the need (0 prescribe on the basis of a group of converging arguments. so
that on each test. the prescribed corrective device ;"lters the result in the desired direction.
Treatment

Follow~up

Within I or 2 months aftcr the !'itart of trcatmcnt. the p,Hiclll

must be seen again. Within this time, a prism can induce all
iatrogenic postural hypertonicity contmlatcral to thc original
hypertonicity. The patienl then merely stops wearing lhe
prism.
After 2 weeks, an area of plantar stimulation may ha\"t~
lost its effectiveness. If the patient's pain has nOI been fully
relieved, another plantur area may be better-the change in
postural tone having changed the distribution of pressun::s
under the feet. For this reason, we prefer treating by prism insofar as possible. because postural tone docs not change con~
tinuously. as it tends to do in response to plantar stimulations.
Prisms must be used with caution, howcver. Small prisms an::
powerful; they can modify nn ant;'llgic posture. and one can
imagine the effect on the patient's suffering.

if,)

:)

_"

",....l...

ul~uH.Ut::H::i U~

1HE BODY AXIS

Contribution of Stabilomctry

_.

"

Although we have mentioned only clinical examination. a

noteworthy means In record the functioning of the fine postural system is the ~Iandardizcd cmnputcrizcd platform for
clinical stabitomclry.' The reason for nOllllcntioning this ap~
paralUs previously is simple: in effect. the platform reduces
the subject (0 a single point, the center of grdvity...md ,maly1.c~ the stahility of thi5- point rc!nti,,!= t':' the surroundings. II
is difficult for a clinician to accept such a reduction of patienls. Nevertheless. stabilomctry remains a basic tool. because it provides much needed certainty regarding the elusive phenomenon of muscle lone. It provides documentary
evidence useful for treatment follow-up and also for COI11piling statistics on groups of patients, making it possible
to sce beyond the random variability encountered in everyday
clinical practice. In addition, stabilometry is indispensable
to the clinician, because disorders of the rcgulation of onhostatic posture often arc not clinically apparent and are
manifcsted only in patients' complaints a:'ld abnomlal sta~ilnmctrk parametcrs. Without its stabilomctric underpinnings, posturology would not have the certainties It has at
present.
ROMBERG'S QUOTIENT AND LOW BACK PAIN

The first objective indicmion that low back pain is improving

is a stabilol11ctric criterion: a :-hift of Romberg's quOticnl to':..:::.i"d :::. :o.armal value. From 600 patieols with low back pain
who had been followed using stabilometry, Guillamon and
co-workers40 selected 125 for statistical analysis because thcy
showed no other impairment, they had received thc same
treatment, and they had not received any other treutment thut
could have modified their postumltonc. Scvcnty-one subjects
of this group benefited from the treatmenl. and of these. 63

, I

r,'

.~

i~
~

!t
11

.."

~
i
t u

250

showed a shift of the Romberg's quotient toward normal

(Fig. 16,11).
The condition of 54 subjects. howevcr. wa:o; no( improvcd
by treatment; of these, only 10 showed a shift of the
Romberg's quoticntlOW<lrd normal values (Fig. 16.12). ;'\l1d
all 10 showed obvious stabilomctric signs of "o\'crcolHrol" of
their orthostatic posture (sinusoidal intcrcorrclation function)
suggesting malingering or "oversimulution."11
:\lthough stabilometry potentially is widely applici.\ble. it
can be carried out only by a specialist. the postllrologist. It is
in lhe intereSI of aU thcrapists to know abom stabilomctry.
howcver. for all can benefit from its contribution.

0-h
--=;:::f=:::;--;::==::::;--(8)

Because oculomotricity plays a major role in th~ tine postural

s}'stem. knowing how well patients' eyes arc functioning is as
important as knowing how well their vestibular apparatus is
functioning. Postllrologists cannot work effectively without
collaboration with ncuro-ophthalmologists as well as neuroolOlogists. Neuro-oplllh<llmologists working with posturologists have developed orthoptic ex:uninatiolls useful in postllrology. e.g .. tests of oculomotor balance in variolls postures
(standing. sitting. hcad straight ahead or ro(at~d. eyes in the
primary position or in different versions) or tests of oculoll1o~
tor balunce under the effect of pmaural prisms.': Casc management is greatly facilitatcd if the results of such tests and of
the clinical postural examination ;Ire consistent and in agrcc~
mcnl. Although it is beyond [he :o;copc of this chapter to describc these orthoptic techniquc:, in marc detail. tile cOl1tributiml of postural orthoptics dcser\"cs mentioll. \Vc never put a
prism in front of an eye unless the p,i1icllt has had ;;111 orthoptic evaluation. In this collaboration. we arc fortlln,HC, and we
wish C\'cry thcmpist the same good fortune.

ii

100

Fig. 16.12. Changes in Romberg's Quotients at patients whose

condition did not improve. Each arrow represents changes in
Romberg's q'uotient 01 one patient tram the start to the end of
follow-up. 250, normal value: 100. limit lor postural blindness.
A, 54 patients whose condition did not improve and whose
Romberg's quotients move away Irom normal. e, 10 patients
whose condition did not improve and whose Romberg's quotients
shifted toward normal.o

Contribution of Postural Orthoptics

81,

.~

cs:;-~
(
10
)

337

100

250

Fig. 16.11. Changes in Romberg's quolients of patients whose

condition improved. Each arrow represents changes in Romberg's
quotient for one patient, tram the beginning to the end of followup. 250, normal Romberg's quotient; lOa, limit for postural blind
ness. A, 71 patients whose condition and Romberg's quotients
both improved. B. 8 patients whose condition improved but whose
Romberg's quotient moved away from the normal mean.~o

1------,-------------------------

.- ....
Postural Training Platform
PoslUr.l1 rehabilitation can he accelerated hy the use of :l
wobbly platform. similar to that dcscrihc~ by FfC~l1lal1 el aF'
but adapted to the fine postural system. The dOI1l~ on wllkh
the platform re~ts has .1 large radius of cur\',lture and the platform construction limits its mean range of movement to -l nr
50 (thc normal mngc of hody sway in (HlhoSI:ltic posturl' thal
is conLrollcd by the linc postural systcm). Therc!<lre_ a slIhjC(1
standing on the pl'ltform commonly remains within these limits of tile fine postural system (Fig. 16.13).
The subject is askcd to stand upright on' the platform.
keeping it as horizontal .md as stcady as possible for ahout
I minute. The exercise is repented several times a day.
Admittedly, this platfoml cuts down the plantar input inlo the
fine postural systcm, because information perccivcd by plantar baroreceptors is not the stlllle as when the ~ubjeel is standing on finn ground. This condition probably increases the
contribution of visunl input to the control of orthosultic
poslure.
For whatever reason, we have observed that postural
blindness responds to this form of treatment within 3
months,7-~ As wearing a prism can result in iatrogenic poswral
blindness, it is advisable to prescribe exercises on a poslUral
training platform every time a prism is prescribed, especially
in the absence of a stabilometric platfonn thai could be used
[Q detect the appearance of postural blindness, These exercises also seem useful in treating mild low back pain.

Psychologic Aspect
How reductive it would be if the posturologist considered a
standing person as merely an assemblage of eXleroceptors and
proprioceptors. the infonnation from which is integrated to
produce the reactions needed for stabilization in his or her
surroundings. To stand upright means much more. To stand
on one's feet means to have the hands free to act and the joy

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of (011tro1 tWL'r 01l~':, hody. Phyl(lg~l1('tically speaking.

humankind is Ih~ OUh.'\ll1l(' or this impulse toward more
freedolll. morc control. more powcr, To reduce the standing
per.. . on W posturologic lCflns is to condemn ourselves to
lllisulldcrsiand the "lnis-"{~llldillg" person.
~n longcr lX'ing ahk 10 sl,md lIprigJ1t is sh,uning. the opposite or being. upright and proud of it: to lose this ability is
III he powcrkss ;lIld dqll'lhklil. Wilh ,I postural p'llicnt, there
f\lre, wc IllUS! asse~s lh(' pSydlOlogi..: aspect of this dison.h.:r
011 his or hcr behalf. for the patient will not be ",ware of the
extent
this break. We arc then faced with a difficult sitlla~
lion, because the ~igl1ilil.::'ll1ec of psychologic disorders that
'\CCOlllp..m)' poslUral disorders is dOllblcsidcd: the individual
1ll:'IY havc experienced ;I'profound \\~()und to the bodily ego
that is expressed ;IS depression and anguish. or the paticnl
may feel depression or anguish thal is being ex.pressed in bocl
ily language. Some postural disordcrs can bc ameliorated
with purely psychiatric trcalment. All pfilctitioncrs musl rc~
membcr thm a purely posll1rologic point of view docs not rc
ncct the entire person,

()

or

CONCLUSION

Everything said about the control or orthostatic posture seems

obvious, but we must l10t forgct Ih:'11 nn "obvious fact" may
<lssume its true weight only after gradually emerging. through
many experimcntal confrontalions_ Thanks to the pioneers of
posturology. and in panicular of stabilometry. a few facts
arc now known abotU thc person standing upright, but there
is still a long way to go before this knowledge comes into
its own.
ACKNOWLEDGMENTS

We thank Susan Millcr for her help with lhe English tr<lns~
lation and Sylvie VillencuvcParpay for her help wilh illustrations_

2.

3.
4,

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9.
10.
II.

a la poslUrologic diniquc.
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67

\\i~!~:!~ ~:G. ~'.'r.f::;: C'.'./: I\l~tur;ll Ihixlllfllpy ;11 til.: human hip.

Q 1 hj'

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'V'M.'''UM.L

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C. Fouche 13:

/\gro:ssIlIO~I" ~~:16l).

7._.

AI1ll:-l~\lpie

profolltlc ct prislIlcs I\oslurau.".

11)91.

Frl'l~Ill;lII ~1 ..\R. \},,:all 1o.IRE. Ibnh:lIll IWF: 'Illc ctiology ,\lid prevclllion
(If hll1,"I\II1::! In_~I;lhililY Ilflhl" i''Clt. J BllllC loim Stlrg IBr!47:(17S. 1(6).

7J. (;;Igo:y 1'.\1: L.I plalo:-l"\lflll,' Ik rc":du<.:alillll l'0stur:lk. "nil Kil\e.~ilhcr.

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Lumbar Spine Injury in the Athlete

ROBERT G_ WATKINS

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Low back pain has b~cn a significant factor in many differenl

types of athlctic activity. Thc ~evcrilY ~\lld extent of back pain
oftcn dctcrmincs the aClUal abilil)' to compete ;lnd is i\ worry
(() the athlete. the family, coaches. trainers, and those persons
responsiblc for p::lying the bills. TrCallIlCn{ of thc athlete with
a lumbar spine injury involves an lInderstanding of basic
anatomy mId biol1lcchanic'll function of the spine. the diag~
nosi$ of conditions ,lffecting (he lumbar spine. proper usc of
diagno~tic ~tudics. and a syslcnmtizcd. all-inclusive history
and physical exmnination. We must also recognize somc factors that predisposc the athlcte to lumbar spine problems. as
well as training <lnd therapeutic techniques to prcvcnt lumbar
spine problems in athlctcs.
Dbtuining ;:\ proper diagnosis in Ihe athlete prescnting
with low back pain is crucial. It is thc key to initiating an approprimcly aggressive diagnostic and therapeutic plan.l.~ A
variety of pathologic conditions can be diagnoscd on the bi.\~is
of plain fHm radiography ,md thcir relationship to the alhlcte
and his or her sport can be addrcssed more spcciflcally..'
Especially in the adolescent and younger athlete, a high index
of suspicion must be maintaincd to accurately diagnose COIlditions such as stress fracturcs and spondolytic dcfccts,~
The bone scan is a vital diagnostic 1001 for the physician C;lring for athletcs with lumbar spinc problems. An iJdolesccnt
athlete with significant back pain that persists for longer tlwn
3 weeks should be evaluatcd radiographically and a bone scan
should be obtained. Unusual conditions ranging from oSlcoid
osteoma. infections, and stress fractures of the sacroiliac
joint, to the more routine spondolytic defects can be found.
Approximately 30 10 38% of young athletes presellli"R willt
significllw lumbar paiu have [Josilive bone seeUl..!!>
Predisposing f'lcwrs to back pain in athlelcs include increased
trunk length and sliff lower extrcmities.f , There is an increased
prevalence of occulta spina bifida in patients who dcvelop
lower lumbar spondolytic dcfects. 7
The study of exercise and back pain in athletics and in the
average populalion demonstrated no higher incidence of back
pain in athletes participating in orgnnilcd sports relative to
regular students. fairbank ct al found that back pain was more
cOlllmon in studcnls who avoided sports than in those who
participated. Fisk ct aP- found that prolonged sitting was the
important factor in the pathogenesis of Schcurmann's disc.lsc
as opposed to athletes lifting weights. undergoing comprc~
sive stresses. or doing hcavy lifting and part-time work. This
study involving 500 17- and 18ycar-old students showed that
56% of young men ~md 30% of young women had some mdi-

ographic evidence of chnnges similar 10 Scheunnann's discasc.'~

Keene ct HI" found that 80% of back injuries occurred during practice, 6"fcJ dliring competition, and 14% during preseason conditioning. Of thosc who sustained injury, 8% were
men mid 6% women. which was of no statistical signifiC;Ulce. The n:lturc of injury usually was acute (59%)~ 12%
\Vcre related to overuse and 29% involved aggravation of a
pre-existing condition.
ANATOMY

The vertebral column is a series of linked intervcrtebral joints.

The join! consists of the intervertebral disk, its two facet
joints. concomitant ligaments. vessels. and ncrves. referred to
as a neuromotion scgment. A neuromotion scgment is considered as onc of the basic units of spine an<ltomy and function.
The lumbar spine has a lordotic curve and plays an important
role in the biomechanics of the lumbar spine.
The spine comprises two basic columns~ an anterior column consisting of the disk and vertebral bodics and the accompanying longitudinal ligaments. the anterior longitudinal
ligamcnt und Ihe posterior longitudinal ligament. The posterior column consists of the facct joints. lamina. spinous
process. ligamcntum Ravun. and pars inarticularis. The disk
itself may be described as a circular, multilaminated ligament
that connects the two vertebrae. TI1C nucleus pulposus is the
central, morc gelatinous portion of the disk. The annulus is
the mulliluycrcd woven basket with fibers at precise angles to
resist torsional <lnd compression forces. This structure is
firmly anchored (0 the end-plale of the venebrae. The annulus. nucleus, nnd the accompanying endplates resist compressive forces well and torsional forces less efficiently.
The orientation of the facet joint is different at every level
of the spine. In the lumbar spine, the facet joints are oriented
in a transitional phase from parasagittal in the upper lumbar
spine to a more coronal orientation in the lowcr lumbar spine.
This p,lrasagittal oricntation allows good motion in flexion
and extcnsion. and less motion in I.Heral nexion. The
parasagittal oricntation of the facet joints would naturally resist rotation~ high lorsional forces can overcome the strength
or the joint, tearing the annulus and injuring the facctjoims.
\Vhen considcring thc anatomy of the spine. one must
consider the important role of the cntire cylinder of the trunk
and iL'i supporting muscles. The static ligamentous structures
provide considcmblc resistance 10 injury, but lhis resistance in
341

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_ .

itsdf would be insunicicllt to pn~tlllce proper spine strength

withom rhe additional supporl provided through (he trunk
Illusculature anti IUlllbodorsal f:ISl:ia. :V1usdc control of lhe
lumbodorsal fascia allows gn.':il1cr n:sistal1ce to bcnding anti
IO~lding stresses. The: rok of 111111!wsacral fasci,l Illi.ly be com
p<trcd to {he anchoring dc\iccs of a circlls lent, which pull 011
thc side of lhc t~nl lil ,q:lhilizc the pole in the middk. The !';IS
ci,] st;lbilizes the spine :lntl allows it to right mechanically.
The IUlllbodorsal f",\.j:\ 'lIlt.1 the muscles allaching to il ,:rc 01"
cqu.al imporltlncc to the ilion: sjli.:cialii'.ed function of the inter....ertebral disk and r:H:~( joints.
DIAGNOSIS

. In dClermining the exact ctiology of lumbar spinc pain in mhletes. age-is i.1ll important fi.1ClOf. l'ounger athletes arc more
likcly to havc slr~ss fractures and congenital predispositions
to slress fractures. Diseases that affect growing cartilage are
more common in young athletes. such as Schcurmann's dis
easc. In the m.Hurc athlete. radiologic assessment often in
volvcs distinguishing between age-related, asymptomatic
changes <HId symptomatic reccntlmum:l. Is the L5-S I disk degeneration.H (he symptomatic level in a 30ycarold athletc or
is it an ,lsymptomatic finding? The diagnostic plan must be
organized to allow diagnosis of the most common conditions
as wcll as such r'lre conditions as herniation of the inferior
lumbar space ll ) or o:,teoid osteoma.
Important diagnoses to make in the athlete with back and
leg pain mc peripheral nerve injury and peripheral nerve en
trapmcnL Thc variety of peripheral nerve problems ranges
from a generalized peripheral neuropathy to carpal tunnel
syndrome. pyriformis syndrome, peroneal nerve injury,
remon]! neuropathy. and interdigital neuroma. The chief rea
son for clectromyographic and nerve conduction studies of
the lower extremities is to identify a peripheral nerve prob
lem. The nerve conduction study. combined with a careful
P!I~ysical .examination. can ~\t least raise the distinct possibility
0 a penpheral ncr\"(~ problem and heighten the diagnostician's skepticism concerning small. potentially asymptom:'ltic
spinallcsiol\s in the role of the patient's extremity nerve pain.

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'pondylolysis and Spondylolisthesis

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Age is important in the natural history of thcse conditions. An

incidencl: of 4.4% ,J( age 6 years increases to 6% by ..dult
hood. It is unusua-' for children to presellt with spondylolysis
beforc the <.\ge of 5 years or with severe spondylolisthesis.
grade III or IV. Most symptoms appear in adolescence.
Fonun:.llcly. however. but the risk of progression after adoles
cencc is low (about 15%). Symptoms cannot be correlatcd
wilh the degree of slip. Rapid progrcssion to spondylopt.osis
is more common in 9 to II year aids and in children with occult spina bilida and doming of S I. Children with high degree
slips may present with dcfonnily and minimal pain" Many
times, it is (he pain of an injury that leads to the identification
Of:'1 signif1cant spondylolisthesis.

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Isthmic spondylolisthesis most commonly develops as a

fracture. A hereditary predisposition to dt:vcloping the
stress fractur~ is likely, and there is certainly the predisposition in conditions in which the bone of lhe pars inarticularis is
nO( sunicicrll to withstand normal stresses. Also, certain mechanical activilies thaI expose the p<llicnt to rcpcaled biol11t:chanical challcng~. increasing stress concelllmlion on the pars
inlcrarticularis. hav~ a higher incidcnce of spondylolisthesis.
Thl: concept of repealed microtraurna with conccntration of
these strcsses in Ihe pars has become increasingly recognized
ill adolescent athleles whe participate in sports such as gymnastics and weight lifting.
The most common site for spondylolysis and spondylolisthesis is L5-S I. 'Ille slippnge in the latter disorder results from
the lack of support of the posterior clemct\(s produced by the
stress fracture of the pars. The spectrum of neurologic inVolVClllCnl funs from rare to more common with higher d~grcc slips. The majority of neurologic deficits ;:Ire an L5
radiculopathy with an LS-SJ spondylolisthesis" Cauda cquin3
symptoms are more likely in grade III or IV slips. Cauda
cquina neurologic loss is ran~.
The diagnostic and thcrnpcutic plan for spondylolisthesis
begins with a high degree of diagnostic suspicion in the ado
lescent athlcte with low back pain As lll'lny 'IS one third of
adolescent athletes presenting with l~w ~ack '~ain havc c\idcnce of a stress fracture on bone scans. Bone scanning hwarranted for patients with low back pain that has not resolved within 3 weeks. If the resultsul iilc bulle: Sl:al1 arc posilive, CT scanning is perfonned to detennine if there is a
demonstrable stress fracture or if the bone is "hot" because of
an impending fracturc. If the results of the bone scan are negative and the patient persists with lumbosacral pain, magnetic
resonance imaging (MRI) is indicated. Using a combination
of MRI. bone scanning, and cr. it is possible to diagnose
moSt signilkant pathologies in the lumbar spine.
The treatmcnt plan for spondylolisthcsis is rest or restriction of enough :Ictivity to relicvc the symptoms. This pbn
may vary from simply removing the athletc from participatiog in the sport until the pain has significantly improvcd W
immobilization in a lumbosacr'll corset. Boston brace. or
TLSO, or bed rest and casting.
The goal is to SlOp the pain through whatever amount
of inactivity is required. For an athlete with <I "hot" bon~
str~ss

scan. we routinely prescribe a bracc and restrict activit)' for

3 mOnlhs. At the end of lhis period, if the bone scan is fl.>
peated and the results are negative. sufficient h~aling has OL'
curred to allow the patient to begin a rehabiliwtiol1 program.
If the findings of the bone scan arc still positivc. and the .nhlete is asymptomatic. it may be difficult to decide whcther III
begin the rehabilitation program or to continue further r~striclion. \"Ie usually initiate the rehabilitation progr'llll and
observe carefully for any return of symptoms. If lhe patieIH i~
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asymptomatic in a full, rigorous, trunk stabilization
(level II Back Class) and aerobic conditioning program. w t : J
allow lheir return to their sport and conlinue the rehabilitation
\
program.

progr~lIn

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I" IUNt:.r"n;j MANUAL

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CHAPTER 17 : LUMBAR SPINE INJURY IN THE ATHLETE

Pal kills wilh unilateral "hoI" h,Iill..' scans. wilh or wil1lOU(

demonstrated fr:\I.:llIfc. have a rC:I'llllably high illL"iJL'llCC 01"
healing. and adnk,(cllt allllcl..:s ill ~l'l1cral should be (reilted
with the idea o( hl'aling Ihe defec!. Bil:l\cral sln:s.", fractures
afC less likely to hL';11 c.kspitc l'olllj'n..hL"n",ivl..' IltHhlpcr:lIivc

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111cr:lpy.
Ir the hom: . . ..,-an lindings ,If\.' 11:.''::;lti\l~ ill a palil'!H \~'i[h a
spondylitiL' tkt'c(1. lhl.' In:atmclH pLtn should be IikL' [hal for
:lll)' patient wilh lllt.:l.:hanic:1I lnw h:h.:k paill. Tilis plan usually
involves a progl'cssi\"c1y vigorou" lfunk stahility rL'ilabilit.\lion program. We put no rennan~nt r~stril.:lions on .ultk(cs
\\lith spondylolysis or srondylolisth~..is. Ckarly. p;'li~ms \\lith
grade III to IV spondylolisthesis ar~ less likely (0 b.: able to
partil.:ip:Jtc in vigorous sports ;ll.:li\'ili~s without pain and oisl.:omfort. Thcy should probably :l\"(lid lhe hC;l\Y.. strength
sports. such as fO{.ltb;.tll. wcighl lifting. etc.
The lm;idcm:c of spondylolysi~ ::md grade I sp()l\dylolis~
Ihesis in sports participants is high, In the long term. this condition is not considered lo be a significant factor in an athklC's ability to pl~l)'.

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BIOMECHANICS

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The understanding of the basic biomechanics of Ihe lumbrar

spine begins with ~n understanding of the forces ilnd stresses
'Ipplied to the spine as rclalCd to its normal curvaturcs.
Because of the lordotic shape of the spine. lhe results of vce
toral force 011 the spine usually consist of a vertical axial
loading compressive force perpendicul;:lr to the surface of the
disk and one horizontal to the disk. producing <l shear strain.
The combinution of Ihese two forces prodm:cs both lensile
slress in the annulus fibrosis and a shc<lr force on lhe neur.11
arch.
The center of gravity of body weight is anterior to the
spine. This weight times the distance back to the spine rm~
duces a lever ann effect of the weight of lhe body. This effect
is reslsled by the erector spinae muscles. lhe lumbodorsal fas
cia. and the gluteus maximu!'. Abnormal slresses applied 10
this equation may result in annular tcars of the imcrvertebral
disks or stress fractures on the neural arch related to this ex
cessive resistive force. The most common pl<lce for stress
fractures is the pars interarticularis.
111e basic mechanisms of injury produce a combined
vcc(Qr of force that may be difficult 10 analy7.c in a force diagram. Three common mcch'lIlisms of injury to consider arc:
(l) compression or weighl loading to the spine; (2) torque or
rotation. which may result in various she<lr forces in a more
horizonl<ll plane: and (3) tensile stress produced Ihrough excessive Illotion on the spine.
The compressive type of stress is more common in sports
that require high body weighl and massive strengthening.
such as football and weight lifting. Torsional Stresses occur in
'throwing alhletes. e.g.. lhe j<lvelin. baseball players. golfers.
etc. Motion sporls Ihm put Ifemendous tensile stresses on thc
spine include gymnastics. bnIlel. dance. pole vaulting. high
jump. ctC. 11

343
SOllie injuries fesult from direct blows. Certainly. sports
slIch as football arc associated wilh muscle contusions, musdt.: stn:tchcs.md lears of fascia. ligaments. and. occasionally.
muscle.
Lumhar fractures can occur as a result of direct blows to
tltl..' hack wilh fracture of the spinous process or twisting injuries that avulse the tnlllSVCrSl: process. Vertebral body cndplate fracture from axial compression load on the disk is a rclati\t.:!y common source of compft::ssivc disk injury. The allIlU
Ius is morc likely injured in rotation. The end-plate is morc
vulnerable to compression than the annulus. Axial loading
compression injuries can result from jarring injuries in motor
sports or boating. Flexion rotation fracture dislocations of lhe
ccrvic;::tl and lumb;'lr spine arc certainly possible. In any sport
in which one athlele falls on another. the mechanism is simiI"r to that of the coal face injury with the rock falling on the
coal miner while on all fours. An athlete can suffer an asymmetric loading. rotational injury to the thoracolumbar spine.
The intervertebral disk is injured predominantly through
rotation and shear. which produce circumferential and radial
lears. Initially. the layers may aClUally separate or lhe inner layers break. As the inner layers weaken and arc lOm, added Slress
is placed on the outer layers. This increase can produce a radial
tear of the intervertebral disk. \Vith the outer layers lOrn, the inner layers of annulus break off and. with portions of the nu~
deus. <Ire forced with axial loading to lhe place of least resistance. the weak area in the annulus. The ouler areas of annulus
arc richly innervated, producing tremendous pain and reflex
spasm when the annulus tears. The nuclear material can produce a chemical neuritis and innammation. The spasm and pain
is mediated through the sinuvertebral nerve with anastomosis
through the spinal nerve llnd the posterior primary ramus. As
the herniated material extrudes and it produces pain from the
trans~ersing or exiting nerve root itself. the patient may develop sci;:nica or radiculopathy. Jntradiscul infiltrali'1n of the
granulation tissue adds increased potential for painful senS:ltion in (he annulus. The annulus. with time. can heal. although
the healing annulus will not retain the same biomcchanical
function capability as the original intervertebral disk.
Biomcchanical functioning of the spinal column and its
relationship to the biomechanics of nerve tissue involves seyeral basic concepts:
I. Flex.ion of lhe lumbar spinc increases the sizc of Ihe intervertebral
canal and the intervertehral fomminaY
2. Extension decreases the $ize of the imervcnel'lral canal and the inlervcrtebral fommina. l :
3. Flcx.ion increases dumt sac and nerve rom h~n$ion.l.l
4, Extension decreases du.!1 $UC and nerve rOl)t h:nsioll,l.l
5. Front Ilexion, axialloilding. Ilcxion. and upright postllrc incn:a:'~
intradisc;ll pressure.
6. With flexion. the annulus bulges- anteriorly.!'
7. With extension, the annulu!' bulges postcriorly.1J
8. Nude,lf shift in an injured disk is poorly dOI,:umcntcd. but prob:lbly corresponds with annubr bulge.'~
9. Rotation ;,nd torsion pruduces annular ll::trs and disk herniations. I '

Conclusion of these faeLs indicah:: that mOl ion docs have

an effect on the nerves and Lhe Ilcuromorion segments of an

injured ..rca. For example. in the presence of a spinill obstructive problem. such .IS spinal stenosis. extension exercises
can funhcr COlllprcss lhe neurologic slructun.::s ami make them
worse. I n the presence of a nerve root tension problem. such
as disk herniatioll, fkxioll can produce incrc:Iscd tension in;1Il
already ten"e nerve alld im:rc.. lsc symptoms.

IlISTOIlY ANIlI'HYSICAL IeXAMINATION

The key

10

a proper history and physical examination is to

hayc a swndardi7.cd format that accomplishes the needed spe-

dlle objectives.
I. QuullIil<llC the morbidity. Usc a scale value of pain. function.
;1Ilt.! occupation 10 undcrsland how sick Ih~ patienl is. Cunvcrsc
wilh tilt: palielH to hear tile infkctioll~ and mnnncr of pain dc~cripliun. Dctail the tillle of dis'lbility and the time of origin of
the pilin.
2. Dclinc;.ltc Ihc psychosocial factors. Know wlmt psychologic effeCi the p;.lin hilS had on the patient. Know the soci.tl. economic.
and Icg:l! res~Jlts of the patient's disability. Undcrstillld wllal can
he g'lincd by his or her being sick or well. Derivc illl underslJ.m.ling of what role these factors arc playing in the palient's complainls.
3. Eliminate the possibility of tumors, infections. and neurologic
crisis. These diseases have n certuin urgency that requires immediate attention and it diagnostic therJ.pcutic regimen that is different from lnnl for disk disc4lsc.
4. Diagnose the c1inicul syndrome:
Nonmcchanic.1l back and/or leg pain. Inflummatory. constilnt
pain. minimally affected by activity, usually worse at night Of
early morning.
Mechanical back and/or leg pain. Made worse by activity. relieved by rest.
Scialic~. Prcdomimlntly radicular pain. positive slrelch sig.~s,
with or without neurologic deficit.
Neurogenic claudication, Radiating leg pain or calf pain. won;e
with umblll:ltioll. negative streIch signs. worse with spine extension, relief with flexion.

Pinpoint the pathophysiology causing the syndrome.

Important dClcnnin<llions are: (1) What level'! \Vhich ncuro~
motion segment? (2) What nerve'! (3) What pathology? What
is. the exact structure or disease process in th"l neuromotion
s.t::gmcnt that is ciJusing the pain'!
The history and physical examination represent the first
step in determining the clinical syndrome. Some kcy faclars arc:
I. TIle time of day during which the pain is worse
2. A comparison of puin levels during \v;:llking. silting. and slanding
J. The effects on pain of valsalva. coughing. and sneezing
4. The lype of injury nnd dur.uion of the problem
5. A percentage of back versus leg pain. We insist on gelling an
nCCUr<:ltc estimate of the relati\'~ amount of discomfort in the
back versus the legs. There IIlUSl be two numbers tlln! add up to
100%.

The physical examination should address:

I. 1l1C prcsencc of sciatic strctch signs
2. The neurologic deficit
3. Back .lIld lower c;(trcmit)' stiffness and loss of rungc of motion
4. The C;('let lociltinl\ of lcndcmc~s and r:ldiation of pain or pares
tht:sias
5. Mallcuvcrs during tile cx'lmination th.ll reproduce the pain

Thc history dClennincs \\'hethcr it is an axial (back pain) or

extremity (leg pain) problem. \Vhat is the exact percentage of
baek versus leg pain? Is the pain made worse by the mechaniC'11 activity or is it a constant resting pain? Docs the pain
worsen with maneuvers thar increase intradiskal or intraspinal
pressure? Is there significant night pain? Do maneuvers thal
decrease spinal diametcr increase the pain? Do maneuvers
that incrcase nerve root tcnsion increase the pain?
Cla'\sic radiculopalhy is radicular pain radiating into a specific dermatomal pattern. with paresis. muscle weakness. loss
of sensation. and reflex loss. The radicular pattern of the pain
and neurologic examination detcmlincs the nerve involved.
The cl~ssic hitory for radiculopathy resulting from a disk
herniation is back pain that progresses to predominantly leg
pain. It is made worse by increases in intraspinal pressure
such as coughing. sneezing. and silting. Physical examinalion
shows positive nerve stretch signs. A derrnatomal distribution
of leg pain is made worse by straight leg raising. sitting .or
supine; leg-straight foot dorsal flexion; neck flexion; jugular
comprcssion~ and direct palpation of the politeal nerve or sci~
atie notch is characteristic of r.adiculopathy. A source of radicular pain not found in this description is that caused by spinal
stenosis. Spinal stenosis usually lacks positive nerve stretch
signs, but has the characteristic history of neurogenic claudication (i.e., leg and calf pain produced by ambulation). Pain
that docs not go away immediatcly on stopping is made worse
wilh spinal extension and is relieved by flexion. The pain pro~
grcsses from proximal to distal.
The pain drawing. completed by each patient. is a major
help in accomplishing the objectives of the physical cX<llnina~
tion. The pain drawing distinguishes organic from psychologic pain fairly well. It also helps in localizing th~ symptoms
for future reference with pain r~productioll studi~~. such as
with diskography "od postoperati\'c evaluations..
The initial history and physical evaluation delcrminc the
;.lggressiveness of the diagnostic and therapeutic r('gimen. The
morbidily rating and the duration of Ihc problem arc impor~
tant facts that help to dctermine the aggressiveness and inva~
sivencss of the diagnoslic plan. The leg pain versu:, back pain
ratio is an impon:lI1t factor in determining which diagnostic
tesls are indicated. Leg pain IC:lds to tests for ner\'e function
and obstructive pathology in EfvtGINC. myelograms. contrast
CT scans. and MR images. Back p,lin evaluation includes
bone scans. MR images. and diskogmms. The clinic<ll syndrome should be divided into predominantly mechanical pain.
axial pain, and leg pain. An appropriate trcatme(\( program
can begin. based on the initial e\'aluation.
Most athletic injuries to tht:: lumhar spine fall under the
\..'I~~gory of mechanic,,!. axial. back or leg pain, Included

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345

I cH 17 : LUMBAR SPINE INJURY IN THE ATHLETE

\\ ithil1 thi~ g.nmping ~Ire several different syndromes. First is

:111 ;ll\lIular h~;lr of Ihe intervcnebral disk, usually a loaded

tion program to correct them requires a great deal of skill on

the part of the lihysician.

~'l\11lpre~~in~ rotatory

injury to the lumbar spine producing sc

h;lI.:k ~pasl11 ,lI1d pain. The pain is usu<1l1y
,,\)r~L" ill Ikxion with coughing. sneezing. straining. upright
1'(I~lUn... siHing, ::ild <IllY other situations that iUCfe,lse illlr:ldi.'-cal prcssul'l.'. Other clinical evidence includes referred
kg l'dill. low hal.:k pain with straight leg raising. and anterior
spillal 1L"lldcl"lle~s. Anllular tears can be p:-ouuccd wilh as litlit: :1:0. three degrees of high torque rot:.ltion. lI F.lcet joint align1lll.'nt that protects the disk from rotatory forces may IC<1d to
facct joint injuries as Ihe annulus faits in rot'llion.
. Seconu is tile raCel joint syndrome, more typically occurring ill extension with rotation. reproduced with extension
rol<ltion during the CX'lOlinouioll. p.llients may present with
pain on rising from nexion. with a lateral shin in thc cdcns,lon motion. Point tenuerness in the paraspinolls area over the
fact:t joint is reponed and m;'IY be associated with referred leg
pain.
Third art: tl:ars of the lumbodorsal f<lscia und muscle injuries .1IlU (untusions prescllt with muscle spasm, stiffness.
and many of the Ch;lfuctcristics of facet joint syndrome in <Innular tears.
Finall y, ~thletic injury_may_result in_sacroiliac joint l?~~n
and pain in lhe posterior superior iliac spine.Jhe mosu;omlllOIl area for referred pal~--from the annulus in the intervertebral disk and the neummotion segment of the spine. Sciatic
pain can hun in the sciatic joilll area as well as ,in t~~_.~~!~tic
notch and bUllocks. Although injuries to the sacroiliac joint
can occur, most sacroiliac joint pain is thought to' be the result
of referred pain from a neur-amotion segment ilJ,Jhe spine:The mOSI imponam !!-oal in ttic physical examination of
the athlete is demonslrati~g what types ormotionsrcproducc
the patient's pOlin, \Vhere exactly is the area of tenderness?
What deformity is prcsent in the spine? If there is a lateral
shift. in which direction? The chief advantage fo~ physic~I'
therapists in th..:. treatment of thc athlete with lumbar spine
pain is lhe hanos-on approach directed specificOllly Lo motions
and activities thal produce and relieve the pain. Local techniques can be directed specilkally to localized areas of inOammalion and pain. Treatment of referred pain areas
through loc,liizeo treatment in the area from which the pain is
rcferrcd plays a major role in the relief of symptoms and rcllInI to performancc. Therefore. tcchniques of treatment of referred pain should be understood and used. including injections of local anesthetic. cortisone injections. TENS units.
ultrasound.1Ild icc.
AnOlher important diagnostic goal of the physical examination is to identify areas of contracture and weakness. The
physician <lnd therapist can make the diagnosis by carefully
examining the patient for areas of muscle atrophy and loss of
range of motion. Sophisticated testing techniqucs and dynamic EMG function mmlysis have identificd localized areas
of weakness in the shoulders as wcll as in the abdominal musculature of ba'ieball pitchers. II' Recognizing these deficiencies
during the physical examination and designing a rehabilita\'l,,'fl'. dis:lblill~

...)

NONOPF:RATIVE CARE

The nonopcmtive treatmcnt plan consists of sc\'cral basie

rules.
I.
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4.
S.
6.

SlOP the inl1:l\ullliltion

Restore stn.:ngth
Ri..'Slorc Ocxibility
Restore aerobic conditioniuf.
R~(ore balance "nd coordination
Adapt the reh3bilitution progmm to sports-specific training and
exercises
7. Sian slowly back into the sport
8. Return to full function

Rest and/or immobilization arc often required to stop inflammation of thc spine in an injured athletc. We tf)' to keep
the period of rest and immobilization to :'1 minimum. Bed rest
produces stiffness and weakness, which cause the pain to persist. Stiffness and weakness arc the antithesis of the body fune
tions necessary for athletic performance. Every day of rest and
immobilization may produce weeks of rehabilitation before
the athlete is able to return to performance. As in motion lrcatment of lower extremity injuries, i.c .. fracture bracing and
postoperative continuous motion machincs. rapid rehabilitation of lumbar injuries in athletes requires effective means of
mobilizing the patien~. 1kd il3st fOi" longa than 3 to 5 days is
not of any bencfit in the natural history of the diseasc.
Rapid mobilization requires thc use of strong antiinflammatory medications, ranging from epidural steroids. oral
Medm! Dose pak. and Indocin SR to other nonsteroidal antiinflammatory agents and aspirin; icc: a TENS unit; and rnobili7...ation with casts, corsets, and braces. Corsets and braces are
used for only limited periods of time. Strengthening tech~
niques begin whcn the brace is applied so brnccs can be rc
moved as soon as possible. Bmces in themselves can cause a
significant amount of stiffness anu weakness.
Exact timetables arc difficult. but determinations should
be based on infommtion obtained during the history and physical examination. As a gencral rule. our patients with acute
disk herniation are treated with 3 to 5 days of bed rcst: scc the
physical therapist within 7 days; usc a corset for nQ longer
than 10 to 14 days; receivc Indocin. occasionally Medrol. and
less commonly. epidural injections. The therapist b<:gins the
neutral position. isometric trunk strengthening progr..un thaI.
depending on the response of thc patient. evolves into rc
sislive strengthening, motion, and <Iaobic conditioning as
tolerated.
Part of the key to being able to initiate early therapy is Ullp
dcrstanding. based on the physical examination. what makes
the patient symptomatic. Nonoperative care should ~ the
basis of any therapeutic appro'lch to alhletes with lumbolr
spine injtlric.o;. With the exception of cauda equina injuries.
this type of care should also npply for the athlete with neuroIOb:~ deficit. The key to effective nonopcrative care is well

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thought out, balanced biomechanical approach. Common

questions are whl;;lher to do extension, nexioo, or twisting
exercises. what type of aerobic exercising should be done.
when can someone lift wcights. what role docs Nautilus beautification exerciscs have in rehabilitation of the athlete. and
what type of nonoperative rehabilitation is bcst for the individual athletc's spon?
A COllllTlon concern is the risk of producing or increasing
a neurologic deficit through Ilonop.:rativc care. So often. nonoperative care. in lhe face of a neurologic deficit, Ili:Is COIlsisted of no carc. A shon pt.;riull uf bell rest is tlte usual. initial
stage of treatment of the athle[c with a disk hcmiation and
neurologic delicil. Bed rest is thought to protect the patient
from increasing injury to the spine and therefore increasing
neurologic delicit.
Unfortunately, bed rCst also produces profound weakness and loss of biomechanical function, which actually increases the risk of injury. If the purpose of bed rest is to
decrease inflammation. the logical substitute is aggressive
anti-innalllI1latory medication. If the objective of bed rest is to
prevent lIlotion, braces and casts can be substituted. If the objective of bed rest is to prevent abnormal motion that could
injure the spine. it is with Lhe understanding that cenain mechanical functions have to take place. Patients get on and off
of bed pans. they get up to go to the bathroom. They roll over
in bed. They cough, they sneeze. and eventually have to walk.
it seems logical that if we could design an exercise system
that would prevent abnofiDa1 motion while restoring strength
and flexibility in a biomechanically sound fashion. we could
protect the spine from the abnonnal motion that produces injury. and possibly enhance healing. This enhancement takes
place through normal biomcchanical motion in the injured
pan through increasing strength and flexibility in the adjacent
portions of the body that Can ~lbsorb the stress potentially directed to the injured pan and in preventing the atrophy, weakness, and stiffness caused by inactivity.
Lumbar spine injuries in athletes demand prevention of
atrophy and stiffness and restoration to maximum function as
early as possible. It follows that if this restoration can be
achieved in athletes. il can function jusl as effectively in steel
workers. sccrctaries! weekend athletes, and housewives. The
key to the program. obviously. lies in safety and effectiveness.
If you could summarize an overall basis to our preferred rehabilitation program. it would tie in thc concept of neutral posilion isometric strengthening for the spine. This program is
derived from work by Jeff Saal, M.D.. Arthur White, M.D..
and others illclluJiflg Celeste Randolph. AUJI Robiuson. Clire
Brewster and others at the Kerlan lobe Orthopedic Clillic.

Trunk Stretching and Strengthening Program

This exercise program concentrates on trunk strength and
(runk mobility. balance. coordination. and aerobic condition~ng. A practical app~i~ation of the .usc of trunk strcngthcni'1
In back trcaUllcnl, IIlJury prevention. and improved perro\'.
manc~ i~ :lthletes.

,- OM

" v l ' i c n . : ) MMI'lUI-\L,.

It appean- th:H the place to bc;;in t:,c id;ab:!i~::.ti~~:~ i'::-:;

gram in an injured lumbar spine. with or without neurologic
deficit. neutral po"ition isometric !'trengthening. Th~ b:lsis of
the trunk st:lbility program is to havc the patient tind a neutral. painfrcc position while supinc with the knees lkxed and
feet on the ground. Not only is this beginning to rehabilitation
a.~ nomraum:ltic ;1" possible. but abu it forms the h:lsis ur :tn
imponant concept in tcrms of b01h athletic fUllction and :1\..
uvuics of <.Jaily !Inng for cveryone. We retrain muscles to
work to support tk spine while the patienl is using his or her
anllS and legs. It b nOl only theoretically ideal. but also practically possible. Teaching muscle control with tight. rigid
contraction of th~ muscles, controlling the spine through the
lumbodorsal fascia. with the gluteus maximus, oblique abdominals, latissimus dorsi, not only produces protection of
the lumbar spine. but also Can improve athletic pcrform<lnc~.
The power ~lIld strength of any throwing athlcte comes from
the trunk. Liftinf: weight requires functioning of the IUIllbodorsal fascia.
'i'runk streng.th is an important treatment mcthod for ba('k
pain, and it also can prevent back injuries. Although treatment
plans for symptomatic back pain patients may include simil;'lr
exercises. each plan should be designed to m:uch thc examination and the symptoms. Any trunk strengthening plan pUl:,
strain on the spine and can produce back pain related to overload. Therefore. it should be conducted in a controlled. pro
gressive manner.
The key to safe strengthening is the ability to maintain the
spine in a safc. neutral position during the strengthening exercises. For upper body strengthening. the spine must be well
aligned with the chest-out pos!'Jre. Doing isometric trunk exercises and upper body exercises emphasizing this chest-out
posture strengthens thc support for the cervical spine.
strengthens the postural muscles necessary for maintaining
proper body alignment. and prevents neck pain caused by bad
postural alignment.
For the lo\vcr body. trunk control plays a vital role in the
;'lbility to rotate and transfcr torque safely. Trunk strengthening exercises such as sit-ups and spine extcnsions prodw..' e
strength. Flexibility produces a protective range of motion.
but often the key is providing trunk strength and comrol at th~
proper moment during the athletic activity. For example. a
baseball hitter goes from flexion through rotation to extension. If the trunk musculature does not maintain rigid control.
despite these changes in the axis of alignment. the player may
lose power or su~tiJin a back injury. An alhlcte cnn havc stron:;
muscles. but ir th~y do not fire in sequence;,n the proper time.
they offer no prot~ction from injury and certainly will not ellhance pcrfonnancc. A key to producing a safe range of motion
is to begin trunk control in the safe, neutral position. establi:,h
muscle control in that position, and maintain control through
the necessary range of Illotion to perform the athlctic acti vity.
We begin our identification or the neutral spine positi(.'n
with the dead-bug exercises (Fig. 17.1). To perform these e:'\.crcises. the indi\'idual is supine with the knees nexed and fe~t
on the noar. With the assistance of the tminer or tberapist. tht:
o

<.;HAPTER 17 : LUMBAR SPINE INJURY IN THE ATHLETE

j
I

(
Fig. 17.1. Begin identification of the neutral position with
dead-bug exercises. The patient is supine with the knees flexed
and feet on the floor. With assistance from the trainer or therapist,
the patient pushes the lumbar spine toward the mat until a mod~
erale amount of painless force is exerted on the examiner's hand.
The patient then maintains this same amount of force through abdominal contraction while: 1. Raising one foot: 2. Raising the Olher
foot; 3. Raising one arm; 4. Raising the other arm; 5. Raising one
leg; 6. Raising the other leg; 7. Doing a leg flexion and extension
with one fool; 8. Doing a leg flexion and extension with the other
foot. These same exercises can be performed with weights on
arms or legs.

player pushes the lumbar spine toward the mat until a moderale amount of painless force. not exaggerated, back flattening.
extreme force, is exerted on the examiner's hand. The player
then learns to maintain this same amount of force through abdominal and trunk muscle contraction while:
J. Raising one fool.
2. Raising the other foot.

3. Raising olle arm.

4. Raising the olher arm.
S. R<lising one. leg.
6. Raising the Olhcr leg.
7. Doing a leg flexinn and extension with one foot.
8. Doing a leg nc:c;iol1 and extension wilh lhe olher foot.
These same exercises can be performed with weights on arms
or legs.

347
The next stage for torque transfer athletes is resistance to
rotation, first supine, then sitting. then standing. in which the
player maintains the neutral spine control position while resisting rotation of the upper body on the lower body. The
player resists (he rotational activity exerted by the therapist or
trainer.
III the next stage. the player maintains trunk control while
actively rotating through a shon range of motion ag.ainst tlie
trainer's resistancc. 1l1is mancuver is done in numerous positions to teach trunk control rcgardlcss of the positions assumed by the patient (Fig. 17.2).
Beach ball exercises can also be of bencfit. A ball that is
4 fect in diameter can be used to do partial sit-ups while
maintaining control of thc ball. \Vilh the trunk in neutral position. the sit-ups and resistive sit-ups are done on the ball
(Figs. 17.3 and 17.4).
Lower extremity, tnmk. and upper extremity strengtl1cning must bc donc with conccmration on maintaining thc neutral trunk control position. It must be taught away from the
sport, without a bat or ball, on thc training table or floor. A
routine is established for the player: think trunk control-neuIml position-tense contractions. Trunk control is incorporated into throwing or batting. This control will ultimately
produce;] more efficient transfer of torque from the lower to
the upper extremities. i.c.. better bat control for a hitter .1Od
better endurance and ball control for a pitcher. An additional
valuable benefit can be prevention of spine injuries and spinal
pain 'assoclated with the athletic activity.
After cstablishing neutral position isometric control of the
spine, extremity strengthening can begin. Probably the most
important muscles needed 10 protect (he spine ilself are the
quadraceps. The ability to return to work after a back injury
is directly related to quadraceps strength. _Yet. qlladracep
strengthening should not be done in the standard. sitting. full
knee extension position in a patient with severe lower back
pain. The goal is to accomplish quadraccp strengthening without irritating the lumbar spine mechanical pain. Also. the ability to move a weight from 90 to zero may not relat<: as specifically to lumbar spine function as quadmceps strength
obtained through funclionul strcngthening. Functional
strengthening initially involvcs wall slides-sliding down the
wall, holding the position for 10 seconds and back up at
varying depths of slide. We begin this exercise immedimely
after surgery for our patients. Throwing the medicine ball in a
flexed knee position. Exercise that involves the use of such
devices as a Versiclimbcr or stationary cycle as well as other
techniques arc used to teach quadraceps function while maintaining trunk control and during sports-related (I<.tivity.
Gluteal and hip extensor strengthening is important. but
must be done without inadvertently hypercxtending the lumbar spine. Exercise bands that provide rcsist;;mcc to hip extension without mllch spine extension arc optimal. as are
other techniques that deemphasize spine motion while producing isometric extensor strength.
Weight machines. with a safe. protected range of Illation.
can be of value in extremity sm:ngthenillg. The key to Ihe

. _." .~._ , ,. ,...... ~...... ''- ..,.

"~L;..

r-n..... V

II I lUl'it:1"1 ;::, MANUAL

Fig. 17.2. The patient maintains trunk control while aclively rotating through a short range of motion against the trainer's resistance.
This maneuver is performed in numerous positions to teach trunk control regardless of the position oflhe patient.

sliccessful usc of thcse machines is good isomctric trunk control in a painfrec neutral position. By first establishing trunk
control. it is possiblc to dctcnnine a safe. protected range of
motion and a good position for the spine. 1l1crefore. military
presses as well as lats, ann, and lower extremity leg strength
cning with machines can be of benefit white protecting the
spine. Spine strength testing machines have been shown
to be of benefit in predicting return to work. The ability
to pcrfornl flexion extension exercises or resistance rotational exercises on a machine, however. may not translate to functional spine :.lctivity during athletics. We have
not recommended a specific back machine for treatment
of lumbar injuries: we greatly prefer the trunk stabiliz:ltion
program.
Stretching exercises are an important part of any rehabilitation program. The more flexible the legs. arms. and upper
body. the more likely the proportional decrease of motion
stress on the injured lumbar spine. If tnmk muscle control
is established flrst through the strengthening program. then
the spine can be held in a stable position while stretching
of the extremities takes place. It is important (Q nOle that
hamstring stretching too often is takcn to the extcnt that
produces abnormal lumbar spine motion. Stretching the leg
pasl the point of pelvic motion only strains the spine and
docs not increase hamstring looseness. Too often. lumbar
spine conditions are irritated because of excessive lum
bar motion during h<ll11string stretching. The spine should
be held in a neutral, stable position during hamstring stretching exercises. Lumbar spine motion is important also. but it
is not lhe initial stage of the rehabilitation program. Lumbar
spine motion begins with good muscle control of the spine
Juring the motion exercises. The most common initial ~l<1ge

of motion is the CAT/COW position on all fours. for example. a position in which muscle control can be easily maintained.
The streIch exercises arc a critical component of the program. Stretching increases the functional range of motion of
the trunk and legs. which in tum decreases the likelihood or
lumbar spine injury 'Juring lhe strenglhening program during:

play.
Most low back injuries occur when the player exceeds (he
strength of the spine and its range of motion. The stretching
progr311l provides a greater area of painfrec and injury-Free
function. For example, if a player who is stiff. having 100 of
spine extension and 20 0 of spine rotation. suddenly reachcs'
for a ball producing 25 0 of extension and 400 of rOlation. injury to the bi:lck can occur through tearing stiff tissue. If mobility exerciscs produce a functional range of motion of 40;:'
of extension i:lIld jOO of rotation. injury is less likely to occur.
This is a protective range of motion.
The chief findings in our ball players with back pain an~
weak abdominal musculature, loss of spine extcnsion. loss of
rotation (usu~llIy more in one direction). and poor mechanics
in rotation. Once the back pain starts. the weakness nnd contractions increa..e, This progrnm is designed for perform,t1h':~
enham:cmcnt and injury prevention, as well as treatment of
back pain.
Aerobic Conditioning
~UI11CrOllS mcthods arc available for aerobic conditioning.
Often \\:e see athletes who prefer a specific techniquc. stich <lS
running. but ha\'e developed pain and problems directly related to its performance.

_______.Jaa~
~

<

349

'CHAPTER 17: LUMBAR SPINE INJURY IN THE ATHLETE

Cross-training is critically important in recovering from

aerouic exercise-induced injury. Not only docs the runner
with an injured back have [0 do the stretching and strengthening rehabilitation progrnm. but also they must learn crosstraining for <lerobic exercise. Willer running. swimming. cycling. crosscountry skiing machines. Vcrsiclimbcr. and
rowing machines can produce the nceded aerobic conditioning ou\si<.k of the injurious sport. The benefit of swimming
and water running program I'" should be obvious. The lOtal UI1weighting of the spine in water removes many of the compressive loads and allows good physical activity without the
tremendous pounding and straining of running. The crosscountry skiing machine builds tremendous conditioning with
strong usc of the arms and increasing cardiac output without
the pounding of running.
The Versiclimber and cycling have ~everal things in COIllman. First, it is possible to assume a beneficial position for
back protection while still getting good aerobic conditioning.
The cycling position is slightly bent forward. which helps the
stenotic spine. The Versiclimber position is erect, which
removes as much nerve root tension as possible. Both devices
arc associated with the same potential hazard: lateral tilt of
the pelvis. For the Versiclimbcr, taking short steps should prc~
vent a lot of pelvic tilting, and in cycling, the legs should nOl
become fully extended when reaching for the peddles. The
goal is to keep the pelvis .,lnd spine in a firm, neutral position with good isometric control during the aerobic condi~
(joning.
Running stairs or stair~walking machines, produce good
leg strength and good hip extensor strength. Rowing ma~
chines can result in injury to the back. but if they arc used
properly, with muscle control of the spine in a limited range
of motion, the benefit of upper extremity and lower extremity
function and quadricep strengthening can produce good aero~
bic conditioning without spine stress. The better the aerobic
condition of the athlete. the less likely he or she will sustain

Fig. 17.4. Extension exercises on the exercise ball while maintaining control ollhe ball and the lrunk in the neutral position.

injury, including lumbar spine injury. Therefore. aerobic cnl1~

ditiol1ing is an important pan of every spine rchabilit;\ti'on
program.
Restore Balance and Coordination
Restoration of balance and coordination is vitullO an effective
return to full activity and spans. Incorporation of balancing
techniques into the strength program as is done in the Spine
Stabili1...1.tion Rehabilitation Program. begins the process of
retraining muscles to lire at the right time with lhe proper
strength. Balance and coordination are the key to friction~frec
pcrfonnance~ it is safer and more effective. Coordination is
the key to $winging the golf club, throwing a baseball. or even
lifting weights. Using the S\\'iss exercise ball, balance beam.
standing positions for resistive exercises. exercises bands. and
techniques such as one leg squats while resisting an exercise
band pulling on the waist uses balance with strengthening exercises. Therefore, it is important to incorporate balance and
coordination into all strengthening. stretching.. and aerobic
conditioning aspecls of a rehabilitation program.
Sport-Spccific Exercise

o
I

Fig. 17.3. Partial sit-ups on the exercise ball while maintaining

control of the ball and the trunk in the neulral position can be of
benefit

;l~

After relief of inflammation and pain: rcstoralion of str~ngth.

flexibility, conditioning. and coordination; and establishing
the rehabilitation exercises. the physical therapist. trainer.
physician. and coach come together in the rehabilitation program to incorporate these techniques into the sport. Much will
be lost and injury will likely reoccur if this application docs
not take place properly. Nc\\. exercises are added that morc
closely simulate the sport. Proprioceptive neuromuscular fucilitalion-type techniques of resistive rotation and others
blend in with techniques used by the athlete normally to prc~
pare for the sport. The coach may be able to change cCI1ain
techniques such as slight external rowtion of the lead foot in
golf. or a different foot plant in baseball.
All athletes should srart slowly back into the sport. The
return is comparable to spring training all over again. They
must take the time to test out the new techniques and the new
awareness of trunk muscle function <1Ild body alignment. Too
fast a reLUrn is too fast back into tho: same old rut that often

have been emphasizcd: keep the pelvis stable, keep the ex~
tension of the spine sYlllllletric over aHIevels of the spine. and
obtain good extension through the hip jointsY
Ballet involves lhe lifting of dancers. especially lifting in
awkward positions. The outstretched hand produces trclllCIldous level-ann stresses across the spine of the lifting partner.
Off-balancc bending and lifting is a hallmark of back problcms in industrial workers. and yet ballet, although a sport of
balance. ohen involves some of the most difficult lifts. Male
dancers follow the body weight of their female partners very
dusely.
Spondylolysis and spondylolisthesis playa critical role in
dancers and may often produce severe mechanical back dysfunction.
WATER SPORTS

In addition to injuries to the wrist and cervical spine. diving

is associated with added strain to the lumbar spine that results
from rapid flexion/extension changes and severe back arching
~tfter (:i"itering the water. Although swimming and water exercises are a major part of any back rehabilitation program. cer~
tain kicks, such as the butterfly. produce vigorous flexion/extension of the lumbar spine. especially in young swimmers.
The swimmer must learn good abdominal tone and strength in
order to protect his or her back during a vigorous kicking motion. Thoracic pain and round back defomlities in young female hreast-strokers (:an be a problem because of the repeated
round shoulder-type stroke motion.
POLE VAULTING

Pole vaulting is another sport that involves maximum flexion/extension and muscle contraction. The range of motion of
the lumbar spine has been documentcd with high specd photography from 40 0 of extension to 130 0 of flexion in 0.65 seconds. One can imagine the tremendous forces generated
across the spinc with these functional demands.~~
WEIGHT LIFTING

Moving from the motion Spol1s-those sports that require

tremendous flexibility and strength and involve large degrees
of changes in range of motion. we go to the "heavier"-those
that require strength, lifting. and high body weight. The most
common such sport is \veight lifting.
The incidcnce of lower back pain and problems in
weightlifters is estimated to be 40%.1~ The tremendous forces
exerted on the lumbar spine by lifting weights over the head
produces trcmcndous levcr arm effects and compressive injury to the spine. Weight lifting begins with the spine in tight
rigid position of llexion. and the lifter lifts with the legs.
Tremendous extension force is exerted at the hips and knees
with the spine in a rigidly stable position. Success in this por~
tion of the lift requires the body to generate tremendous rigid
immobilization of the spine in lhe power position of slight
flexion.

T~1 p;':iform <I rur\\'~IIJ lJClll Irlutil"i with the spine (Jut of
proper position can be dangcrous. Lifting weights with the
spine flexed at 90", whether they arc lighter arm \veights or
weights across the upper back, generatc tremendous lever ann
effect forces. The weight times the dislance back to the spine
results in tremendous shear forces across the lumbar spine. es"
pccially if weight is to be moved in this position. One cannot
imagine muscles that must be strengthened in this dangerous
and mechanically disadvantageous position.
A dangerous lime for weight lifters is the shift from spinal
flexion to extension that occurs with lifting the weight over
the head as in the clean jerk maneuver or the "snatch."
Making this transition must be done with rigid. tight muscle
control. Inexperienced lifters. especially, have no muscle con~
tral as the spine shifts from flexion to cxtension. A traincd
lifter, again, cOlltrols that shift with rigid muscle cOlllrol of the
lumbodorsal fascia.
Holding weight over the head invariably draws increased
lumbar lordosis. These tremendous cxtension forces of the
lumbar spine naturally lead to discussion of spondylolysis and
spondylolisthesis. The incidence of spondylolysis in weight
lifters has been estimated at 30'10. and the incidence of
spondylolisthesis is 37'7c.: 6 Many newer training techniques
in weight lifting emphasize the role of general body conditioning, flexibility, aerobic conditioning. speed. and cross~
training. in addition to the ability to lift \veight.

FOOTBALL

Football players lift weights. It is part of the sport. For most

~thletes involved in the sport. football requires trcmendous
upper body forces and leg strength. Some football players rely
on great agility and jumping ability. throwing ability. and
eye-hand contact. but strength is the backbone of football.
Every year, professional teams need heavier. s.trongcr athletes, especially for the offensive line. Players go through
their period of mechanical back pain as training c::nnp begins.
it is difficult to prepare an athlete in the off-season for the
tremendous, rapid back extension against weight necessary
for blocking in the offensive line. Extension jamming of the
spine produces facet joint pain. spondylolysis. and spondylolisthesis. The effect is similar to the weight-lifting position
of weight over the head. except that it must be generated with
forward leg motion, off-balance resistance to the weight while
trying to carry out specific maneuvers such as blocking a man
in a specific direction. Lumbar spine problems in these athletcs requircs specific training in back strengthening exerciscs
to prevent injuriesy,2x
Safety in weight lifting is an important part of football.
Having a promising football player injured in the weightroorn
is a relatively common occurrence. It has been eSlimated
that more injuries occur in training than cOl11pclition.~<) This
situation can be avoided by using proper weight-lifting tcch~
niques.
In addition lo extcnsion lifting-type forces. football in'.'olves sudden off-b:~lancc rotation. which may produce trans-

------------------------

verse process fractures, IOrsion<li ui:-i-.. illjllfil.::-. and tears ill the
lumbodorsal fascia. Sudden off-h'll'lIlce twisting is pan of lh~
game and may be caused by tr~ll1clldous I(Klds or a loo~c, llllloaded position. Football has Ihe ;H.1ded dimcl1:,iol1 of rccciv.
ing unexpecLed, severe blows 10 the lumb.u :,pine Lh;.n may
produce contusion or fracture: impact from a helmet to th,,'
ribs produces rib.fractun::s. and ~ill1ilar impact ill the nanK (,",Ill
produce renal contusion, relfopcritoncal hClHt.)rrhagc. ;'1110
fracture of the transverse '.lIld ~pinous proccSS6. lvtany <lCW'
batic receivers and runners suffer spondolytic ckfccts for the
samc rcasons as gymnasts and ballet dancers. but the most
common cause of problems is the wcight lifting. The role of
the strength coach in teaching propcr lifting techniqucs and
designing training schedules that prcparc the lumbar spine for
what is expccte~ with football is important to prcvclll lumbar
spine injuries in football playcr~.
RUNNING

Another SpOrL that produces stiffncss is running. Distance runners must cross-train with f1::xib:!ity to prevent injury.
Running involves mailllcnance of a specific poslUrc with
trcmendous muscle exertion oyer a long pcriod of timc. Low
bnck pain as well as interscapular .md shoulder and neck pain
are commonly reported by runners. The majority of runncrs
with mechanical low back pain arc "cured" with stretching
exercises. Runners also have a natural tendency to develop
isolated abdominal weakness. Running docs not naturally involve constriction of abdominal and spine-stabilizing musculature. A significant inbalance is often noted between flexor
and extensor muscles. not only in the legs but also in the
trunk. Inlrascapular and back pain also results from abnormal
posture during running. As statcd previously, the key to posture is good isometric trunk strength that holds the body in an
upright chest out position.
Treatment for runners with low back pain should include
the following:
I. Vigorous stretching program thaI stretches trunk as well as lower
extremilies
2. Cross-training and lTlu:-c1e strengthening Eedmiques lhal also
strengthen the antagonist muscles. such as hip extensors and knee
eXlensors.
3. Abdominal strengthening. using isometric trunk st:.lbility exercises to enhance abdominal control
4. Chest-out strengthening exercises. beginning with abdominal
strengthening and adding upper body :-houldcr shrugs, arms behind the bilek-type exercises 10 emphasize chest-out posturing
:llld tight abdominal cQmro!. The basis of bOlek pain prevcnlion in
runllers is stretching exercises.
5. Proper fOOl\Ve:lr for cushioning .md enhancement of foot
functillll.
ROTATIONAL AND TORSIONAL SPORTS

Rot;Jtional and torsional spans have ccnain charactcri$tics in

common despite the exact span itself. Baseball. golf, and the
javelin all require rotation and have distinctly different de
mands Oil the spine,

jQl'eliu Throw. The ja"clin throw requires an athlete to

gcnCr..1h:: .1 tr~m~lldous 'Huoum of force to go from a h)'p~rex
Icnded po:\ilion to .1 full lkxion forward through position.

Athletes do nnt throw il j3vclin 200 fcct with their <Inn.

Ahhou~h :-houlda .IllU ;.\fIn injuries arc common in javelin
Ihr(.)\\'er~. Ih,,' k~y is rigid ahdominal sLrength thilt prouuces
the ton_lllt: Il~,,t:s~ary to thrll\v theja\'clin. Attempting to throw
wiLh the ;1fI1l only re:-uhs in :tnll i"njurr and in no way can gent:rate illly ty~ of distalH,'c. E'cry arm injury in a javelin
thrower lllUq be trcated with tfunk exercises and truilk
strengthening. A rmittory lumbar spine inju!)' in a javelin
thrower is a completely debilitaLing injury that requires
trcmendous (3re :lIld corrcction beforc rt;turning to the sport.
Golf. Golfers notoriously havc Lhc- highc~t incidence of
hack injury of .my professional athlete. In onc review by
Callaway and Jobe of injuries on the 1985-1986 PGA tour,
230 of 300 professional g.olfers were injured (an incidcncc
of 77%). Of the total injurlcs. 43.8c;'(.1 were relatcd 10 the
spine: 42.4(!c were lumbosacr:lI. Lumbar spinc pain in golfers
results ill torsion.1! stress on the lumbar spinc, :md the key
to p<1in prcyentioll is to minimize the torsion stress by absorbing the rol:llioll in the hips, knees. and shoulders and
spreading the rot:ltional stresses on the spine over the clltire
spine. Maintaining rigid, tight control through the power portion of the swing is critical. Proper technique in golf bcgins
when addressing the ball. The knee flexion of the address position tenses the abdominal musculature. This tension is initiation of the trunk control necessary for <I properly placed
swing. The cmphasis is on m.aintenance of parallel shoulders
and pelvis through the majority of the swing. which rcquires
rigid abdominal control and rotation betwecn shoulders and
hips. Loss of this rigid parallclization of the shoulders and
pelvis can generatc rotational strain on the lumbar spine,
Rotation occurs between the hips and shoulders in (he back
swing. and the amount of back swing is nOI as imponant (0
the power of the swing as the ability of tilt; golfer to regain
tight muscle control as he or she proceeds from maximum
back swing down through the power ponion of the s\ving. h
is the ability to obtain and maintain tight control and parallelism that produces the powcr and protection for the lumbar
spine.
Advice for any recreational golfer with back pain is as follows. First, cut down the back swing and the follow through.
Concentrate on the power portion of the swing. Concentrate
on tight abdominal control during the power ponion and minimize the exccsses of rotation with .back swing and follow
through. Keep thc golf swing symmetric. The same arnount of
extension on back swing and follow through is imporwilt.
Avoid lateral bending, especially in the follow through. There
is a tendency to bend to the left side: an aff-balancc lateral
bcnding position and .lsymmctric I();jding of the spine produces injury. Golf is usually self-restricted according to tile
player's symptoms.
There is no condition of the lumhar spine for which we
specifically restrict golf. Many peoplc with spondylolisthcsis,
through superb conditioning and care, can play rekllively

..

----._-----------------

painfii:e. Prem~i;ure..~ymjitoni,ltic UC'::Clll.:r<liiv(; Ji~k di~easc

is common among golfers who playa great deal. c~pccially
among professionals who not only p1.:ly. but also practice long
hours. People can return to golf after dccompn::ssi\'C lumbar
spine operations or spinal fusions. The effect of a spin:l1 fusion on an adult. professional golfer raises significant _luestions. The effect on adjacent segmcms and on overall spine
function may not allow any better function. Under these circumstances, a fusion should be a last resort.
Baseball. Torsional problems dcYelop in both pitchers
and hitters. Throwers require a rigid cylinder of strength to
transfer torque from their legs to their throwing arm. Trunk
and leg strength generate the velocity of the throw and the
arm provides the fine control strength. Fatigue reduces the
control of the pitching motion and ball location. A major factor in ball control is a loss of tone and strength in tk trunk
caused by trunk muscle fatigue. A loss of the rigid trunk cylinder produces a loss of synchrony between the legs and arms.
which in turn causes abnormalities in pitching mechanics.
Our initial attempts at scientific stLldy of the role of trunk
musculature in throwing athletes started with throwers and
progressed to professional pitchers. We used cle('tromyo~
graphic evaluation of muscle activit),.
As abdominal Illusculature weakens because of fatigue.
lumbar lordosis increases and the back arches. The subtle
change of a few degrees puts the amI behind in the pitching
Illotion, promoting earlier ball release. and the pitch comes
up. Arm strain increases as the trunk musculature fatigues.
Attempts to compensate for loss of trunk strength'and a "slow
ann" increase the use of the arm musculature and predispose
the shoulde .. to injury. Developing power in torsion depends
on trunk strength, i.e.. strengthening abdominal, back. buttock, and thigh muscles. Trunk strengthening exercises arc
designed not only to enhance the performance, but also to prevent ann injury. Trunk strength is superceded only by balance
and coordination. The firing sequence of trunk muscles in a
professional baseball player follows a consistent median pat~
tern. Any alteration produces an inconsistent, uncoordinated
pattern that leads to arm strain and back injury.l'
Hitters arc required to initiate a violent lumbar rotation based on instantaneous accular infomlation. and so the
role of the lumbar spine in a baseball hitter begins with
visualization of the ball. If a hitter docs not see the ball
properly, the mechanics of the swing are disturbed. The most
common situation is the delayed recognition of the ball
producing a rotation with the hips in front of the shoulders. a
loss of parallelism of shoulders and hips. and increased
torsional strain of the lumbar spine. The successful player
sees the ball properly and initiates a symmetric swing. The
trunk should move quickly as a solid unit, through the baseball swing.

(y)(,:;, 1. t~nnis

(219C l. and badmiltoll (20S~'). It has been reportcO thaI 3~W(1 of professional tenni::. players have missed
tourn:.nllcnts because of back pain. Trunk strengthening
should ~ a major part of the tennis player's regimen.-II
Tennis involves spt:'cd. rotation. and extremes of llexiotl.
later:d ;~lldillg.. and extension, as well as the pO\ver aspects or
tile (l\ ~'rhead serve-lhe effect of lfunk strength on shoulder
t'UllCtl( l i1-many of the aspects brought out in other sports.
The rn~ht consistent ami important factor in protecting the
spinc m lennis is bending. the knees. Leg strength. quadricep
strcll~th. and the ability to play in a bent-knee. hip-flexed position \\ hile protecting the back is the key to prevention of
back p:.tlll. In the servc. trllnk strength in proc,!:cding from the
back c\tended to the follow-through positioil requires strong
abdOll1lnal control. Ciluteal latissimus dorsi, abdominal
obliquc~. and rectus abdominus- strength control the lumhodor<:l fascia and deliver the power neccssary through the
legs up into the ann.

The b:~ '.; to proper management of lumbar spine problems for

athlcte:,:
I. tvt:.k.:

<.l

comprehensive diagnosis.

2. Prcn ide aggrcssive. effectivc nonopcralive care.

3. Pinpoint operations thai do as lillIe dam'lge

tisst.::: but correct the pathologic lesion.

:lS

possible to normal

REFERE."CES
I. Ket~;~ 15: LI1\\" h'u.:k pain in thl: ;llhlc!c from sptlildylogenic injury durin t ;~;:realilln (lr competition. Postgr'ld Med 74:2t}9. 19~G.
2. Sp<:,,~::r CW. Jackson DW: B,lCk injurics in the athletc. Clin Sports t-.-kd
2:1'Ji. 1983.
3. C>l~::::orin. ED. Hochh>luser, L. PClro. GR: Lumbar thoracic spinc pain in
the ::::hlctc: Radiographic C\'aluatillli. Clin Sports r.. l cd 6:767.1987.
4. Mi.::h-:li U: Back injuries in gymn:lstlcs. C1in Sports Med 4:8S, t985.
5. P'lp::.nicolaou N. Wilkinson RH. Emans JB. ct al: Bone scintigraphy and
radiography in young <Ithlctes with low h<lck pain. AJR Am J Rocntgeno(
1~5:HJ39. 1985.

o.
7.
8.

9.
10.

11.
12.

13.

TENNIS

14.

When reporting on racquet sport injuries. Chard and

Lachmann1o separated inciden-.:c data according to squash

15.

!'<IirDank Jc. Pynsent PH. Van Poortvl!!:! lA. ct al: lntluellcc of :nllhwpom::lric faetors :mu joint l:l.\ily in thc im.:idcIKc (If auo!t.'scCllt baek pain.
Spin:: 9:.:161. 1%4.
Jack;ot! OW: Low back pain in young alhleles: Evaluation of stress rcaction and dis<.:ogcnic problems. Am J Sports Med 7:364, 1979.
Fisk lW, Baigent MI... Hill po: Scheuerman's discase: Clinical and radiological survcy of 17 and 18 year olds. Am 1 Sport.s 1\'1cd 63: 18, 1984.
Keene JS.Alhert MJ. Springer SL. e! al: B>lek injuries in collcge aLhletes.
1 Spinal Dis 2: 190, I\)%
Light HG: I-krnia of the infcrim lumbar ,pace. A causc of back paill.
Areh Surg 118:1077. 1983.
Keene J5, Drummond DS: Mcchanical back in lhc athlete. COl1lpr Thcr
II :i. 1985.
Sdmebcl BE. Simmons lW. Chowning J, ct al: A digitizing tcchniquc for
the qudy of movcment of intradisl.:al dye ill respollsc l\) llexion and cxlen<ion of the lumbar spinc. Spine 11:309. 1988,
Schnebcl BE. Watkins RG, Willin WII: The role (If spinal lle:o::ion and extcmion in ~'hanging nerve r<x); ,oTllprc~sion in disc hcrniations. Spine
14:835. 1989.
Whi,c AA. l\lIljabi 1\1M: Clinical BiolJ1echanies of the Spinc.
Phil;;.delphia. Lippinc()t!. 1971'.
Farf<tn HF: \kchanic:II Disorders Ill' thc l.ow ItH.:k. Philadelphia. Lea &
Fcbiger. 197.~

j----_._--_.

1(" brIan HF: Muscular lII'':-:..llIi~llI tIl" [hI; htlllt-Jf 'rilll' ;lud Ihe rn~illt\ll uf
(low~r and cfficicllc... Cniwp Clin NUrlh Am (.: 1.;5. 1975.
17, F;lrf:11J !"IF: The bio;ll... .:h.~:~i,;l1 .1l1~-;11\Ia;:~ ,It" l\'r,h\~i~ and hip nlO:lIsillll
fllr upright 'll':livily. Spine' .~.~.j6. ItJ7S.
IX. Walkins RG. J).:.:nis S. Dillin WII. ..'I

;11: ll~n;llllk

EhlG ;1ll:lly"i"

of IOlquc Ir:Hll'fa in r~,';.:"illll;\1 h:hd'.lll ru.:ho:rs. Spilll' IJ;JIW,

19~9.

RG. Buhkr II, L,'\~m\.:k 1': Thc" \\';Il~'r Worlw\1t R..:~',\\.:ry

Pwgrarn. Chic:l';;'''_ C"n:,,' ;,;,,'r;U) Bnob. P.l,".:"
20. Sicm;lIl Rl.. SI':III!:=kr D Ti,..: "i!-=llili'":lIlrl' of tUlIIhar spOllllyl{lly,j, in
collcg.: (oolh;11I playa.... S;'inc 6:171. 19~1.
21. Schnook GA: Jlljuric., in \\\)J\lcI1's g)'I1lIl:l\II(\: ..\ Ii\'c YC;lr study. Aml
SpurtS ~kd 7:1..\::!. 1971),
22. (iarric:k lG. Ih'qua RK: ErlJcrniulo~y Ill' \\\,nh.:I1\ gylllll,lSlics injurics.
AI111 Sll\Irb ~lcd S:1(d. 19S0.
23. l-hlWS~' A1G: ()rth\lpcdht'~ ;:iJ h;llkl. CORR S9:;'i~. )'171.

19.

,i
!

I
:~

I,

\Valbll~

2..\. G<linor B1. H::lgcn Rl. Alkn WC: Biomcch::lnics of the spine in the flOlevault...' r ;IS rdah..' (! 10 spondylolislhcsis. Am J Sports r-.1cd II :53. ;983.
1.'1. Aggrawal. ND. Kaur. R. Kumar, S. ct al: A siudy of changes in weight
liners ami olher alhklcs. Br 1 Sports Met! 13:58. 1979.
26. Knl;tui 1'1', khikaw;t MO. Wakabayashi MO, C( 31: Studies of lipond)'IlIlislhc.:is found all1(1n~ weight liflers. Br J Sports Med 9:4.19$1.
2i. Cantu RC: LUlllhar spille injuries. In Canlu RC (cd): 111e Exercisiu~
Adlilt. !..C:.. illg.hHl. CnllalllOrc I'ress. IYSO.
1X. Fcr,t:usllil RJ, IvlcMa'l<:r JH, SI:lIliski CL: Low back pain in <:ulkge I"oot-

halllincnlCIt. j Silurts ~kd 2:63. 1974.

::!lJ. D:I\'ies m: "11,,:;- spine in sf'>ons injuries. prcvention :lntl In':;llll1ent. Br J
Sruns Mcd jUlL 19$0.
JO. Ch:trd MD. bellm'lIlll SM: Racquct sports - rattcms of injury pre~llt
jng 10;1 SJ'Xlrts injury dinie. Br 1 Sports Mcd 21: 150. 1987.
.11. ~'Iarks MR. Haa.~ 5S. Wcisel S\V: Low b:lck pain in the competitivc Icnnis pl:tycr. Clin Spons :""1cd 7:277.1988.

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ACtIVe KehabllltatlOD protocOls

CRAIG L1EBENSON

-----------

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-----_._._-----_. . _-_._---

Symptomatic treatments for pain relief <Irc imptlilant. but they

Not every patient is a candidate for functional restora-

should be used to promote active rehabilitation rather than as

lion. Some patie!H~':~with pain have conditions that require

<In end in themselves. I.: Rehabilitation is of value for the pa-

cmcrgency mcdical attention or urgent referral. which are

tient with a chronic problem. but its carly usc can also prevent

cd led H:JI pags (sec Table 18.1). I.~

dccondilioning and disability." Rehabilitation focuses on

Patients presenting \vith low back pain initially should be

cbssilkd into one of three categories u (Table 18.2) (see
PaticlH Classi lication. p. 3(1). As stated previously. those
with red flags identified by a medical history and physical examination should be referred to the appropriate specialist
(emergency room. oncologist. rheumatologist. etc.). Simple
backache accounts for the major.ity of patients who seck care.
Their prognosis for recovery is good: 80 to 90'!c of these in~
dividuals recover spontaneously within 4 to 6 weeks. Spinal
manipulation is advocated because it hastens this process.
Other pain-relieving approaches. such as activity modification. over-the-counter pain medication, light aerobic exercise.
and reassurance arc recommended for usc within the acute
stage. Unfortunately. the recurrence rate is high. Therefore.
active rehabilitation principles arc important to improve the
quality of care. 2
Persons with signs of nerve root compromise also have a
high rate of resolution (80%).1.2 For these individuals. hmveva. bed rest as many as 7 days and stronger pain medication
may be required until the severe pain or impainnent abates.
Management strategies similar to that for nonspecific back
pain arc recommended. but progress is usually slower. Highvelocity thrust manipulation is lIsed with caution in these
patients.
Patients whose recovery progresses rapidly (within :2
to 4 weeks) do not need a sophisticated rehabilitation
approach. Patients with chronic or recurrent pain. those
considered of subacute status but \vith significant symptomatology after 2 to 4 weeks. and postsurgical patients.
however. are ideal candidates for aggressive. active rehabilitation. Rehabilitation involves a functional and biopsychosocial approach. Functional testing to identify \'alid retumto-work or activity outcomes is important. Other functional
tests that can direct the choice of therapcutic intervcntion. such as identification of specific mcchanical sensitivities or functional pathologies, arc also necessary. A
biobchavioral approach is stressed. because the longer the
patient surfers. the greater the likelihood that illness bchavior will become entrenched. This approach involves
patient reassurance, education. and promotion of self-

functional restoration and reducing illness behavior. not tilL"

promotion of son tissue healing. The goal of rehabilitation is
to control ralher than clire symptoms. This changes the doctor's role from one of heakr 10 helper. Functional restoration
takes place within a biopsychosocial context, in contrast to
the pathoanatomic model. which emphasizes treatment of injured tissucs. Most spinal pain syndromcs arc nonspecilic
conditions that may become disabling because of physical
and psychologic deconditioning. The <lim of rehabilitation is
to address the pain. impairment. and disability of the suffering individual. Accomplishing this task requires a new paradigm and new protocols.
Rehabilitation involves more than just exercise. It is a
comprehensive management approach incorporating patient
education, physical training. and identification of complicat~
ing factors (i.e., psychosocial issues). Passive interventions
such as chiropractic adjustments arc useful as catalysts for
functional improvement. Rehabilitation permits the usc of
passive interventions if they arc used with the goal of promoting functional restoration. \Vithin the biopsychosocial
model. it is possible to direct treatment at both functional
restoration and providing pain relief. \Vhat is important is to
make functional restoration the primary aim and therefore active care the primary method. Rehabilitation is the highest
quality approach because it <:lddresses disability prevention by
promoting patient reactivation and functional restoration.

FUNDAMENTALS OF REHAIIILlTATING THE

MOTOR SYSTEM

Identifying Appropriate Candidates for Rehabilitation

Patient selection is crucial to successful functional restoration. Those paticnts with serious pathology (spinal or nonspinal) should be referred to the appropriate specialist.
individuals with traumatic injuries should be stabilized before
functional restoration is attempted. Patients with nerve root
conditions also require aggressive conservative care to reduce
their nervc tension signs before rehabilitation can be pursued.
in gencral. once the status of a patient is subacutc. restoring
l

ft_'"_C_l_i,_'"_C_"_"_,_II_,,_I_S_h_O_II_I'_I_b_C_C_O_"_'C_'_I_hc_._p_r_il_"_,,_r_,_g_'_"_t1_'_'f_C_-'_If_C_-

rC_.I_i<:_"_JC_.C_.-

3_5_5_ _

Table 18.1. Red Flags'"

Fracture
Trauma
Strain in osteoporotic individual
Medical pathology
Infection

Tumor

InUammatory
Cauda equina syndrome

Table 18.2. Low Back Classifications U

Simple backache
Nerve root pain 5'%)
Se,ious spinal pathology 1%)

Functional Testing
Functional testing is the first step down a rehabilitatioll pathway. Functional testing secks to uncover various functional
pathologies and mechanical sensitivities (Table 18.3).
fuJ\t.:tional testing performs two basic functions. First. it
provides i.I bi.lsclinc level of functional capacity, Second. it
idcmifks targets for functional 'restoration, The baseline functional deficits me objective. quantifiable. and measurable.
Thus. they arc ideal outcome assessment [Dais. The most
valid tests relate specifically to relevant job trailS. They do
not. however. usually tell us what dysfunction in the motor
system is causally related to the patient's symptoms or "pain
generators:' Such information is obtained through a rigorous
analysis of bioll1cchanical and neuromuscular links in the
ilrthrokincm<uic chains of the body. These all-important funclional chains arc concerned with our most important activi~ies
(sec Chapter 11). Examples, include gait, sitting posture,
standing posture, prehcnsion. respiration, mastication, and
lifting or bending..'
Depending on the patient's work requirements or lifestyle
activities. Olher skills may also be targets for analysis, such as
overhead reaching. pushing. pulling, kneeling. crouching. and
the likc. Tlte thrusl of.mclt lHl analysis offimctiof/al chains in
the body is to link. a specific dysfunctioll or series ofdysfunctiollS to lhf! patient :\. area of complailll. Sllcce.\,,\fullrelllment
hinges on !in ding the key jlUlclional pathologies lilli' are bio-

mechanically or kinesiologically re/ared to the symptomatic

area. Unfol1unmcly. the results of these tests are often "soft"
and only qualifiable. Because many outcomcs related to return la work al.'c valid. they often arc mislakcnly considered
<.1n aid to the clinician in decision making. This infonnation
docs provide a quality check for the clinician. but the practitiOiler "in the trenches" with the patient must have the freedom to use tcsts of a "softer" variety if they can change the
course of lreatment.
The utility of a functional test is bascd on :.tn overview of
its safety. validity. and reliability. Rissanen found that "nondynametric tests correlated beller with disability than did dynametric tcsts."~ If rcliability overshadows validity as a criterion for a good functional tcst, then we may falsely conclude

that nothing is wrong with many of our patlcnts (false negative result). Grabiner addreSsed this point when he found abnormal asymmetric muscle activity during bilateral clcctrom)'ographic (EMG) assessment of trunk extension on
patiellts who passed Cybex dynametric extension c"alllalions.~ The Cybcx lest proved to have poor sensitivity (high
false-ncgative ratc). Limiting ourselvcs to only quantitative
examinations may result in mismanagement and an ovcrdiagoasis of psychogenic disorders as a result of the low sensitivity of lhese tcsts to truly idemifying meaningful functional
pathology.
CompHcating Factors of Recovery
Complicating factors may interfere with patient rccovery. Our
history and examination should uncovcr these factors to allow
us to form an accurate prognosis. No one has a crystal b:.\ll
for seeing when a patient will rccover. but various clues
can help to identify who might take longer to do so. Such factors are helpful in making projections. which are increasingly
important in the utilization rc.... ic\'., process associated whh
managed care. Table 18.4 summarizes the Mercy. Agency for

...

Table 18.3. Functional Testing Evaluates

Joint mobility
Muscle flexibility
Muscle strength/endurance
Movement coordination
Static and dynamic balance
Posture and gait
Lift capadty
Weight-bearing sensitivity
Movement sensitivity {I.e., flexion or eXlension bias}
Postural sensitivity (i.e. sitting intolerance)

Table 18.4. Complicating Factors

History/consultation
Previous history of low back pain~
More _than 4 episodes"
Total work loss in past 12 months"
Heavy smoking?
Personal problems: alcohol, marital. financial 2
Adversarial medicolegal problemsi'
Longer than 1 week of symptoms belore presenting 10 doctor.:.
Low education attainmenF'
Heavy physical occupation?Questionnaires/pain drawings or scales
Radiating leg pain (pain diagram)'-H
Severe pain intensity"
Low job satisfactioni' 0:.
Psychologic distress and depressive symptomsl.:'~l>
Examination
Preexisting structural pathology or skeletal anomaly (Le .
spondylolisthesis) directly related to new injury or conditionl>
Reduced straight leg raisingl.Z
Signs of nerve root involvemenl 1. l
Reduced trunk strength and endurance"
Poor physical fitness (aerobic capacity)2
Disproportionate illness behavior (Waddell's signs)l.i',1i
'Only sJighlly increase ite risk or chronicity, but significantly increase the
dillicullyof rehabiiil<uivr.

.,

.,j

Hl"ahh Care Pt\li.... y and Rcscan:h (AHCPR). and British

Guiddilll"S t"Olh:lu.;ioIlS with respect 10 this yit;ll issue in C<1SC
1ll:lllagl"lllClll.

Findin~ the

Rl'~;lrdkss
if:IL"Ll.

h.tY Link
of till' ,Irucwral diagnosis or "pain generator"

that

"

\'

Alter prolonged standing

linked

[0 lhe

aSSCS.\llh,,'tll.

Functional improvement is diflicuh if not impossible to

achieve unless inappropriately handled extemal demands arc
identilied. f-or example. any <.lctivity. sport. or work demand
that is unusually repetitious involves great external load. Of
requires a biolllcchanically improper movement (i.e., bending
and twisting) must be tlushed out. Such factors can be uncovered during the hi.Hory by asking the patient in what activities
they arc involved. whcn they typically get their symptoms.
and what aggravates the p<lin. Examples of key information
gained arc provided in Table 18.5.
External demand and internal functional capacity arc
equally important in the prevention of recurrences (sec Fig.
2.4). The individual involved in ma~lY high risk activities will
require gre.lIer funclional c<lp<:lci(y~.ln contrJst, the sedentmy
individuallllay only fequire;'1 slight increase in functional capacity and some basic advice.'

<., '.

Un(ovcring key functional pathologies

HISTORY

i~,
f

Pain-provoking activities

C[l:.).

patient's symptoms is the goal of func

!<c!labiliw(ioll (1 the !,wiell! with spinal
SIt'tWX;s. a r<'c(ln'rillg sciatica. or {llacel syndrome involve...
idcIIlU)'j"g 'he ..dusters" of!um:li01wll'alho(ogy of the locomO/or -,".".\'fem 11/(/{ arc rclar1/ biomeclulflically or Ileurophys
i%gie-olly /0 ,he hyporhc.'l;z.f'c! I'oill ~ell('r(l/or. When a key
functional palho~('Igy is found. its successful improvement has
far-reaching cff~('t,"
Biomechanil.:ally. the hody consists of a series of fune
lional chains. The lower extremity functions in human beings
as a dosed kinetic chain. Any dysfunction in the foot, such as
poor ankh.: dorsiflexion. inevitably involves the knee, hip, and
lumbar spine. A sliff hip joilH nwy develop as II result of
hip nexor tightness. in turn leading to compensatory lumbar
hypcfmobility and parnspinal trigger points. The result may
be low back or bUllock pain Of. even worse. a lumbosacral
nerve root syndrome. In reg.mj to b'lck or bUllOCk pain, local
trcatme11ls invoh'ing manipulative (joint or soft tissue) lherapy may impro\"c the situation. To prevent recurrences or to
treat chronic pain. however. a more comprehensive approach
is required. Treatment aimed .Il relaxing a tight psoas and
strengthening a weak gluteus maximus may be the primary
treatment for lumbos'lcral f.lcet pain or par'lspinal myofascial
pain. Although Ihcorctical. this model incorporalcs biomechanical and neurophysiologic rationale into the transition
from manipulative therapy to active :"chabilitalion. While eli,,
icio"... should (Idhu(' ro newly e.'irablished guidelines. they
J/lOuld /lot become pri.<i(Jl/er.\ to rhem. In fact. futurc research
questions emc;rgc as a result of the creativity of clinicians.
;1l"C

tional

l'

High risk activities

Prolonged sitting
Driving
Heavy lifting
Repetitious bending and lilting
Torsional sports (tennis, hockey, baseball)

rehabilitation im'olvcs the cn~

myot'asl.,j;!I. disk.

IiI'\.' !1ll'Pllllllor ~Y~h.l1l.

Table 18.5. Prognostic Factors

After prolonged silting

After prolonged walking
With bending
In the moming
When changing positions
With weight bearing

PHYSICAL EXAMINATION

Once a fimClional evalualiOll Iw.'O becn pc/formed. it is essen

rial to attempt to differentiate rhe key functional pathologies
from those that are secondary. Lewit said we must not mistake the pain for the problem, but ~nstead identify and then
treat the dysfunction responsible for the pain.' First. we must
tap the patient's hislory for all relevant information. Pain location and what aggravates it often helps make the diagnosis
before any testing is performed at aiL Therefore, this information is the crucial starting point. The next step includes
various tests to localize the source of the pain (palpatar)' and
mechanical). It is validating for the patient to have lhc;ir examiner find their pain cither through palpation or spccilic
provocative testing. To be able to provoke the patient's pain
experience is to hit "pay dirt," This information gives the doctor and patient a baseline or ideal outcome assessment tool
that can serve as a "barometer" of the success of our interventions. It also helps the examiner "zero in" on what tissues
arc involved. Although trigger point palpation or McKenzie
or Cyriax provoca~ive testing is not as reliable as an anesthesiologist's needle. such an assessment can be useful in day-to
day practice.
Provocative tests. whether static (e.g.. prolonged sitting).
dynamic (e.g., lumbar flexion), or palpatory (e.g.. trigger
point identification). are invaluable as signs of irritability or
dysfunction'~'')These results, however. should not be mistaken
for the dysfunction itself or its cause. Once a pain gencrawr
is found. the all-important job of hleJllifying why that lissue
is irritated ("the perpetuating factors ") begins. 910
For instance, if a patient has buttock pain and a triggcr
point is found in the quadratus lumborum that refers to the region of the primary complaint, we may have found the "irritable focus" of pain. but we have not necessarily found the
"problem" or source. To find the key link. we must discovef
what could be responsible for the quadratus lumborum becoming an "irritable focus," Evaluating gait and movement
patterns may help to identify this patient <lS a "hip hiker" with
a muscular imbalance involving gluteus mcdius weakness and
overaelivily of the piriformis and quadratus lumborum:
Recurrent sacroiliac dysfunction may also be explained by
this kinesiopathology. Th~ entire kinetic chain from the foot

-----------------------------------~----------------

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II

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i

up should be evaluated with the goal of finding the joint or

muscle dysfunction that is "upstn:::am" of the "irritable focus,"
This t'lssessment is the only way in which we can separate the
adaptive compensations of the locomotor system from the
true source of functional pathology.
To nile OUI the chances of a shorHcml dfcct. treatment
may be rcpc<1tcd over a period of 2 (0 6 weeks to change nClI
romuscular paHcming. If longtasting results prove diffkuh to
.achieve. it is best 10 perform functional rccvalualion for other
key links .lIld to rcinvcstig~\lc complicating f:lctors (i.e., psy
chosocial or high external demand).
CASE MANAGEMENT

General Principles
According to recent American and British back pain guidelines, patient rca~5urance, pain-relief methods. and exercise
should be included in case management. I~ Patient reassurance
is required to allay fcars of back pain resulting from a serious
disease. It also helps 1O inform patients .. bOtl! a favorable
prognosis if back pain is managed properly. Pain-relieving
methods such as timelimited passive care (i.e., manipulation). pain medication. avoidance of biomechanically delete
rious activities. and reactivation with light exercises arc ap
propriate. Exercise or active rehabilitation gains in impor
tance us the acute pain phase subsides. Exercises should be
aimed at restoration of function and prevention of dcconditianing. In particular. trunk strength, cndu'rance, flexibility
and cardiovascular fitness should all be addre.c;sed.
Treatment aimed at pain relief should not be the only gOlll
of care. Even if a primary pain generator is identified. it is important to restore function in the locomotor system to reduce
the likelihood of painful recurrences. Rehabilitation has two
primary goals: (I) through education. ergonomics. or training
in load handling. to Jecrease extrinsic mechanical stress (i.e..
sudden or repetitive overload) on the painful area; and (2) by
functional restoration to improve the intrinsic functional capacity of the spine or its stability.
Patient education helps to decrease mechanic..1 stress
plilced on a painful region. The combination of manipulation
and exercise restores function in the locomotor system. thus
improving thc ability of a painful region to adapt to increascd
mechanical stress. Essentilll inerediel1ts in achievin~ a successful outcome are finding the key sources of tissue ~verlo3d
and identifying the key functional pathologies to address.

Key Link
It is casy to become overwhelmed when attempting to separate important from trivial function..1 pathologies or deficits.
.So many sfr/u:lIlral and jUfIf.:tiollal pmh%gies are preselll ill
as)'mpro!JIatic individuals rlwlthey may /lol be clinically significant whe" secII ill symptomatic patients. Lc\Vit and Jandu
outlined a biomechanical and kinesiologic appro<.lch that
"culls out the wheat from the chaff: 7. 11 The primary goal of
assessment is finding tht: t..t::)' functional pathologies of the

motor systcm. the associated dysfunction of \;:hich can !:.:ad ~~)

mechanical ovcrload aI a distanc~ throughout a kinetic chain
of a particular posture or movcment. \Vc 1l111~l cardully analyze historical data ;lite! observc the mOlor system of our patients in ,Ictian to identify the kcy function,,1 pathology. Thi~
approach enables us Lo find .1 relevant dysfunction that can
significantly alter the trC:ltmCl1l program.
Pathokillcsiology that results in tissue overload and thus
pllin can be identil1~d by evaluating posture. gail. and k.c)'
stcreotypic movement pattcms.7.Il The impli<.:atiolls of Lhis
analysis for chiropractors and those involved in manualmcdicine is that specific muscle imbalances (tight and weak musclcs) that ;.lfe functionally relatcd to the painful area can be.::
identified. Thus. wc can fonn a prescription of which muscle
nceds to be stretched or rclllxcd. those that need to be
strengthened or facilitatcd. and the joints th:l! nced to be .it!justcd. By finding the specific patllOkinc.'iio!ogy reilltcd to (/
pain/ul area. (III exercise prescriptiolJ (:(1U be ratio1/ally linked
to lhe mallipulable lesion.
Pathokinesiology in' a kinctic chain can be nushed out
through posLural and movemcnt analysis.II.I~ Posture. gait.
skills analysis. and key movement patterns all pill)' a part in
cv,alulltioll of the motor system. Low back pain m4.lY h.we
arisen afler an overstrain. On examin4.ltion. a paraspinal trigger point may be discovered. Trcating thc local functional
pathologies mllY be all that is necessary. If the condition pCI'
sists. however. further evaluation of the locomotor system
will be required. The problem may be found in a dysfunctional chain of C\'enlS involving a biomechanical foot faull.
shortened iliopsoas. gluteal inhibition. and lumbosllcral joint
dysfunction with accompanying trigger points. Finding the
chain reaction is CruCi~lllo removing key perpetuating factors
for motor system disorders. A further and more difficult situation arises when longslantlin~ abnorm4l1 posture and movemcnl patterns ha\'c been learned by the cerebellum. This situation requires treatment of not only periphcral tissues but also
the central nervous system {e.g.. proprioscnsory retraining).''
Each stcreotypical movement pllltCm is important for its
rcl.nionship to basic skills performed many Limes each day.'
These skills include l:ait, sitti"!: postft1'(,. ",randing posture,
prehension. respiratiOIl, I1lll.'iticatioll. {//ul lijiillJ.: or bClldill~
(T.able 18.6). For instance. hip extension {psoas, hamstring!
gluteus mllximus muscle imbalance> rdates to gllit (toe olT
and forward propulsion). stllnding posture.lOd lifting. Hip
abduction (tensor fascia latae ITFL). adductors. quadratus
lumborum IQLI. pirifonnis/gluteus mcdi'llS muscle il1\b~lI~
ance) r~latcs to foot strike and stance phasc of gait (pelvic stability). Trunk flexion (erector spinac. hip Hexor/rectus abdominus muscle imbalance) relatcs to lifting and trunk
stability in general (during carrying. reaching. pushing. and
pulling). Shoulder 3bduclion (upper and lower fixmOfs of (he
scapulae muscle imbalance) relates to prehension. reaching.
gr'lsping. and holding 4.lctivities. Trunk lowering frulll a push.
up (pectorals/serratus anterior muscle imbalance) rcli.lte~ to
pushing and pulling activities. Head/neck ncxion (stcrnoclci
dornaslOid (SCM I. sliboccipiwlldeep neck llexors muscle im-

--------------

lIb.

....3

Table 18.6. Chain Reactions in the Locomotor System

i,,

5;';111

Movement Pallern

Gait/loe off. lilting. and

standing posture
GaiFslance

Hip eKlension

. Lifling and trunk sla-

Trunk flexion

bilily
Prehension. reaching.
grasping
Pushing/pulling

i
~
i

.~

Maslicalion and siUing

poslule
Respiration

iI
,
~

Shoulder abduction
Trunk lowering from
a push-up
Head/neck Ilexion
Respiration

Weak or
Inhibited Muscles

Stiff Joints

Hypermobile Joints

Psoas, hamstring.
erector spinae
TFL. QL. adductors.
pirirormis'
Psoas, erector spinae

Gluteus maximus

Hip joint

Lumbar

Gluteus medius

Hip joint

$1 joint and LS joint

Rectus abdominus

Lumbar flexion

Lumbar extension

Upper trapezius, levatar scapulae

Pectoralis majorl
minor, subscapularis
SCM, suboccipitals

Lower and middle

trapezius
Serratus anterior

CfT junction, SIC joint

CS-C6. GfH joint

CIT junction. mid-

GJH joint

Scalenes

hal'IIKe)

,
)

,I

,,

to sitting and mastication. Rcspiration

relates to breathing. Other important

~lcli\'ities pcrforlllt:d include squatting. stooping, crouching,
overhead reaching. 'and the like. depending on the particular
work or SP0rl ,lctivity in which a person is engaged.
Weaknesses of spt:cific muscles, such as quadriceps i:lnd crcelOr spinae. that occur with dccondilioning arc also key links
to c\'aluate as arC<1S of high risk during activities like lifting or
squ<1lting.
Oncc lhe mechanical relationship between certain postures. activities. muscles, joints. or kinetic chains and the patients symptoms has been revealed. a treatment program can
be outlined, Intcr\'cntion involves three levels of care, Advice
(patient education about biomechanics and ergonomics), manipulation (manU'll or reflex therapy), and exercise (Table
18.7). In general. advice is the easiest intervention followed
by m'lnipulalion and lhen exercisc_ Chiropractors have
thrived on the powcr of m<lnipulation. and physical thcrapists
on advice and exercise. The usc of all thrcc clements in combination with a complcte cvalu.ltion constitutcs the highest.
quality of C'ln.: a\'ailable 10 thc public.
A good guidelinc to follow for improving the clHirc kinetic chain linking key muscle or joint pathologies is listed in
T<:tblc 18.8. Table 18.9 outlines principles of case 1l1anagcmerH for nonspecific back pain. which includes asscssment
(red ll'lgs. diagnostic Iriage. complicating factors. outcomes,
functional pathology) and treatment (advise, manipulation,

"

rdate~

(s<:.il~nes/di~lphragmJ

'~

; ,

exercise).

I
~;

.;t,

I .
I
~
I <)
--_

Complicating Factors Encountered \Vith

Exercise Trnining

'

Such f.lctors include low mOlivation. poor flexibility. incoordination, or a mechanic,tl scnsitivity (postural, movcment.
or weight-bearingJ. Motivational problems arc addressed
through appropriale goal selling. gradual conversion of the
patient from .1 pain avoider to a pain manager. explaining lhe

,~
t

''-;

~
~

,?
\

Deep neck flexors

crr junclian in lIexion,

Diaphragm

TMJ
Rib cage. lower
cervical-spine

CSC6

.~

upper Ihoracics

TFL. tensor lascia lalae: OL. quadratus lumborum: 51, sacroiliac; LS. lumbosacral; GfH, glenohumorJI: err, ccrvicothoracic; SCM, sternocleidomastoid: TMJ,
tcmporomandlbular join!. SIC stcrnoclaviculJr.

'i

Hip abduction

Tight or
Overactive Muscle

I
I

Table 18.7. Trealment of Key Functional Pathologies

Advice (patient education)
Head set for neck pain in receptionist
Ice and 90190 rest position for acute pain from lumbar strain
Lifting advice for recurrent low back pain sufferer
Ergonomic workstation modilication lor carpat tunnel syndrome
patient
Manipulation
Trigger point therapy 10 upper trapezius muscle for neck pain
Adjustment to lumbar spine lor back pain
Manual resistance techniques OlrecteO at scalenes or pectoralis
minor (or thoracic outlet syndrome
Adjustment 01 foot far low back pain
Exercise
Strenglhening abdominals for low back pain
Improving muscle imbalance between hip flexors/exlensors and
paraspinal muscles for back pain
Propriosensory retraining for chronic back pain
Trunk stabilization program for chronic back pain
Improving scapulohumeral rhythm for rolator cuff syndrome
Improving laleral pelvic stability by restoring muscle balance to
gluteus medius, tensor fascia latae. and quadratus lumborum

Table 18.8. Addressing Functional Pathology in the

Kinetic Chain
Relax/stretch overactive/tight muscles
Mobilize/adjust stiff joints
Facilitale/strengthen weak muscles
Re-educate movement pallerns on reflex, subcortical basis

difference between hurt und hann. and. if ll~ccss<:lry. refcrral

to a pain psychologist. Flexibility deficits arc <H.ldrcs~cu by
chiropractic adjustments. joint mobiliz:.ltion. muscle relaxalion. and stretching. Incoordination, if present. will lead to
poor training fC.1wlts. Simple exercises should be prcscribt:d
that can be carried out with proper motor control. It is helpful
to limit the training range to reinforce the proper quality of
movement and kinesthctic aW,]fcncss (see Chapter 1-.+).
Focusing on the quality or form of Ihe exercise anti not on th~
qu~~~:!j' of repetitions or resistance is I:~s~ntial. Restoring

Table 18.9 Case Management for Nonspecific Back Pain and Sciatica'.... (see Fig. 2.24 a-b)
Conservalive Care

Rehabilitation (Active Carol

BiopsyChosociill Assessmcnl

Diagnostic triage
Simple backache
Nerve root pain
Serious spinal pathology
Rule out red flags
Trauma (fracture. instability)
Medical pathology (tumor, infection, etc.)

Functional assessment
Quantifiable. outcomes
Functional pathology
Exercise (temporary increase in
pain acceptable)
Stretching
Strengthening (not within the
first 2 weeks)
Propriosensory

Special studies (biologic)

Radiography

> urgent referral

3 weeks)

Rheumatologiclinflammalory > urgent referral 3 weeks)

Major neurologic compromise (cauda equina syndrome)
> emergcmcy referral
Diagnose nerve root compromise
Molar. sensory, reflex testing
Nerve tension tests (Le., SLR)
Evaluate for complicating factors
Abnormal illness behavior (distress, depression)
Job dissatisfaction
Past history of more than 4 episodes
Preconsultation duration 01 symptoms> 1 week
Severe pain intensity
New conditionlinjury related to preexisting structural pathology
or sketetal anomaly
Aggressive, conser:vative care (~i'mplom control) (6 weeks)"
Rest 2 days. unless sciatica <7 days)
Manipulation (ioint dysfunction, soft tissue dysfunction, and/or
trigger points)
(Maximum of two different 2-week trials if no progress documented)
Advice (reassurance, earty activation, activity modification)
Exercise (light aerobic activity, McKenzie. gentle stretches) (increase over time)
Physical agents and methods (decrease over time)
Medication (NSAlDs, acetaminophen) (more import~nt if nerve
root pain)

After 6 weeks
Active care> Passive Care
Consider alternative symptomatic measures

ff unresponsive after 6 weeks, a

biopsychosocial assessment is
indicated.

CSC, ESR
Bone scan
MRI or CT if tests indicate
specific nerve root compromise
Psychologic assessment
Fear avoidance beliefs
Distress, depression
IItness behavior
Social assessment
Family attitudes or reinforcement
Job satisfaction
f:lhysical demands 01 job
Other lactors rclating to
missed work

If unresponsive afler '2 to

16 weeks
Disability management
Job modification
'!'hrk hardening
Vocational re-education
Pain management
Multidisciplinary approach

If unresponsive, a more active approach may start within the

first 2 weeks, but no later than 4 weeks.
"If nerve root compromise progress is slower and treatment less aggressive. Thrust manipulation is avoided with severC."lr progressive neurologic dehcit.

muscle balance, correcting 3nicular dysfunctions, and facili!aling enhanced perception of the "weak link" will contribute
to improved coordination.
A mechanical sensilivity, like gravity or weighl bearing inlOlerance, is no bar to exercise therapy. Non-weightbearing exercises can be performed on {he floor. All major
muscle groups can be challenged before gmdual reintroduction of gravity forces is ullcmptcd. A person with a pos{Ural sensitivity, such as to silting, can exercise while upright
or recumbent. Another common sensitivity is to movement
in a ccnain direction. A paticnt with pain on flexion that
is relieved with extension (extension "bias") is a classic
McKenzie pillieot (see Chaptcr 12). Othcr patients who have
pain with trunk extension, but relief in the slump posture
can be trained to identify their "neutral rangc" and to learn
10 stilbilize their back from potenti31 harm. They also may
havc a common altered movement pattern-hip extension, in
which they extend their thigh <It the lumbosacnll joint rather
than at the hip (because of hip hypomobility andlor iliopsoas tightness). Improving coordination simulwncously
elirnin:llcs this movement sensitivity and expands the fune
tiollul range.

Releasing Patients to a Private Health Club

Much has been said about chiropractors working with priv:lt~
health club facilities. Although this praclice is certainly good,
a few points are worth mentioning.
Proper spinal posture must be l~lUghl
NautilwHypc machine!> arc open kinetic chain and thus uo nOI
tr.tin rcOex control
Nautilus-type machines and Olhcr health club exercises often
cncou(;.\ge "frick" movements. Be on the lookout for the fol-

lowing:
SubslilUt~ng for the :lbdominals
....:.....Lumbar hyperextension during hamstring curls.
tensions. and stairclimbcr

-Hip flexors

seated leg ex

-Slumping during. bentover rows, lunges, st.tirclimhcr. inclin\.'

Ircadmill. or bicycle
-Chin poking during pull downs. bench press, abdominal excrcisco bicycle, or squats
-Shoulder shrugging durin~ ovcrhcild lifting. arm exercises. tlr

rowing
Free wcights arc preferable but require spcciric instructions
-Lunges should be performed with proper lumbosacral siabilil.;l
lion ("ncUlml position")

"

-1

I
!

-)

vV'

-Avoid shouldl.:r shrugging with biceps curls

-Avoid excessive shouldl:l .:xtemal rotiltion during bench press
Aerobic exercise is I:xccllcnl, but wilh certain exceptions
-Slaircli11lbing is ddelerious if paticnt has wC:.lkness of gluteus
m:lxilll\ls or gluteus medius or o\,cr<lclivity of erector spin~lc.
qU:ldr..lIUS Iumborum. or tl.:llSOr fascia lalac
-Stationary bicycle may not be aJ\'isablc after day of desk .md
<luto sitting
-Floor Illust be properly p:ldded
-Introductory classes must be 41v,lii"blc to prevent knce injuries
in Ihe novice
Typical posturJ.! faults and clinical cOl1Sequc:lcCS that result from
improper exercise programs (as described in T'lblc 18.10)

i,,
i

II
i

I!
~

FUNCTIONAL RESTORATION OFTHE

LOCOMOTOR SYSTEM

,I
l

i,
~

I
!

,l

I
I
m

;
')

I
~

Table 18.10. Typical Postural Faults and Clinical

Consequences that Result from Improper
Exercise Programs

~j

i
~i

I
~(

Different classification schemes for back pain patiems have

been proposed. Those dealing with pathoanatomic diagnosis
were rejected for lack of proof. The Quebec Task Force proposed the following classification ~cheme for spinal disorders
(T<.lble 18.11 ).I~ This c1as~ification has been simplified by recent British and American guidelines (sec Table 18.2).1.2
Most patients (70 to 90%) fall into the back pain category.l.:! This nonspecific label replaces pathophysiologic
hypOlhcsis such as facet syndrome. sacroiliac (51) syndrome.
myofascial syndrome. or radiogr.lphic diagnosis such as disk
or joint degeneration. Usc of lhi~ iavd uut:~ nut mean that
most low back pain has no cause. just that the cause is not
yct known. Recent evidence suggests that some of these
causes are becoming clearer. Using a double anesthestic injection technique (one is a control block), it is possible to
identify thc primary pain generator in more than 50% of
both chronic neck and back pain patients.IS.IC.-I" Sacroiliac
joints arc pain generators in 13%. zygaphophyscal joints in
15%. and disks in 39% of patients presenting to specialized
spine centers. IS.I:t.19 Unfortunately, no physical signs Imve

~-

Posiurai Faulls

Clinical Resull

Overactive slernocleidomastoid in
women performing sit-ups incorrectly
Rounded shoulders in men doing
100 much pectoralis work without
working their upper back

CeNicocranial syndrome and

headaches

Shrugged shoulders from too much

upper trapezius work and not
enough lower trapezius strength
Mililary posture (anterior pelvic tilt
with chest Slicking out) Irom abdominal and gluteal work without
lumbosacral stabilization (poste
rior pelvic Iill)

Thoracic outlet syndrome,

shoulder impingement
syndrome. cervicocranial
syndrome
Headaches and shoulder impingement syndrome
Low back pain

Table 16.11. Quebec Task Force Classification oi

Spinal Disorders
Pain without radiation
Pain + radiation to extremity. proximally
Pain + radialion to extremity. distally
Pain + radialion 10 exlremity + neurologic signs
Confirmed neNC rool compression (advanced imaging or clec!rodiagnosis)
Spinal stenosis
Postsurgic~1 status <G months
Postsurgical status >6 months
Chronic pain syndrome
Other diagMsis (tumor. infeclion, fracture. rheumatologic disease.

etc.)

been corrcl.ltcd with anesthctic relief of p.lin.I~.I(..I~.l'l Ho~

fully. anesthetic block techniques will be used .lS a gold
standard to adjudicate less expensive physical examination procedures as diagnostic lests for specific spinal syn
dromes.
Moffroid "and colleagues subdivided group~ of patients
with nonspecific back pain into discrete functional Cale
gorics. 21l These authors arc studying the effects of stretching:
versus strengthening exercises on both flexible and innexible
patients. ~,
The Quebec Task Force also classified patients according
to the duration of symptoms. Acute was defined as less than
7 days; subacute as 7 days to 7 weeks; and chronic Cl..'\ greater
than 7 weeks. TIley also recommended classification by working status-working or idle. An important development in the
classification of spinal syndromes was revealed by Dclino
and Erhard. 22.23 who found that nonspecific back pain could be
subclao;,siflcd into a few catcgories that rcsulted in improvcd
treatment outcomc. An extension and an Sl category were
identificd by specific provocative movcment and functional
tcsting. respectively. Cntegorization and customized treatment resulted in improved results over gencric trcatrnem for
all patients with nonspecific low back pain. Using reliable
tests, they showed lhat they could subclassify cases of nonspecific back with pre~criptive validity.
11lc Qucbec Task Force recently published a promising
classification scheme for whiplashrclated disordcrs_1~ Neck
complainls were divided into four categorie.o; as follows: C;,llegory I: neck complaint without musculoskeletal signs ti.c..
mobility tenderness); catcgory II: with musculoskclctnl signs:
category Ill: involves neurologic. signs; category IV: invo!\'cs
a fracture or dislocation.
Spinal St.<'lbilily, PathokincsioIogy, and the Importance of
Muscular Imbalances
Spinal stability depends on three intact clements uf the locomotor system. 2S First is the centrul nervous system. in particular the cerebellum. which conlrols posture and movement.
Second is the articular and ligamentous structures. which are
the major passivc structures involved in the locomolor sys-

I
,,
~

-----,--------------------

!
t

I,

tem. And Lhird is the muscular system. whkh n::prcsI.:!l!S !h"

active part of the motor system. This system is under the direct control of our will during conscious activities. but it is
also responsible for rene;.;, subconscious Ud'lptations to irritations or injuries.
Any internal structural pathology or excessive external
biomcchanic<llload causes pcnurb;uions in the motor syst~lIl.
An intact mOlor system can adapt via centr..11 nervous system
control <lnd muscle system activity_ Over time. however.
repetitive overload Icads to perturbations 10 which we cannot
adapt, and instability results. The adapt<1tions of the molor
system are represented by muscle imbalances that can be as
sessed simply. These adaptations signify that "old" trauma or
repetitive strain has perturbed the spinal stability tlnd caused
an adaptation by the motor system to adapt and prevcnl further ins~abi1ity. Unfortunatcly. these ad;;lptations arc less than
ideal .md lend to new pathokincsiology. The joints t bcing the
passive structures. arc along for the ride. They arc not only
bony shields to the spinal cord and vital organs, but also mobile Icvers that allow the muscles to perform a variety of actions. They also serve the critical function of providing afferent feedback to the motor control cenlers of the central
nervous system to maintain efferent muscle function at an appropriate level.
Pathokinesiology of the locomotor system develops as an
attempt to adapt to injuries, improper alignment or posture, or
perturbations such as from rcpetitive strains. An injury or inflammation may lead to reflex muscle inhibition or muscular
splinting. Poor foot posture. such as hyperpronation. may
alter the arthrokinematics of the entire lower extremity and
result in pathokinesiology. For ifl<:;tance. hypermobility in
the foot may result in compensatory hypomobility at the knee
and hip joints and then hypermobility and instability in the
lumbar spine. Typical pathokincsiology associated with this
chain reaclion would be a muscle imbalance involving tight!
overactive hip flexors, hamstrings. and erector spinae and
weak/inhibited gluteus maximus. These muscle imbalances.
the result of adapt.nioIl5 to dysfunction, pathology, or over~
load themselves, perpetuate a dO\vnward spiral affecting
spinal stability.
BOlh clinical and scientific studies have generated much
evidence supporting the importance of muscle imbalances as
kcy functional pathologies. \Vatson and Trott demonstrated
that muscle imbalances in the neck can distinguish chronic
headache and nonhcad<1chc 5ufferers.=/l Trcleaven and lull
have shown that lhe same Inuscle imbalances occur in post
cOllcussional headache patients. but not in normal individu
als.~7 According to Janda. muscle imbalances occur in a predictable mallner (see Clwpters 2 and 6).
Certain muscles tend to become inhibited. whereas other
muscles tend to become overactive. Postural or antigravity
muscles arc those that tend to bccome overactive or short
eneu. Phasic muscles have a predisposition 10 becoming inhibited or weak. This muscle imbalance seems to be reinforced by reciprocal inhibition of ,lOtagonist muscles. as well
as by Iwbitu,11 patlerns of stcrotypic:'ll usc. Scientific and din-

I,
"

ical cvidcm:c :-ubstantiah.:s this mood fur pres(.ribing. exercises (T:'lbks t S.I:? and t S.l.'!.
The grouping of muscle imbahlllcrs described by Jallda
arc not isol;lt~d dinical phenomena. Patienls Iypically //(/\'('
"wlly./i'llefitllld /'atlln/ogie.\" alld .\"(J!l'iflg tll(' mysrclY (~r ('(lch
!'min/{ \ illtli.-idl/o/ .lil/Wliollo/ I'(lt/wlng." 1"('(Juil"(,s .IiI/ding (l
eltaill r('(/('Ii(ll/ in lite moto,. .\".'".\r('l/1. Ul1lh:rsl<luding. the lllllsde

imb<ll'lIll:cs ;IIlJ the rcl:ttinll ... hip hctwccn muscle and joint
dysfunction cn;lblcs the practitioller to quickly ''<.:r:'H.:k tlte
cotlc 01" the p:Jlicllt's dysfullction.

Chain n.cactions in the Locomotor S.ystcm

LOWER CROSSED SYNDROME

One of the mo~t clinic'llly relevant patterns of muscle dysfunction is (hc lower crossed syndrome. which is typified by
Ihe following pain: of tight and we"k muscles Crable nU-l-).
Awareness or lhis pattcrn is important for low back and pdviL'
conditions related to abnormal sitting. standing postun:. g"it.
bending. or twiiiting <.lctivilies. Table 18.15 shows the signs
related to various dysfunctions associated with the lower
crossed syndrome.
The combined result of this posture is that tilt:' tUIllbosacwl. thoracolumb'lr. 51. hip. and knees joints arc :'111 o\'er~
stressed. Joint dysfunction ,HId trigger points naturally result
from lhesc Illu:\c!e imbalances. accompanied by low ba<.:k
pain. buttock pain. pseudo-sciatica. and knee disorders.;,lIAI .. I~
Each of the threc muscle imbalances that contribute to the
lower crossed syndrome are discussed in the context of the

.)

Table 18_12. Clinical Evidence for Muscle Imbalances

FOlWard head posture and decreased isometric sltenglh and en

durance of neck flexors correlated with headache patients~~
Upper cervical joint dysfunction, weak neck flexors. and tight
suboccipitals correlated with postconcussional headache patients:;Cerebral lesions result in poor descending control of tonic pos
tural reflexes'"
Most reflexes involve reciprocal inhibition~8
Hypertonia with antagonist paresis is the norm u

Table 18.13. Scientific Evidence for Muscle Imbalance

Increased tension or tightness
Relative type I muscle fiber hypertrophy on symptomatic side
in chronic low back pain (LBP)29.30
Prolonged nociceptive bombardment can lead to flexion reflex
from excessive contraction 01 skeletal muscles in the vicinity
of the nociceptors 31 ,n
Fibroblastic proliferation occurs in injured tissues if inflammatory stage is prolonged33
Muscle inhibition, weakness. or atrophy:
Reflex inhibition of vastus medialis oblique aller knee inllammationlinjuryJ.l.-3G
Unilateral, segmental lype II muscle fiber atrophy aller acute
onset 01 LBP):
Bilateral. type II muscle fiber atrophy in chronic LBP~!U"
Atrophy of type II muscle fibers in multifidus patients wilh herniated disks)l)"'o

,---------------------------ti
~

"'1.

Table 18.14. Lower Crossed Syndrome (See Fig. 2.22)

Imbalance in the following pairs of muscles:
Weak gluteus maximus and short hip flexors
Weak abdominals and short lumbar erector spinae
Weak gluteus medius and short TFL and QL
Seen commonly with gait. lifting. sitting. kneeling, crouching, pushing. pulling. ele.

I
j

"TFL. tensor fascia lata.. ; QL, quadratus lumborum.

Table 18.15. Postural Signs of Lower Crossed Syndrome

,
I,
~

Postural Finding

Dysfunction

Lumbar hyperlordosis
Anterior pelvic lilt
Protruding abdomen
Foot turned Oul
Hypertrophy of thoracolumbar

Shortened erector spinae

Weak gluteus maximus
Weak abdominals
Shortened piriformis
Hypermobile lumbosacral

junction
Groove in iliotibial band

junction
Shortened lensor fascia lalae

1,

.j

key movement pauem that is affected-hip extension, hip ab:

duct ion," and trunk llexioo.

Altered Hip Ex/ellsioll (Table 18.16)',11,1)

Hip extension is important for its relationship to the
propulsive phase of gait. lifting. and the standing posture.

Weak agonist: gluteus maximus

Overactive antagonist: psoas. rectus fem"ris
Overactive stabilizer: erector spinae
Overactive synergist: hamstrings

II

Trigger Poillls
Gluteus Jlluximus

Coccyx
Iliopso;ls

Erl'ctor spinac
(onlrable-raJ uprx:r trapczius and/ur k\';l!or sCapUI;IC

Mo!)iliry (j oim

[).",~rltllcJi(J/IJ

Hip joint
Lumbosacr~ll (US) junction
Thoracolumbar (Tn~) junction
Contrnlalcral ccrvical spinc

Altered Hip Abductiou (Table 18.17YII.0

Hip abduction is !Illportant for its rdationship to the
stance phase of gait and any balancing activity.
\Vcak agonist: gluteus medius
Ovcractive antagonist: adducLors
Ovcractive synergist tensor fascia latac (TfL)
Overactive stabilizcr: quadratus lumborum (QL)
Overac.:tivc neutralizcr: piriformis
SympJomJ (ue Figs. /0.10. 10./1. {/wIIO.13J

Lew back or buHock pain (51 or myufascial syndrollld

Pseudo-sciatica (m)'ofascial syndromc)
Lateral knce pain (knee cxtensor disorder)

Postural Analysis
Prominence of the iliotibial tr.1Ct
Lateral prominence of patella
Turned Qut foot (sec Fig. 6.11 a)

Symptoms
Low back or buttock pain (facet or myofasciill syndrome) (sec
Figs. 18.1 .nd 18.2)
Coccyalgia
Recurrent hamstring pulls
Recurrent or chronic neck pain

II

Poslltral Analysis
Forward-drawn posture (sec Fig.. 18.3)
Anterior pelvic tilt
Hypertrophic erector spimle (sec Fig. 18.4)
Hypotonic gluteus maximus

~:

I.)

Gait Analysis
Decreased hip hyperextension

,~1

Compensatory incre<lsed lumbar lordosis

Muscle Lenglh Tests

I,-' \
I

11
,

Shortened hip flexors (sec Fig. 18.5)

Shortened hamstrings (sec Fig.. 18.6)
Shortened erector spinae (sec Fig. 18.7)
Conlralateral upper trapezius and/or lcvu(or scapulae

\'aluarioll oj Key Movcmelll Pallems

Altered activation sequence during hip hyperextension (sec
Fig. 18.9)

Gait Analysis
Hip hiking gait
Asymmetric pelvic rotation (blocked SI joint)

A-Illscle Length Tesls

Shone ned hip flcxors (sec Fig. 18.5)
Shonened QL (sec Fig. 6.12)
Shoncncd adductors (sec Figs. 6.IOa and b)
Shoncned TFL (sec Fig. 6.7)
Table 18.16. Treatment Approach for Altered Hip Extension
Relax/stretch ipsilateral hip flexors
Relax/streich overacLive erector spinae
Relax/stretch overactive hamstrings
Adjustlmobilize tow back and hip
Facilitate/strengthen gluteus maximus (bridges, squats. leg raises)
AbdominaVgluteat stabilization exercises and biomechanicaV
ergonomic advice 10 correct lumbopelvic posture

Table 18.17.

Treatment Approach for Altered Hip Abduction

Relax/stretch thigh adductors

Relax/stretch tensor fascia latae and quadratus lumborum
Relax/stretch piriformis
Relax/stretch hip flexors
Adjust/mobilize sacroiliac joint, low back. and hip
Facilitate/strengthen gluteus medius (1 leg bridge, PS retraining)

-~-----------------------------

S~

I
~
~

1:


;,

EVlIJUlll;OIl oj Key MOl'cme,,' Plltl<:nl.'"

Altered coordin,llion during hip ahduction (~l;C Fig.. 6.17)

Trigger Points
Gluteus

I1

I
~

I$

tJlcditl~

GltllCUS Illinimll~

Pirifonnis

QL
TFL

Mobility (laim Dy.t!/tJU:lioll)

51

Hip internal rotillion

II is important to I\\~ntion lhe psoas paradox. According

to Janda and Schmidt. the iliorsoa~ normally lkxes Ihe hllllh,ll" ~pinc:I.\ If. h()\\"('\cr. thl.: erector spinae ;.Irc shortened.
the psoas wil! instead :i-Upport the rc~ultant hyperlordo~is. The
hyp... rlord(llk spine Clll he lifted up hy lhe PSOi.IS without
lhe dTol"l or the abdl11llinals (i.e.. polio). The tighta lhe
Cl"l..... lOf spinae. llle l11\lrl' the pSO,lS pawdox is ill clTe<:!. Thu:,.
if the crc<:wrs ;lrt..' tiflll. it is llec...s~;lry t() strctch them as
well as perform .1 p'-... 'Ierior pdvil' lilt before anempting.
trunk cLlrl cxcrcisc~ IN the abdominals. Abdominal cxcr
cisc:, thai <Ire performed with an' ,1l11~rior pelvic lilt or with
the fect held down cnl.our.lgc activation of the hip J1cxors.":.1
Such exercises maximize lumhar compressive alld shear

I
I'
I

!"(lITCS ..I1

TIL ilnd L2/L3

Altered Trullk Flexioll (Table IS. IS!""'"

Trunk Oexion is important for its rdationship to lifting.
trunk st;]bility. standing posture, and spinal statics.
\Vcak agonist: reClus abdominus
Overactive antagonist: erector spinae
Overactive synergist: iliopsoas

Symptoms
Low back or bUllock pain (facet syndrome. inslability) (sec
Fig. 18,1)
Neck pain

Postural Analysis
Increased lumbar lordosis
Protruding abdomen

Gail Allalysis:
Increased lordosis
l~fllsde

Length Tests

Shortened lumbar erector spinae (see Fig. 18.7)

Shortened hip flexors (sec Fig. IS.5)

Evallllllioll of Key Mm'emclIf Pallertl5

Ahercd coordinalion during trunk flexion (sec Fig. 6.18)

Trigger Poillts
Erector spinae (sec Fig. 18.2)

UPPER CROSSED SYNDROME

Muscle imbalances alY~ct the neck i.lnd upper extremity just

as deleteriously .IS they do the low b<lck :.Inc! lower ex
tremity.~/,n..I~ Janda identified :.in upper crossed syndrome wilh typical p~irs of tight :'1110 weak muscles l :
Crable 18.19).
Knowledge of thi:- paltern is ImpQnallt for neck, shoulder.
or upper back conditions rcl:.ltcd to abnormal silting. respiralion. masticmion..md prehension <Jctivilks. Tnble 18.20 provides lhe signs rdated to various dysfunctions associated with
the upper crossed syndrome.
The combined result of this posture is that the ccrvicocranial. ccrvicothoracic. glcnohul11cml. and tcmporol11undibular
joints (TMJ) arc all o\crstrcssed..\.7'~ Joint dysfunction and
trigger points nuturally result from these muscle imbalances.
associated wilh headache, neck pain. shoulder blade pain. and
TMJ and shoulder disordcrs.I:.:I,.~1.~~..l6 Each of the three muscle imbalances that contribute to the upper crossed syndromc
arc discussed in the context of the key movement pattern that
is affected: scapulohumeral rhythm. neck flexion, <lnd trunk
lowering from ~l pushup. Rcspirmion, which is also affected.
is discussed as \l,'cll.

--~

1I

j}

Table 18.19. Upper Crossed Syndrome

Imbalance in the following pairs of muscles:
Weak lower and middle trapezius and short upper trapezius and
levalor scapulae
Weak deep neck llexors and short sUboccipitals and sternocleidomasloid
Weak serratus anterior and short pectoralis major

MobWly (JO;1I1 Dy,'ifIlIlCt;OIl)

Table 18.20. Postural Signs of Upper Crossed Syndrome

Lumbar-spine

Table 18.18. Treatment Approach for Altered Trunk Flexion

Relax/streich erector spinae
Relax/stretch iliopsoas
AdjusVmobilize low back
Facilitate/strengthen abdominals (dead bugs. trunk curls, sit backs)

POSlur31 Finding

Dysfunction

Round shoulders
FOTward-drawn head
COC 1 hyperextension
Elevation 01 shoulders

Shor1ened peclorals
Kyphoti(: upper thoracic spine
Shor1ened suboccipilals
Shortened upper trapezius and levator
scapulae and weak lower and
middle trapezius
Weak serratus anterior

Winging 01 scapUlae

-'

,,

-~,y

- - - - - - - - - - - - - - - - _...... \..,

-..

_._

...

Altered Scapulotlzoracic alld S'capuloJrumcral RIlJtll111

(Table 18,2/)"-',"'''
The scapoluhumcral rhythm is impol1ant for its n::I:Hion*
ship to prehension. rcaching. grasping. and carf),jng aCli\'itics,

365
Taole 18.21. Treatment Approach for Altered
Scapulohumeral Rhythm
Facilitate/strengthen lower and middle trapezius
Relax/stretch upper trapezius and levator scapulae
Relax/stretch subscapularis
':"dj\.tsVmobilize cervicothoracic junction and slernoclavicu
lar joint
3 r eathing correction and ergonomic advice

Weak ;\gonist: lower and middle trapezius

Overactive synergist: upper tmpc.zius. levator sCilpula\..'. and
rholnboids

Sympto/1/s (see

,,,
~

J0.6. 10.7,

(II/(/

10./4)
Table 18.22. Treatment Approach for Altered Neck Flexion

Neck pain

"

,~"
I

Fi.~s.

Relax/stretch sternocleidomastoid
Relax/streich suboccipitals
AdiusVmobilize CO-C 1 and cervicothoracic junclion
Facilitate/slrengthen deep neck flexors
Correct poor sitting pos!ure
Lumbopclvic stabilization exercises

HC:ldachcs

Rotalor cuff syndromes (i.e .. impingement syndrome)

Shoulder blade pain

Postural Allalysis

1
~

Gothic shoulders (sec Fig. 6.25)

Upward rOtillioll of the scapulae

i
~

1::l'alum;(JIl of Key Movement Pall em..,;

Gaif Atwly:..i.c

Altcr~d;.trlll SWillg
Shoulder de-vatian \'::th aml flexion

"

Muscle Lengt" Tesl.5

Shortened upper trapczius 'Hui Iev,Hor scapulae (sec Figs, 6,1

:<

;;md 6,2)

1
l'

I,

z,

valllarion of Key MOI'cmcllt Pallems

Ahcrcd sC<lpulohumeral rhylhm (sc<lpular fixation) (sec Fig, 5.20c)

ParJ.doxical respiration

Trigger Points

;~

Upper. middle. and lower tr<lpczius

Lcv:.JIor sc;;spulac

Subscapularis.
Mastoid process. C2 and C3 aHachmenl points

I,<

i.

Mobility (Joint Dysjimcfioll)

'i
~

Upper cervical

spin~

Ccrvicothor.acic (Crr) junction

Altered Head/Neck Flexioll (Table 18.22Y7,,~,~Ii,!7,.J,'

Head/neck flexion is imponant for its relationship to

Altered (oordilwlioll

dllril~g

lied flexion (see Fig. IS.34)

'/i'iggl!r Paims

SCM
Suboccipitals

Middle trapC7.ius
Maslicalof)' muscles
Mastoid process
MobiliTy (joilll D)'sjtmclirm)

CO-CI and err junction

Lower cervi cui spine
TMJ

Altered Scapular Fixation during Trunk Lowerillg from

a Push-up ITable 18,23)'-',1','"
Scapular fixation is import'lIlt for carrying. pushing. mu.l

pulling activities,
\Vcak agonist: serratus anterior
Ovcr;]cti\'~ ~mtagonist: rhomboids
OvcrJ,cti\'e synergist: upper tmpczius. Icvator st:apl1\;;!e. and
pectoralis major. minor

standing or siuing posture and mastication,

Symptoms

Weak agonist: deep neck flexors

Overactive antagonist: suboccipitals

Overactive synergist: sternocleidomastoid (SCM)

Neck and shoulder blade pain

Rotator cuff syndromes
Ccrvicobruchiul syndrome

Symptoms (see Fig.\'. /8.29 alld /8.3/)

Postural AfWlys{\'

Head'lClte

Neck and shoulder bludc pain

Round \houlders (see Fig, 10.20)

Winged ~c;;splliac (sec Fig. 6.24)

TMJ

Postural AlUllysis
Head-forward posturc (sec Fig. I S.l2)
Prominence of SCM (sec Fig. 6.4)

Muscle Length Tests

Shortened SCM (sec Fig, 18.33)
Shortened suboccipilals

Table 18.23. Treatment Approach (or Altered Trunk

lowering from a Push-Up
Facilitate/strengthen serratus anterior
Relax/stretch pectoralis major and minor
Relax/stretch upper Irapezius
Adjust/mobilize upper thoracic spine
Postural re-educalion

f<

'1

1'c

-~

...,..

CLINICAL APPLICATION OF
REHABIl.IT.HION PROCEDURES

Gail Allalyxis
Winged :;capulae with

;Ifill JlhnCllIClll

Differential Diagnosis of J\tyofasdal Trigger Points and

Joint Dysfunction

Muscle Lel/gth Ti'xts

SI,OrlClled pt:cloralis lIl;\jm {... ~'\.' Fi::. (1.31
Shortcned upper It";lpCJ;ill ..

;llid

k\,:llor scapula\.'

t .. \.,\.

I':i,t:s. (l.J

and 6.21

Ewtfuluhm

(~,. f..('y

Mm'ctl/cllt !'afferl/.,

Altcrcd scapul'lr li.\:llillll

(!'ce Fi~. 6.19)

duril\~

trunk

100vcrill~

(wm a pushup

Trigger Poi",.\"
Pcctmalis lIl;lj{lf
Upper trapezius

levator

~l:apul;lt:

Pel'toralis minor
Mobility (Joilll Oys/wlClio,,)
DCCrl.':t!'cd uppcr thoracic !'pilk' c:\tClIsiml

Respiration (AbNQrmal or /Jarad(JXiclll Uespiratiol/)

(Table /8.24)
Agonist: diaphragm
Overactive ~yncrgist: scalcllcs. imcrcostals, upper trapezius

Symptoms (xee Figs. 10.6 aI/(/ !O.S'

Neck p"in and headaches
Chest wull pain
Thoracic outlet syndromc

iVl)'ofascial Pain Syndromes

If an active trigger point (TP) is found (taut band. twitch
response, + jump sign, referred pain to larget area). lhe approach is as follows 6 '''l\:

Posrtlml Analy:iis
Round shoulders

Evaluation of Key Movement Patterns

1.,.

prcdomillate~

o\'cr abdo-

Trigga Points

SC~llenes

Mobilily (Joi"t Oy.\/WlClioll)

Decreased laleral bcnding and extcnsion of lower cervical spine
Del.:reased lateral excursion of the rib cage

Table 18.24. Treatment Approach for Altered Respiration

Relax/stretch scalenes
Relax/stretch upper trapezius
Facilitate/train diaphragmatic breathing
Adjust/mobilize lower cervicals and thoracic spine

Postural re-education

),

i)

-.j
i

\.)

I. Assess for muscular imbalance

2. Assess for joint dysfunction
1 Identify work or lifestyle factors
4. Aim trclltrncnt ai restoring muscle balance and rcmcdi:lting joint

Forward-dmwn head
Thoi..lcic kyphosis

P:lradoxical breathing (chesl bre:llhing.

minal breathing)

II is dt=ar Ihal l1HISC!t= ;IlKl joint dysfunction are imer-twined, If

you take IlIl' \l-=w th;lt muscles ,Ire responsible for reflex COIllpensations 10 joint Of disk stress, then evcrylhing possible
should be done to feduce joi;H stress before addressing trigger
points. In g~ncral. triggcr points require little directtreatmcnt
(needling. isch~mic compression) if joints are treated first.
Oftell, howcwr the muscle imbalances must be addressed to
prevent joint slress. The proof ~f the success of the therapeutic intervcntion is disappearance of the jump sign on posttreatment checks.
It is still important to be able to differentially diagnosc
Illyofascial from articular sources of palpable tenderness.
Bogduk .1I1d Simons discussed this issue.'" Trigger points sari.\!\' lite lo/lOll"i1l8 (:rilaia: (I) a palpable band with :1 local
twitch response (+ jump sign); (2) reproduction of pain on
palpation of the trigger point: and (3) relief with trigger point
ther'lpy. If a joint is cOl1sidered tlte .WJ1lrc,~ of!Jain, the followillg ,:,-ileria apply: (I) abnormal passive movement, especially of cnd-fecl: (2) reproduction of pain when moving the
joint: and (31 relief with joint anesthesia or manipulation. It is
not possible to differcntiate betwcen joint and muscle sources
on the b3Sis of the location of the pain. Both muscles and
joints can cause local or referred pnin.

dysfunction
5. If treatment fails to eliminate TP use
Ischemic compression (5 to 10 second!' of sufficienl pressure to
recrcate referred pain)
Postisometric relax'ltion
Nutritional or metabolic factors m<lY also undermine success
Rule out fibmlllyalgi<l and corticalization of p~lill (sec
Chapler 2)
F~lcct

and Sacroiliac Syndromes

Manv of Ion back dISorders of the 80% presently labeled

nonspecific are undoubtedly related to problems of the facet
or SI joints. The 51 syndrome is prescnt in 1010 30CJc of patients with chronic low back pain.'~ Unfortunately. anesthetic
blocking technique is the only known way to make the diagnosis. and it has not been correlated with any physical tests.
Similarly. zygaphophyseal joints have been proven 10 be rc~
sponsible for low back puin in at least 15% of pati~nts, al-

{]

i:

"!
~

:",

"'1I.

"01

"
.'

Fig. 16.1. Facet pain. (From McCalllW, Park WM, O'Brien JP: Induced pain referrallrom posterior lumbar elements in normal subjects.
Spine 4:441. 1979.)

~
!

I
I

J,
!

?I

it

\.

Ii

!
)
)

., ..J

L)
S

ill

I
~
W

~
(

~;

ji

I,

I ,) I

1~~
'",'"
\'

though no physical signs have been correlated with anesthetic

relief of pain."l~
Two goals when constructing an appropriate rehabilitation
program for a patient with pain arc as follows: (1) to reduce
stress at 111<11 tissue site. and (2) to improve the ubility of til.1t
tissue to handle stress. Facet syndromes arc likely to correlate
with pathokincsiology involving altered hip extension and
(funk nexioo. Improper loading in the sagitlal plane. especially in a hypcrlordotic individual. would be the probable
pathomcchanics of a facet syndrome. Predictable functional
pathologies affect the hamstrings. hip flexors. and erector
spinac (tightness). erector spinae (poor endurance). glutcus
Illi.lximus. rectus abdominus (weakness), hip joints (hypomobile), and lumbar spine (hypcnllobile). Pain provocation of
the hypcrmobile joints and trigger points (in both the tight and
weak muscles) will be present. Typical flndings include a for\V<lTd~drawn posture (weak glutei and tight hip flexors) and increased lumbar lordosis (tight erector spinae and hip flexors
with weak abdominals and glutei).
Altered hip extension synergy leads to overstress of the
lUl11bm facets because of load tmllsference from the stiff hip
joint to the hypennobilc lumbar spine. Extcnsion of the thigh
occurs through a fulcrum involving the lumbar spine rather
than the hip joinl. Thus, the lumbar extensor muscles, in par~
licular the superficial erector spinae group, become ovcractive during hip extcnsion mOlions, such as gait, standing from
a chair, climbing. and jumping.
Pain referral c.an be exPected from lumbar facet and ereclOr spinae trigger point sources (Figs. 18.1 and 18.2). A for~
ward drawn poslure (sec Fig. 18.3) and erector spinae hypcrIwrhy (Fig. 18.4). as well as lightness of Ihe hip flexors.

Fig. 18.2. Erector spinae trigger points. (From Travel! JG. Simons
DG: Myofascial Pain and Dysfunction: The Trigger Point Manual.
Vol. 1. Ballimore. Williams & Wilkins. 1983.)

---~------------------------------

Rd'lx/ lrl'..:h ill\'ul\"cd crl'l'lnr spinae (Fig. I~.171

Rd".\I lr~l~'h involved !l;l111Slrings (Fig. IS.;S)

Thl.' k('~ i:-: to lind a spc.:t:ilic manipul'lbh:: lesion which reduces pain l'fOvot:.uion (lendcr point or movcmcnt) ~lItd/or fal"ilil;IIC", Ihe "wt:ak lill"" {glutt:us m;lxilllllsl.
EX-':fl.'.";'" fnr illlpn)\"in~ slrt:nglh. endurance. ;:Ind Ikxihilily should .:1 .. \1 h-.: t.:onsidl'f-.:d:
Sdl-str...' kh (or liglll

iliop."~las

iFig. IS.19)

Sdf:-lro..' h'h f(lr li~ht cn:ctur spinal.' (Fig, 1};..201

Self-slreldl fllr light h;lI11strings lpig. IX.21 )
Slrcng.lhl'n ~llllCliS Ill:lximus (Figs. 11';'~210 IS.25)

Squ;lIs :lnd Iungr.:s <Figs. I::L26 and 1:0':'27)

Ellliuranel.' exercise I,)r Imnk eXlension (Fig.. Ilt2X)
Pathokin~si()logy

involving altered trunk ncxiQI1 al~o

the L51S 1 joints because of poor IUlllbopclvic
sl.,biliziltion, Trunk S1<lbiliwlioll through impro\'~d cocll:m.lctiol1 of abdominals an<.1 glutc;ds is essential to preVCI\!
fUrlher lumbar overstrain.
The 51 ~yndromcs <lrc intertwincd with uhcred hip abduction. Weakncss/inhibition of the gluteus 'mcdius will resull in
ill(:r~'lscd lateral shear forces .1CfOSS lhc pelvis. Often. O\.'Cl'activity or :-.hortcning ofthc adductors :Idds torsion to lite pelvis
through the pubic bones, which ,Iggravatcs an SI joim problem. The gluteus mcdius insuffic:icnc)' is .11 sa often <.:ombincd
with pirifomlis ovcractivity. which '1lso C;:IUSCS rotation of the
pelvis and odds [0 the 51 woes. The QL nmy substitutt: for gluteus medius weakncss wilh excessive hip hikilig, 'iih.L ,il()iig
wilh concomilanr lumbar problems. will refer pain into tht: 51
joint from its trigger points.
It is always best to look for dysfunction in the feL'1 when
the glutcu!l mcdius is weak or inhibited. Hyperpron'llion is the
most common problem and with it come many manipulable
()\'crstress~~

Fig. 18.3. For\'larddrawn posture,

,,
,)
,
!
/)

()
i

')

h'lmslrings, and crt.:c1(lr spinac may ht.: prcs~nt (Fi~s. 13.5 to

IS.?). Trunk cxtension should be: rcstc:t1 for lack of elH.1urance

<Fig. IS.S,. The hip cXlcn:"ion movement paucrn may be altered with ovcr'H.:tivily of the ereclor spinae and h'111lstrings
cOllpl~d wirh inhibitillll of th~ ghueu:-; muximus (Fig. 18.91.
Rehabilit<ltion l11:lIlagemcnt includes o.ldvicc. mo.lIlipulation. and e.xcrci",c (sct.: Tahle Ig,7). For a typical facct sytldrolllC. simple ilJvicl.' includes lilc following:

..."

Il\~tnlclioll aboul tl\'l.'rhe'KJ ;telivilics and e"rrying (avuid lumbar

hYP~'n:xtensiul1 by pcrforming ,I poslcri(1r pch'ic till (Fig, '8.1(.11

Instruction ahoul the liSt: or a fOOl SlOt)1 during typical '1('li\,illc., of
~I:lil~' li\'in~ (fig. Is. II)

,-\'oid.mee of Ihe 1~'lll.kIlCY 10 hYrer~'_\.II.'.u.l the.: o:.ll:k Ull(illg l1lall~

\.l'IllIllUn hcahh club o:crt:i",e.:~, such ,IS lhe ",tairclilllbr.:r. sit-lip'"

",t,lllding hip m'l<.:hilll:. l,lIer,11 pulldowll. step :lemhics. hamstring

curls. ;l1ld Cllhcrs er:i~. 18.121
~\'I~l11ipul<ltion (i.e.. adjustmcnl~, !llObilization. Inanual rcsistam:e techni<jlll;S) may address allY of the following func:lional pathologics if pr~sent:

Ci\-rr lumbar spine

~h)hilizchip(rig.

IS.I.1)
1vlvbilize libular head lFig. 11$.14)
Rl'1;tx/slrclt.h iJ1\"lll\-...' d hip rk.'<ors lFi:;:>. IS. IS <.lrllJ l}i.lfl)

._~

__ ._~,

Fig. 16.4. Erector spinae hypertrophy.

...

369

'.,

)
I

,\

, I

,I

Fig. 18.5. Test for shortened hip flexors.

lesions in the talocalcancona\~icular region. Evaluation of the

lower extremity kinetic chain is esscntiallo solving the riddle
of many 51 and [<leet "yndromcs.

function and reduce pathokincsiology acts as a catalyst

for reducing nerve root compression. C<lfC should be taken
to emphasize extension motion of the three-.ioint com-

plex. McKenzie techniques have been l'hown to quickly

Disk Syndromes
Regardless of the C<luse of a clinically signific:ant disk syndrome. the start of relli:lbililJ.tion must wait until conservative
care has succeeded in reducing the irritability or compression
of the nerve root. As soon as nerve tension signs decrease. exercise is highly beneficial (Table 18.25).
Advice to avoid positions of increased inlr~ldi.sc;:i1 pre.s~
sure. such as silting. arc important in thc carly stages
(Fig. 10.1 S). Patient" should also learn (0 avoid any bending Of twisling 11l0\'CIllCnls to which the disk is particuInrly vulncmblc (Fig. 10.5). Manipulation lO improvc joint

t
,
~

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Table 18.25. Disk Protocol

Conservative care until nerve tension signs disappear
Nonweightbearing exercise
Aerobic exercise
Spinal extension mobility
Quadriceps strength/endurance
Traction assistance nonweightbearing exercise
Isometric trunk slabilization
Quadruped, kneeling, ball. standing stabilization exercises
Address muscular imbalances
Seated exercises

nific;lIltly more oftcn in pOSICol1cussional headache patient..;

than in norillal indi\"iduals.~i
Patients who experience morc ~c\"cre hc:ul;lI:hcs (usually
women). ()(;c:lsion.al mig.rainc sufferas. ;md thnsc wilh forehead and eye pain OflCIl ha\'c weakness of their dcep neck
ncxors and loss of lower ccrviGL! extension. Such lilldil1g~
certainly help us g.i\"t.~ affeclcd paticnts;l realistic goal. Result"
arc oft.;n not illllllt'di;\lc. hut:ls he;\{.1 and neck l1exioll coordi

n:Hion

~ll1d

lowcr ccn'i:.::t1

c.';I::n~:i\~:l :11(1hlll[j"

impro\c. Ilh..'

heOldachcs will likely occn::;lse. Any P:lticllt can c1carly SCl,,'

the Lonlleclion between not heing. able to hold their hl:ad
up against gra .... ity with their head nexing too far forward ami
the development of illlractahic headaches. This information
is better received th<ln the suggestion Ih:lt adjustment~
:llonc will do the job. or worse. 'IS sl<ucd by many neurologists
(after brain scans and the like). th'lI there is nothing wrong.
except stress (the p:1l diagnosis
a psychogenic disorder III
explain typical symptoms of l"ullctiomd patholug.y of lllL'
motor system!).
From a rehabilitation perspe~ti\'c. hcadachc syndromes
arc likely to correl<lte with pathokinc~iology i:~n)l\'ing allercd
neck nexion and scapulohul11eral rhythm. Pn::dict<lblc fUI\(,:tional pathologies elffect the SCi\.'1. suhocl:ipitals. uppcr
trapezius. Icv:ltor scapul;lc. ;md pcct(Jr<lb (tightness). decp
neck flexors. lower and middle trapezius.1I1d serratus anterior
(weakness). ccr\'icolhoracic junction (hypol1\obilc). and C4C5 joint (hypcrrnobile). Pain provocation of the hypcfmobik
joints and trigger point5 (in both the light and weak muscles)
is present Typical findings include a slumped. heOluforwaru
posture (weak lower fixators of the scapulae and tight pectom Is) and increased cervicocranial hypcn::xtcnsion (tight
suboccipitals ,lIld SCM with weak deep neck Ilexors).
Altered neck ncxion syncrgy leads to overstress
thc
cervicocmniaJ junction because
the ..ulterior carriage (11"
the hC'ld. Also. the middle to lower cervical region (C4-5 and

or

Fig. 18.6. Test for shortened hamstrings.

centralize symptoms relatcd to nervc root compression (sec

Chapter 12).
Head"che
The variety of types of hC<ldachc includes cervical. myof<.lsl.iaL nutritional. vascular (migraine). other (cluster). The ccrviGil and myof<.lscial hcad<.lchcs arc ;1n1cnable to chiropractic
nnd rehabilitation. Most headache sufferers have chronic or
recurrent symptoms and thus rehabilitation should be included in the chiropractic care of <lny headache paticnt, rcgardless of the degree of cervical or myofascial involvement.
As mentioned prc\'iou~ly. Watson and Trott dcmonstrated that
Illuscle imbalances in lhe neck can distinguish bc(\.. .ccn
chronic.: headache uno non "headache sllfrcrers.~(' Trclcaven
and Jull showed lhat the SiJlllC muscle imbalances occur sig-

or

or

Fig. 18.7. Test for shortened erector spinae.

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Fig. 18.9. Hip hyperextension test.

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Fig. 18.10. a, Incorrect overhead reaching with back hyperextended. b. Correct overhead reaching with posterior pelvic till.

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Fig. 18.11. a, Typical ironing position. b, Use of a fool stool to re~
duce lumbar lordosis.

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Fig. 18.12. Harmful hamstring
exercise.

Fig. 18.13. Post-isometric mobilization of hip joint.

Fig. 18.14. Mobilize fibular head.

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Fig. 18.15. Postisometric relaxation rectus femoris.

Fig. 18.16. Post isometric relaxation iliopsoas.

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Fig. 18.17. Post-isometric relaxation erector spinae.

Fig. 18.18. Postisometric relaxation hamstrings.

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Fig. 18.19. Self-streIch for light iliopsoas.

Fig. 18.20. Self-streIch for light erector spinae.

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Fig. 18.21. Sell-streIch for light hamstrings.

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Fig. 18.22. Basic bridge.

Fig. 18.23. One-leg

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Fig. 18.24. Bridge on the ball.

Fig. 18.25. Superman

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Fig. 18.26. Squat.

Fig. 18.27. Lunge.

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Remcmber. it is time saving to find lhe "key link" which

if manipulated can affect improvement in provocative tests of
the inhibilcd muscle (deep neck ncxors).
'nlc following exercises arc recommended (0 improve
posture ,lIld promote strength, endurnnec. and ncxibilily:

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c~ercise for the deep neck flexors (Fig. IR.43)

Strength/endurance exercise for deep neck Ilcxors and lo\vcr
scapulae stabilizcrs (Fig. 18.44)
Strenglhen lower and middle tr.\pczius (Fig. 18.45)
Lumbopclvic stabi1il.ation exercises (Figs. 18.4610 18.48)
Upper b"ck cat (Fig. 18.49)
Upper lhor.\cic spine eXlcnsion l:trclch (Fig. 18.50)

Postural
Fig. ~ 8.28. Back extensor exercise.

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C5-6) is affected by the flattening of the lower cervical

curve and resultant biomcchanical change in the spinal stability of the cervical spine. Patients experience typical pain
referral from trigger points in the SCM and suboccipitals (Figs. 18.29 and 18.30). Joint sources of referred
pain may also overlap with common referred pain patterns from muscles (Fig. 18.31 ):(1 Some patients may have
a head-forward posture and prominence of the SCM
(Figs. 18.32 and 18.33). as well as tightness of the suboccipitals. pectorals, upper trapezius. and levator scapulae
(sec Chnptcr 6). The neck flexion movement pattern may be
ahered (Fig. 18.34).
Rehabilitation management includes advice. manipulation. and exercise (sec Table 18,7). For a typical headache
syndrome. the paticm is advi~ed !c: !.!s!= :: hcad~et if on lhe
lclcphone for prolonged periods, make available an ergonomic computer workstation (sec Table 10.2). and correct
poor sitting posture (Fig. 18.35).
Manipulalion (adjustments, mobilizalion, manual resistance techniques) involvc the following potcnlial functional
pathologies:
CMT ccrvicocranial and ccrvicothor.lcic junctions
Relax/stretch SCM (Fig. 18,36)
Relax/stretch suboccipit.l1s (Fig. 18.37)
Manuallraction cervical spine (fig. 18.38)

When the scapulohumeral rhythm (SHR) is ahnorm,,1, any

reaching or grasping movement can trigger ~\ he~\(lachc.
Prolonged static overstrain from keyboard or writing work is
also a common culprit. Muscular imbalance involving ovcractivity of the upper trapezius and Icvator scapulae and inhibitcd lower and middle trapezius arc usually responsible.
Upper cervical and cranial ::lttuchmcnts for the upper trapezius
and levator scapulae can become hypersensitive and Iheir
joints become hypcrmobilc. These headache patients sense
most of their pain in the back of the head. but occasionally
they describe pain over the eyes.
Advice about an ergonomic warkst.uion helps immeasurably to improvc SHR. One intcrvention involvcs the usc of
ann rests. which allow the arm to rcst in a relaxed position,
Secondly. the writing surface. typewriter. or keyboard should
be at a height at which the wrists function in their neutral
rnnge. the elbow is flcxed 900 and the shoulder girdle is relaxed (sec Table 10.2). Manipulation should focus on relaxing
the upper trapezius and levator scapulae. Specific joints in the
ccrvicocranial or ccrvicotharacic areas may need adjustment.
Exercises to strengthen the lower fixators of the scapulae are
necessary to avoid further ovcr.activity in the clcvmors of the
shoulder girdle.

'----'

.,:~

Fig, 18.29. StArnocleidamastoid trigger points. (From Travell JG, Simons DG: Myolascial Pain and Dysfunction: The Trigger Point
Manual, Vol. 1. Baltimore, Williams & Wilkins, 1983.)

1-:-----

._

Fig. 18.30. SUboccipital trigger poinls. (From Traveli JG, Simons DG: Myolascial Pain a~d Dysfunction: The Trigger Point Manual.
Vol. 1. Baltimore. Williams & Wilkins, 1983.)

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Fig. 18.31. Referred pain from celVical spine joints. (From Dwyer
A, April C. Boyduk N: Cervical zygapophyseal joint pain pattems:
A study in normal volunteers. Spine 15:453, 1990.)

Fig. 18.32. Head forward posture.

Abnormal "respiration should also be evaluated in all

headache pntients. Those patients with weakness of the deep
neck flexors and upper thoracic kyphosis may have an aggravation of their pain if we adjust their necks too aggressively
or too frequently. As the upper thoracic spine extends more
(and the lumbopelvic junction stabilizes), neck adjustments
will be more successful.

downward shift of the ccrvicOlhoracic junction:I'J~1l f\ccording

to Janda. the ceryicothof:.lcic junction can move as low as
T3n4. This positioning is not biolllcch'lllic.llly sound, and
certainly is unattracliye.
Unfortunatcly, such posture certainly can lead to the lho
racie outlet syndrome (TOS) from scalene anticus or peclOf<Jlis minor entrapment. easily verified by lhe AER (abduction. external rotation, lest of Roos.SI.S~ M:.my "authorities"
say TOS is an example of a psychogenic disorder. yel the dysthcsia is so prcdictil.bly on the pinky and not the thumb sid\?
and is reliably reproduced by the AER test. Indced. its origin
is neurogenic .md not vascul<lr or psychogenic.

Thoracic Outlet and Cervicobrachial Syndromes

Shoulder blade pain. chest pain, ccrvicobrachial syndromcs.
:.md headaches can all come from a forwan.ldrawn head and

 .. _ .. _ ._......... ' ... "I"\I'V'~

377

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Fig. 18.33. Screening test lor sternocleidomastolCl

Fig. 18.34. Altered coordina:ion during

neck flexion.

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Fig. 18.35. Corree! poor sitting posture.

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Fig. 1&.36. Post isometric relaxation sternocleidomastoid.

Advice would include avoiding slumping. cspcci.l!ly

when silting. Manipulative treatment may sian with the pcc~
toralis minor and scalenes, but progresses often to include
middle and lower trapezius raciliwlion. Exercises to improve
posture. strengthen the lo\\'er fixators of the scapulae. stretch
the pectorals and hip ncxors. and stabilize the lumbopclvic
region may be necessary. Improved rC\piralion. hC"lcVncck
flexion coordination. and lower cervical extension mobility
are also esscnti:.l1. Overly cilgcr fleck adjusting may aggr,lvate lhe complaint. especially if the patient has a cervical rib
or \\'eak deep neck flexors. The soundest principle to follow
in TOS involves stabilizing the b.ISC of the spine and improving the mobility of the upper thoracic spine.

Cen'icaJ Acceleration-Deceleration Syndrome

P.;ui~nls who havc suffered Illotor \'chiclc accidents autoIllaticnlly must be considered difTerently from those with

other neck or back complaints. Trauma involves inflammation. and a~ such, treatment follows a slower coursc/'
Rchabilit.ltion C<1Il1101 begin until the "chemical" signs of ill
fiamm"ltion decline and thc pain becomes morc "mechani-

ca'" (sec Tables 2.15 and 2.16). The usc of physical agents
(ultrasound. electrical muscle stimulation. heat. icc. etc.)
may be required until completion of the inflammatory ph,lsc
of soft tissue healing.
Both muscles <.lod joints have becn identified .IS sources
of chronic pain after whiplash injury or concussion. 1(,.~7 From
50 to 70% of patients with chronic ncck pain havc been
shown to have posterior zygapophyseal joint syndrome, If>
Typical muscle imbalances invQlving weakness of deep neck
flexors and tightness of the suboccipitais have been identified
in postconcm.sional hcadache paticntsY
In patients who arc victims of trnuma, it is imporwnt
to be alert to psychosocial problcms that could intcrfere with
a full rcco\:"cry.~- A biobchavioral approach is a nlll:-i.

Fig. 18.37. Postisometric relaxation

suboccipilals.

Fig. 18.38. Post-isometric traction cervical spine.

,,

Overemphasis of the usc of passive means (physical agclUs)

10 treat pain and promote soft tissue healing promote illness
behavior. especially patient dependency. A rch'lbilitation ap
proach should begin as soon as mechanical symptoms pre
dominate over chemical signs of inflammation (radicular
complaint subsides and relief positions other than rest an:
present). The goal of patient education and advice is to reassure the patient aboullhcir overall positive prognosis and Ihe
benefits i1nd safety of carly mobilization and activity.
\Vhen the inflammatory phase is subsiding, within I week
in cases of mild 10 moderate truuma (sec Tables 18.26 and
2.20). aClivc rch<.lbilil<.ltion may proceed. Manipulation may
stan wilh gentle musclc relaxation tlnd joint traction or mobilization procedures. Typical functional pathologies targeted
include overactivity of scalcncs, SCM. upper trapezius, levator scapulac, suboccipitals, and the pectorals. Early rehabilitation efforts should bc directed toward preventing the "programming" of any of these typical muscle imbalances. Gentle
PIR (no strelching) 10 the overactive muscles helps in thb
regard. Gentle mobilizntion, adhering to McKenzie princi-

pies of p~lin ccntT;Jlization. ~lids in restoring the cervical

lordosis.
Early exercises may address the glutcalhlbdominal mu~
des to help maintain the imegrity of lumbopclvic junction.
Stability in this region is crucial because poor trunk stability
or a forward weight-be:.Ifing position inevitably le~l(.Js to cervical overstress. Calf strctching and dorsal cxtension l1exibility exercises (cats, doorway, ball stretches) and strengthening
exercises (back extension on the ball, supenmms) also arc tolerated well in the subacute stage, and should reduce cervical
ovcrstress.
For paticnts in whom excessive muscular guarding is
maintained for more than 2 to 3 weeks, regaining lower ccrvical extension becomes a key to improving o\'erall function.
Adjustments, joint mobilil<uion, and gentle stretching tcchniques arc important in such cases.
The question of resistJncc exercises to the ncck is an important one. Physical therapisls havc advocated that the patient apply isometric resistance to the neck. Recently, chin.l
praetors have begun 10 incmporate resisHlI\c~ exercises to the
neck (i.e.. McdX or Neck Sys programs). Bt:c.H1sc of the inherent instability of the neck. such exercises should not be undertaken unless the patiellt is clearly out of the acute, inflammatory phase; has no periphcralization of symptoms; is' perfonning movements that minimize joint compression (avoid
uncoupk:d movements like side bending with (,'ontralalcral 1'0talion); and has no aggmvalion of local p'lin. MOVCIllCIll patterns described by Janda should be assessed before the st.H1 of
any resistance training, and post-treatmcllt checks should
confirm that incoordinatcd movement patterns have not wor~
cned as a result of overaggressive neck exercises. Pre- .Illd
posHrcmmcnt checks of trigger points should also adjudicate _
the merits of these exercises by clearly showing that sort tissue lendemess is decreasing as a result of the wlining.

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Fig. 18.39. Facilitation 01 the lower fixalors of tile scapulae.

Fig. 18.40. Facilitation of the middle trapezius.

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Fig. 18.41, Facililation of the middle trapezius.

Rotator CulT (Impingement) Syndrome

Imping.:mcnl syndromes in the shoulder represent one of (he
more iruriguing rehabilitation probk:ms. The shoulder girdle
functions as pan of a kinetic chain linking the neck to the
hand. ~lany mus(,;1cs in this region.mach 10 the ccrvic.;;al spine
and thorax: thll .... addn..'ssing the shoul(kr is crucial to many

spin.1I disordl:rs. The shoulder is an inherently lHlstablc

joilll-;l large h<tll and :t small 'Ockcl-in cOlllrast to the hip.
\vhich has many related joints and muscles that acl in COllcert
10 allow a wide v:.tricty of 1ll0\'Clllcnls. \Vhcn we speak abollt
the !'ilwuldcr we should begin by discussing the sc;\pulo~
humeral rhythm (SHR): Especially in cases of impingcmcnt.
in comrast 10 instability. the SHR is tilL: most important fUllc.:lion.1! ph~nomc;na rchued IU clinical problems in the shouldCI'.-t" It rel:'lICs W the movemcnt!\ of Ikxioll. abduction. and
"SGlplil1ll" (scapular plane abduction).

Fig. 18.42. Facilitation of the lower and middle trapezius.

The SHR is the pancrn of joint and muscular aClivity occurring during shoulder 'lbduction and nexion. Its purpos~ is
to kecp the glenoid fossa in a biol11cchanically optimal position !O receive the humeral head. If the ann is internally
rotated (impingemcllt test). abduction will be limited by tile
grc,ller tubercle striking the acromion process and l,'or;lcoacrolllial ligamcnt. Total abduction is 1800 The gkllllhumeral contribution i... 120(.1 :.md the scapulothm:.u.:ic c{)lltrinutioll is 6()o. Thus. there :'Ire two degrees or glcllohulll..:r~11
nHHion r(lr evcry one degree of scaplllolhoracic IlH'lioll. In tllC
first 30(' to 60 0 -thc .selling phase-virtually all mOVC1ll\.':l1t is
glcllo!lulllcml. Afler that ph'lsc. 'lb<.luction occurs roughly
equally hctween the two functional joints. Two other j~lints
also participate in this .symphony 01" motion. tmmcly. til,,' sl..:r1UH.:1'lvicular ;In<.l i,l(;romioclavicular joints.
i\S lhe arm moves into ahduclioll. thc scapula rotalc" upwardly (inferior/medial bordcr 11l0VL:~ iater:.lIly) 10 p()sitipl1

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the glenoid fossa at the proper angle to receive the humeral

head. The serratus anterior. upper trapezius. and lower trape
j'jus help to achieve this movement. Downward rOlation is
promoted by the rhomboid major and lcvalor scapulae. For
the prime abductors of the shoulder-the deltoid and
supraspinatus-to operate near capacity. the trapezius and
serratus anterior must act synergistically. The upward rotation
of the scapulae allows the deltoid and supraspinatus to keep a
proper IcngtlHcnsion rcl:.ltionship. so they do not lose their
strength.

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381

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Exccssiv(' dC"iltion of the shoulder girdle caused by too

much upper trapezius. levator scapulae. and rhomboid activ~
it)'. along with 100 little lower trapezius and latissimus dorsi
activity, GIU:\t.:S impingemellt.
TIlC rchahilitation of shoulder disorders is complex but
n;\\';mling bCI'~llISC of the v<lriety of muscles and joints interacting in a far from str;'lightforward manner. Much more
is involved than just strengthening the rotator cuff muscles
in the manner laid out by orthopedists and their physical
therapisls (in fact. the f<.lmous "empty can" internal rolation scaplion exercise is contraindicated). The key to
success is focusing on thc SHR, as well as joint mobiliza~
liO!.1 and muscle relaxation and training. Muscle stretching aimed ;l[ improving shoulder external rotation (infr:lspinalus. pectoralis major and minor) often facilitates

the rehabilitation. The role of a tight subscapularis (internal rotator) is still import;.tnt. but typically this problem is
of greater concern when assessing the stubborn "frozen
shoulder."
Two new developments in shoulder rehabilitation are
worth noting, The first is the inclusion of proprioscnsory exercises for this !lonweiglllbc<.lringjoinI.J<-~.l\Yall pushes may
be lead to exercises on all fours. The practitioner should
\.....ltch for proper scapular fixation. Patients may then progress
tn tripod positioning and. eventually. the hand may be placcd
on a balance board or other labile surfacc.
The second dcvclopment is the usc of medicinc balls
and a rebounder to plyometrically train the shoulder gir~
dlc.~ Throwing and catching is a simple. fun activity that
can be varied to reintegrate the muscles into a coordinated. stable functioning. The main advantage is that eccentric and concentric actions are combined in this powerful
approach.

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1- - - - - - - - - - - - - -

Hand wt.:'i!!hl~ ,mtl t:abks .Ire m'linst<lys fur shoultkr tr"illin!!. Excrci!'c -tullin!!. avail hk ill a variely of resisl;,uKCS. is
al~u "Ill incxpcnsive-. simph: Ir:lillill~ 1001 r(lr home lise.

Extensor i'vlechanism Disnrc!t'rs of the Knl'e

Knce disonlt.:rs su..: h ;I.... qu'ldrit.:cps (rullllcr"s !\1h..'C) or palell;l1
(jllillpa's kncc) h:mlinilis ,Ire 1.:UlllmUIl .1I1l! t.:\'t':l1tl1i1l1y wind
lip in the surgeon"~ parkir. fI.'losl tr;,u.:!\ing disorders arc CUlllmonly thoughl 10 restlll from an imhalancc bctween the
quadriceps ,\lid the hamstrings. ~:lost likely, Ihc)' also lIlay hc
attributed to btt:rallr;ll.:king 01" the patclla causcd by an overilctivc TFL sllbstilUting for a weak glutcus mcdius. Comlllon
muscular problems asso<.:iated \\'ith knee problems indudc

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Fig. 18.45. Home exercise for middle and lower trapezius.

Fig. 18.46. Posterior and anterior pelvic lilt while Kneeling (butlocks on heels).

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Fig. 18.47. "Dead bug."

Fig. 18.48. Ouadrapcd opposite arm and leg raise.

lighlnl..'sS of Ihe TFL. hip flexors, gastrosolcus, hamstrings.

If th~ glulcu\ I1K'dius is wC~lk, the TFL will only hl..'l..'ol11c

tighler. Ikfon: an iliolihi.d hand friction syndrome de\d(lpS.
km.:e pain can occur. Re:,1. icc, and the usc
1Il1llslcrllidai

adductor:-. <ll1d pirirorl1lis.~~ and weaknt.:ss or the hamstrings

,lIld gluteus mcdius. Proprioscnsory and other bioll1cchanical

faults from the ,"ecl ,Ire also prohlcllwlic. Lumbar spine, as
well :I:' Sl. IalpUufal. ,lilt! hip joint dysfunctions must also bc
;tdllrcssL'll.

or

arui-in!l,11lll11"t\ory

:lgCllts arc nol Ihe solution. Along ",ilh

looking til the fecI. .Iss('ssing lhc glllll..IlS medius for In\\'cr
lilllh 1..'I\1I1rol durin.:; olll..'-k.:; weight he rill~ is e:-.selliial (the

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10 : J4.L. J I Vt:

Ht:HAtilllTATION PROTOCOLS

383

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hip abduction \~S( is an casy screen). The key is not to wait
unlil cartilagt: or meniscus damage occurs or for the surgeon
to pri.IClicc Ihdl' l,ltcr'll rclc~lsc pro<.:cdurc.
Lilllih.:d r.mgc squats and lunges can be <Incmptcd. If .the
tracking docs not allO\\' Ihis 1ll0VCmclll 10 occur painlessly.
several steps arc n::collllllenucd that obviate retreating to open
chain exercises. 51> Streich out the light mllscles. sran pro
prioscnsory balalll.:c training. and facilil<.llC the gluteus
medius. Then. rclUrn (0 squ..us 'lIlU lunges ,tIld gradually increase the depth of knee flexion. The training or functional
range should quickly expand.

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Dizziness
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Bal.anlc Disordcrs

The mOlor ~y"lcm lk'pClld~ Oil appropri,lIc inpul from somalosensory, \cstihul;'lf. ;'lIld \"i:..ual pcripheral alTcrcfll s)'slems.~~~s Without one of these sy.. tcm..... sud\ a!'o in bliiluncss.
b;,i1:.mce ;'IllU equilibrium arc not ..acriliceu. In the event of a
l:onllict belwccn two of the sy~lcms, howcycr. a problem will
cnsue. Classic examples ;'Ire the nausea that dc\"e1ops on a
boat whell lht: vestibule notes the motion hut the fcct <lnd eyes
do not. or when lying on the ,grass on a breezy day \\lith big.
puffy clouds floating by. The skin and vC.'Hiblllc rcgislcr no
movement whilc th(' eyes do. Dizziness or n;'lllsca may result
from such a ~cnsory eonl1il'l. Neck pain or C\'en low back pain
can result jf ~uch ;\ sensory conflict is maintaincd.~' The so-

I
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j

Fig. 18.50, Upper thoracic spine extension stretch.

.J...

matoscnsory affercm system depends on the soles of the feet.

the neck. and the lumbar spine for input.
Lewit studied the rclutionship between ccrvicocr:lI1inl
joint dysfunction and equilibrium problcms,w HalHant"s leSl
is an cssentiul screening tool for finding the cervical dysfunc.
lion and then treating thc related muscles or joints. Postwhiplash injury dizziness is most likely ccrvic;,11 in origin as
well. 6 I.l'! Gugey developed a systematic way of studying the.
connection between the poslural system and the balance system. 5'> Differentiating between primary feCI. lumbar. and cervical disorders is crucial.
Vestibular dysfunction is known to be related to poor
motor development in children. Children with vcstibular
deficits cannol stand in a darkened room (you need two of
three afferent systems to maintain motor function). Longstanding vestibular exercises for the trerltInent of dizzin~ss include thc usc of hammocks and gyill balls lO help train th~
labyrinth <.lnd tracking exercises for the eyes while the hC>1d is

moving.
The visual "'ystcm C;,1I1 be an interesting area in\'oh'cd in
dizzincss or neck pain. Optokinetic reflexes can be trained
(e.g.. lighter pilots and figure skaters). Gagey found that a
mapping error of visual fields often results in increased tension in the upper lr:lpezius. 5') Following correction with special prism;,nic lenses_ the trigger points dissoln~ :-pOIlWneousl)'.
Brandt found that eldcrly indi\'iduals wilh al<.lxia \,.'..\11 b~
Ircateu succc!'.",fully with balance training. I '! Brandt rcponed
th;lt 2 weeks of training led to signitic'll11 impron:mt:nl 9
months later \.'. ithout :'lo)' home maintenance program. Thick
foam is lIsed on the 110m to deprive lhe feet of sensory feedback and the eyes are closed. thus forcing the vcstibuk- and
som:Hosen.. . ory systems to train hard. Similarly. it is possible
to train the eye" and feet by le,lving the eyes open. bll! lipping
the he<ld back (laking the otoliths Ollt of their fUJ1l-lioning
range).
In different ways, bOlh Lewit and Gag.ey reponed on lhe
relationship between the fect. balance. ;,uH.i vestibular probklllS. 5'IN.r-l Lc\\'il ;11"'0 found th,lt corrcclion of a pmhol(lgic

problem involving the. cervical spine plays a role in improv-

ing standing postllwl dysfunctions.'oO Corrcdion involved PIR

to the SCM or masticatory muscles or the COC I joint.
ETHICAL OFFICE PROCEDURES

Soap Notcs
At the initinl examination, be sure 10 rc('ord the: presence. of
any rcd flags. Then. perform the necessary tests to identify
nerve rool or inflammatory conditions. Fimlily. review all po
tential complicating factors (sec Table 18.4). Thc hislOry,
physical examination, and sholl form questionnaires arc all
that is needed to identify these complicating factors. The use
of expensive pathophysiologic diagnostic testing equipmcnt
or seeking special psychologic expertise arc unnecessary.

~~

Our SOAP noles for each paticn! should rcflcci Ihal our

i
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i

I
I

I
I
~
~

II
~

I
I

I
it

management strategy is rehabilitativc rather than traditional.

To 'Iccomplish thi!'i t<l!'ik, the p;:llient"s .mbj(xti\( complaints
arc objectified by recording a visual analog scale and a pain
diagram every 2 weeks. Objective lindings arC' ql!2!'1!ified by
using functional capacity mcasuremcllIs. which arc quantiliable yet incxpensive (sec Chaptcr 5). Even lenderness can be
quantified without needing to purchase an algometer.
Functional changes and results of provocative tests arc noted
so that treatment has some b"1Sis and progress is noted.
Assf.!ssmeflt should indicate the presence of a functional
disorder as opposed to a pathoanatomic problem. The treatment plan should address functional changes naled in the objective section. Active care procedures should be clearly described so they arc not mistaken for passive procedures.

Billing procedures should also renect the use of active approaches. Therapeutic e::ercise (97110) and thel'dpeutic activities (97530). arc excellent examples. Medicolegal repoTts
should clearly state the positive results of orthopedic or neurologic tests along with findings of functional assessment. It
is improper to assume that long-tenn care is Ilccess<ll)' or appropriate for the majority of our "whiplash" patienls.~' Under
our care, mild tmuma should resolve within the samc time
framc as would be expected without any treallnent (6 weeks).
Unless we can demonstratc that a moderate or severe injury is
present, it is hard to justify treatment beyond the time of spon~
taneous symptom resolution.
This statement does not ignore the f'Jet that some patients
take longer to get well. nor docs it imply that symptomatic relief is the only goal; restoring function is an extremely important goal in rehabilitation. According to the Rand rep0rl on
spinal manipulation. if a patient is progressing v,:ith nmnipulative intervelHion. then tremmeot should nol be cut ofLI'.\ This
conclusion is in fact an albatross to insurance adjusters. If.
however. a patient is not making objective improvement. lhcn
manipulative treatment C"1Il be cut off after 2 to 4 \\,-eeks.l'....folo
Be prepared to document the patient's progress and to defend lhe aSSC!'ismcnt with rcsjJt;l;l iu injury scverily. The great-

"i!
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1
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i

_.

". __ ,

....... " ,

............ "

"

..... n

.... "

....... , .....................

est error in the treatment of paticnts suffering motor vchide

:lccidents is the a.~sumption of a moderate to severe injury
when in facl the injury is only mild to modcrate.~' It is diflicult to differentiate between a mild and a moderate injury/'7
Without proper documentation. a mild or mild to moderate injury must be assumed .\ltd. with it. the appropriate type and
duration of carc (TJble 18.26).
[f an insur.mce adjuster or auomey questions your servicc
codes. SOAP noles. or neccssity for active carc. sevcral points
can be raised to legally defend your treatmcnts. Standards of
care or guidelines have emcrged in neuTOl11usculoskclctal
medicine, and this political hot potato has not been a welcome
sight to many practitioners. Guidelines, however, arc an accurate representation of the state of science if not the state of
the art. As such, they arc not meant to be applied \Vilhout exceptions. but to serve as guidelines. These guidelines for care
have been established as a result of review of scientific evidence and. where evidence is !:Icking, expert consensu!'i opin~
ion. Many practitioners arc s.urprised to realizc just how help
ful guidelines can be. In the past, reviewers could SlOp
payment on an insurance claim without good reason. Now,
you can defend your practice and quote the guidelines. There
arc no longer any secrets. which can only work to the advantage of the honest. ethical doctor. Quality assurance is a go"ll
of managed carc. Thus, providers practicing to the highest
standards will be sought.
The Mercy Ccnler Conference was an example in which
such a guideline process occurred.6 Active care wa.'\ dislinguished from passive care in several ways. First. they addressed stages of treatment and their goals (p. 120):
Passive Care

Report Writing

I. Acute intervention

Active Care
I. Rcm()biliwtion

2. Rehabilitation
a. Re~toring slrength and cndurance
b. Incrc"lsing phy<,ical work capacity
3. Lifc:'lylc ~ldapla(iuns

Second. thcy clearly sWlcd lhat aClive carc was essential

(p 110). It is beneficial (0 proceed to rehabililation plmse ~IS
rapidly as possible. and to minimize dependency upon passive forms of trcatJnentfcarc." Again (p 125). "AII cpi!'iodcs of
symptoms that remain un<,:hanged for 2-3 weeks should be
c\'aluatcd for risk factors of pending chronici.ty. Patients at
risk for becoming chronic should have treatment plans altered
to de-cmph:lsizc passivc "arc and rcfocus on active care
approaches."
Table 18.26. Grading Injury Severitr '
Mild

Pain on stress 01 tissue, local tenderness. mild

swelling. no gross instabilily
Moderate = Pain on stress of tissue. generalized and marked tenderness and swelling, mild laxity, no gross instability
Severe = Gross instability. generalized swelling, disruption ollis
sue, sometimes minimal pain
=:

',,)

385

Th~ British St;mdarus Advisory Group for Back Pain sim~

llarly slalcd thm <ll.:livc rare \\,<\s a distinct and impor1ant type.;
or case lll:lnagcJ\\clll.: On page 38, "At prescnt, the main em-

or

phasis physical therapy fOf back pain is on symptomatic relief or pain. despite e\'idence thallll<lny of the modalities used
an: incffective. Symptomatic measures to control pain are fClluin:d hill lhis should be lIscd to embark on active rehabilitalion rather than he seen as an end in itself:' TIley went on to
state (p 46) "We recommend.... There should be a change of
clllph~lSis ,111<..1 rcdin::ction of resources from symptomatic

treatment. to the provision of active rehabilitation and patient

education...
The American guidelines from AHCPR were emphatic
in their criticism of physical agents: "Physical modalities
such as massage. diathermy. ultrasound. biofeedback. and
tr~tnscutaneous electrical nerve stimulati~n (TENS) also
have nu pruvell efficacy in the treatment of acute low back
symptoms.
COIl\'illcing scientific evidence is beginning to emerge
ahollt the usc of active c~rc before the chronic stage. Refer to
Chilptcr I for a full revicw, including the topic of chronic
carc. Linton dcmonstrated that carly aggressive treatment (p'l~
Iienl education. exercise instruction. physical therapy) WOlS
superior to traditional treatment approaches (rest and analgesics without physical therapy for 3 months). "Properly ad~
ministered Eurl)' Activc Intervention may therefore decrease
sick leavc and prevent chronic problems. thus saving considerable rcsourccs. hS This study is particularly powerful in lhat
the risk of dcvcloping chronic pain was eight times lower in
the early active intervention group than in the traditional
group.
In a comparative study of passive physical therapy versus
rehabilitmion. Mitchell found. "Active exercises to provide
mobility. muscle strengthening. and work conditioning lUIS
shown superior results ... substantial saviofs have been real~
izcd in the number of days absent from work .md savings in
the dollars expended for compensation benefits. There WaS an
initial incrca~c in health care costs resulting fromlhc intensity
of the treatment. but these costs were morc than offsct by savings in wage loss CO;-;.."/I.I
Lindstrom ct al compared a group of patients trealed with
exercises and education to a marc traditionally treated control
group <lnd documcrHed earlier return to work and decreased
rc-injury in the rehabilitation group.111 The notion that active
exercise can be harmful to an individual experiencing pain is
incorrcct. Guided exercise by a properly truined rehabilitation
specialist is the optimal treatment program for lhe subacute
population. A key is exercising to a preestablished quota
rather than to a pain Iimit.~71 Waddell stated. "There is no cvidence that activity is harmful and, contrary to common belief, it docs not necessarily even aggravate the pain."n
Saal and S~l<Il trcated a group of patients who had back
and kg pain ilnd were referred for surgery. They concluded
"All patients had undergone an aggressive physical rehabililation program consisting of back school and stabilization exercise training ... 92% return to work ratc.".,.1 Act::~ :-ehabil-

itatian is esscntial for all palients, including those considered

candidates for surgery. Saal and Saal said, "Failure of passive
nonopcrarive treatment is not sufficient for the decision to 01'crmc:' In it randomized, controlled trial looking at exercise
and passive care in failed back surgeI)' patients. Tim1l1 found
that 100\-tcchnologic exercises (stabiliz'ltion and McKclli'.ie)
were of greater benefit thiln were high-tcchnologil.: exercises
(Cybcx). physicalmcthods. or joint mobilization. 7-4
CONCLUSION
Rehabililation is .m exciting new way to practice. This paradigm allows us to evaluate regional conditions in light of dysfunction in lhe entire locomotor system. It is also a highly ethical way 10 practice because it reduces patient dependency on
passivc. pain-relieving approaches while leaching patients the
sclf-treHtlllent techniques needed to develop control over their
symptoms. By focusing on functional restoration (instead of
promotion of tissue healing). we can achieve quicker and
more lasting results with spinal adjuslments. b~'cause we are
:ldd... ::~:-.:ng tl1:: underlying cause of most pain syndrornc~.
Future neuromusculoskeletal specialists will not only bc expens in manipulation. but also know how to transition from
passivc to active care. and evaluate the biobch;l\'ioral component of musculoskelet'll illness. Improved results in our practices and accompanying cost savings in the health care system
will be rcalized by the improved managcmelll afforded by the
new rehabilitation paradigm.
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~8_

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59. Gagc)' Pr-.1; PO"lllf,,-1 disordcrs among workcrs Oil huilllill~ sill'S. In Bks
W. Orandt T h.-d,': Disordcrs of Posture and Gait. New York. Els\.'vicr
Science.. 1%6
60. LCW!1 K: Dj,tud:...:d balafl~'e Jlle If,) 1c_~ilJll.' or the cr;miol'ervical jllll"'li"lll.
J Onhop r-.lcd 3::'8. 1988.
61. Odk\'isl I. Odb i~t LM: Phys;othcrJpy in \cni!=\l. Ael3 Otolaryn,;:t1\
Suppl (Stockh! ":55:74. 1985.
62. B(lf:UCI J. 1\-'loofe :So B()i,~l1larc F. et al: Vertigo ill Pos!concu.~.~i()nal :llIti
llIigr;linl' p:Jticnb: llllplie;ltioll of thc autonomic Ilcrvous S)"SI~Ill.
Aggrcssologie ~J:2)5. 198J.
63. Brandt T. Krufczyk S. Malshcndend I: I'o\lural imto"l:lIlcc wilh he:ld \.\tension: ImpRlH:ment by tr.linillt " .. a model fllr ataxia therapy. Alln;,\Y
Acad Sci :636. 1\18 t.
64. G;*cy I'M: :"on\-eslibul:lr diaillcs~ ;md "Ialit: postumgraph)'..\\Ia
O\(lrhillolar~n{J1 Belg 45:335. 1991.
65_ Shekel Ie PG...\d;Jffis AU, Ch;l... ~in MR. el al: Spin:.l Illanipulalinn f\lr
kl\v-back p~ill ...\nn Intern Metl 117:59IJ, 1992.
66. Shekcllc PG: Spine updale: Spill:11 manipul<lti\1\1. Spine 19:H5~. 1991.
67. Co:\ JS: Injury rlorncnc!:lturt::. Am J Srons Med 7:211. 1979_

fiX. Linlon 51. Hellsillg, AL, Andersson D: A controlled study of the effects
or an early intervention Oil <lcute musculo~:":cletal pain problems. Pain
54:353.1993.
NJ. Mitchell RI, Cmllcn Glvl: Results of a multicenter trial using an intensin:: active exercise prog,ram for the tre,llmen! of acute soft tissue and
ba<:k injuries. Spine 15:514, 1990.
70. Lindstrom A, Ohlund C. Eek C, el ,II: Activation of subacute low back
p:llicnls. Phys Thl.'r ::'93. 1992,

71. Fordyce WE, Fowler RS, Lehmann JF. et al: Operant c0!:ditioni;:;; in :~:~
treatment of chronic pain, Arch Phys rvlcd Rehabil 54:399. 1973.
72. W,lddell G: A new clinical model for the treatlllellt of lOW-hack pain.
Spine 12:634. 1987. ."
73. Sa,ll JA. Saal JS: Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy, Spine 14:431, 1989.
74. Tillltl\ KE: A ralldomilcd-colllrol sltldy of activc :llld passive trc;ltnl\.'nts
for chronit: low bJck p:lin rollowing L5,

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ASPECTS OF REHABILITATION

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19 Psychosocial Factors in Chronic Pain

GEORGE E. BECKER

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----------------------------_._-Psychological .md physical ["clors arc incxlricably involved

anti imcrrdatcd in virtually every case of chronic back pain.'
The art of healing begins with recognition of the se\'eral dc
tcrminants of chronic back pain, and 1Il1dcrst<lnding tlmt a
good mall)' of them ;ue totally unrecognized .lI1d outside of
the conscious aW;lrcncss of the paticlll. The goals of this chap'
ter arc as follows:
to define

:-;OTllC

of the terms helpful in describing alld understand

ing the patient with a chronic back pain syndrome

10 describe those charilclcrislics lhilt will alert the clinician and en
able COlrl)' recognition of tht prohkm'lIic patient
10 review <I comprehensive hislo')' format encompassing psychosocial ;IS well as biological issues
to dc~cribc thc Jdjuncti\'c diagnostic usc of sclc=clcd ps)'chologic;\1
tesls
to rcvicw trc~ltlllcnt strategic::. for helping this extremely challenging and orlcn frustr~lIing grollp of p:tlicnts

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The notion of a mutual intcraction bctween mind and

body in health ..IS well as in illness is not ncw. It is likely
that some of the miraculous cures ascribed to the man Jesus
in the New Testament <.Illest to his charisma .lIld the empowcnncnt transmitted through him to the unheahhy believer.
(Clearly all healers possess the ability 10 empower patients
with whom they have established a healing relationship or
therapeutic working alliance.) In the seventeenth century.
Sydenham recognized and described syndromes [hat. despite the outward appearance of physical maladies. in reality
were related 10 identifiable, heavily emotionally charged life
event.s and circumstances_ He described but did not name
sOl1latiwtitm. which is the experience and expression of psychological stress and connict in physic;:i1 rather than in emOtional terms. Bunon latcr described the physical (somatic)
and hypochondriacal preoccupation that today is a recognized
concomitant of mood and anxiety disorders. Almost a half
century ago. and long beforc the popularization of the holh;
tic approach to h~alth and illness. Alexander: wrote: "Onc~
<lg<lin. the patient as a human being \I.'ith worries, fears, hopes,
and despairs, as an indivisibk whole .lIld not merely tltt.'
bearer of organs
of a diseased liver or stomach ... is
becoming the legitimate object of medical interest. In the
last two dec'ldes incrc'lsing ,Ittention has bccn paid to thl.'
causative role of cmotionnl factors in disc'ISC." Brown ,md
colleagues\ wrote an insi.ghtful landmark paper identifying six striking charactcristics appc<lring repeatedly in "
number of patients 111,lI1ifesting obvious functional overlay_

Th::...e characleristic.. inclmk: (I) ,-ague history, confused

(hronology. or illtfOUlH.::tioll of matcrial ostensihly h;n-ing
nothing to lIn ",ith the injury and SYlllptOIll!: (2) ~:fpressiol1
of OpCIl or veiled rcsclltlllCIl! low.lIll Gll\'~I<lkers hecausc
of alleged mismanagemcnt and Ilegkd: (:;) dl':lmatil: dl,.'scriplions 01" the symptoms and thc p;l1icnt's rcactions 10
them: (4) difficulty in 100::lli'l."tioll and description of pain and
other symptoms ... or a complaint of p;lin in lllallY arc:!:--.
obscuring ;1 pain that might originally have. had an ana
tomie focus: (5) f:'lilurc of the usual forms of treatlllent to
gi\"(; sigl1ilh:'1111 relid of pain: ,1Ild (6) Olccompanying neurotic symptoms: acute and chronic 'lllxicty. insomni'l. irritability. prcssure-like hC<lda<:hcs. deprcssion. crying spell:--.
chronic fatiguc. aClIte anxiety atla... ks or chronic anxiety
and pcculiar gaits suggesting hysteria_ Al Ihc samc tilllC'.
thes~ authors ullderscored the faci that ill 12 of 12 1';\.
tiCllts, the "clinical picture \vas frolll hoth somatogenic
and psychogcnic causes:' Thl; first sentencc of this charter is meant to dispel once and for all the either or
notion-that chronic pain is of either org'lI1ic.: or psychogcl1ii.
origin.

DISABILITY AND CHRONIC PAIN

The problem of chronic pain and uis;.Jbility. which is gro\\"il1~
...t an a"!fIning r.ltc, has rc"ched gargantu'lI1 proportions and i:,
;lssoci:.ucd with aSlronomical costs for health l'ar~, Work~r=,
Compensation, and physical injury_ in 19S5. r:rymoycr lind
Gordon~ wrotc that low back pain disabkd 5.4 millil'll
Amcric'llls each year and cost at least S I (1 billion annually. {n
1992, Ford\ reported th.1t .It least \o(iO 01" :.l1lmcdical'surgh:;11
patients have /10 objective t'\'ide/lce of phy:dcal disease_ {The
,lUthor's cxp~ricncc suggests (hm 10% is a low cstill1at~"1
Lipowski l described an evcn higher percelltage of functional
illness. especially depression. among patients prescllling ((I
primary carc providers with physical, nol psychological. ('Olllplaints. The messagc is clear: depresscd ami otherwise p=,y.
chologically unwell pcrsons frequcntly de,) nOI rccognil_c Ihe
psychological nature of their problem. In f<lL'L they usually
deny vchclllclHly any psychological or clIllHional L1imcnsk'n
in their clinical picture. Their massive uCllial. lack of insight.
and resistallce to accepting and ~onrn.lllling psycholog.ical
factors involvcd in their chronic pain makes Ihem p;;Jl1icularly
difficult to IrC'It.
Thc faL'! that .WJl1lmi:.e,..\" often !!o wccks. momhs, or C\-l,."11
years with ;\11 incorrect diag.nosis a~ld ongoing disability indi391

cates thal somclhim! is wrong wilh our appro,ldl lO cllnmic

pain. Misdiagnosis ~f lhe ~oll1atiz~r is thi,; ineviwble precursor to prolonged and ineffectivc tn:allllcni. and frequclltly to
lllultiple and inappropriate chcmical. elcctrical. and imaging
studies: inappropri:Hc mcdic ..llions. induding ll<.lfcotics
(which frequcntly compound the prohlem); or. worse yet. to
invasive procedurc$. including surgical intervcntion. After
(lvcr 40 ye:lrs of experience caring for bac.:k pain. it is dear to
this author that ,mrgay i,\" rarely i/ldicmccl. ~,tost ''failed
backs" arc found in unfortunate indi\"iduals who should never
have hud surgery in the first place. or who, necding sllrgery.
did not have the right procedure at the right timc and ;,It lhc
righllevel. Frymoyer 1 states thut the "failed surg.ical back" is
usually the result of poor surgical judgmenl.
TIle purpose of this chapter is to .describe and dclinc the
dynamic and psychosocial issues involved wjth ;'lntl frc~
quently fueling chronic pain syndromes, to rC\'icw Iho:-oc
presenting signs and symptoms that should alert the astute
clioician to the issue of functional o\'erlay, (0 outline bricny"
comprehensive hislory format. to review the adjunctive
usc of psychological testing, and to describe management
stmtcgies for this frustrating and often passivc. rcsistant. and
noncompliant group of paticnts. Typically, many of thcse patients simultaneously proclaim ardently how much they wanl
to get better while conveying, with their mixcd~message behavior. that they really are going to (and unconsciously wish
to) remain disabled. Timely recognition and appropriate treatment of the chronic back pain patient not only is cost effective, but also ultimately benefits the doctor spiritually and ma~
terially. In the highly scrutinized health care environment of
today. the practitioner must cSlablish a reputation for the kind
of comprehensive treatment protocol that gets !J0lieflfs back
to work (am/to life ill full) and keep., them there.

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bcing dis.ahk'J. On..' doL'S nOl1k'cd;1 proks:-oional tkgrcc to

understand thaI ;~ i~l'r.;()n :-ouing ror an illjury-rclatcd disahility
willles:-o likely pr\~lit linallcially it"lhc disability rcsol\'es. Thi:-o
~itt1atinn kilds n:ltur~llIy 10 a cOI\~idL"r,llinn of gain (scc suhsl.>
ljUCI\! section).

\111

COll1pliallrt
Some patient:- f~lil hI ((,Imply wilh trc,lll1lt,'llt regilll(lls tksiglled for their r.;:lh:liL This f;tilufl: may hest he ulHkrstood
as an illlpeuilllelli h_~ or as UlKolhL'ious fesistallo: 10 healing..
These lInfor1Ullat~ sOllls. for reasons they themselvcs ran:ly
understand :md llf which they usually arc un:lW:lrc. Il('('t! to he
in pain. /1('c'(/ 10 ~\IITa. /1('('(( to rccllikc powcr1css victims. i111tL ~
Il('rd to he cared for \\';111(",1 foxing fact'. Olhers. a smaller
subsct. arc at k~l ... t partially ;\\\';11\' or their motivcs: They exhibit pain behavior fllClcl.l by anger. n:sclltl1l..;llI, or ;1 wi:-;ll 10
rcwhate.
Denial
Individu::i1s who !'onwlize typic;lIly deny that they ;Ire cxpcri~
cncing signific<.Jnl emotional or psychological stress. much as
an alcoholic dcnic:s having a problem with <llcohol. Denial
blinds an im.li\idual to the psychological problem and pre~
eludes insight. Denial can and frequi,;ntly does constitute a
tremendous barrier to recovery.

Depression

Several terms and concepts frequently encountered in the

chronic pain vocabulary arc defincd or discusscd in the following section.

Many persons who arc deprcs:-ocd neilher look nor feel depressed. If <.IS ked <.Jbout their mood. thc)' will deny <.Ieprcssion.
Instead. they exhibit chronic pain <often chronic b;,\ck pain} or
other somatic complaints. :'lS an ;llitill/lIllIllUt'-"llIlicJIl of their
depression:J often deluding Ihe well-intentioned doctor. Their
pain allows them to seck and to receivc IllcdicallchiropraLtic
care and anemion while simult<.tneously denying Ihe mood
disorder and onen [he life strcss. Ch"IOS. and conn il.:l fueling. it.
Emolion<.ll neediness is a hallmark of depression. UnfOrltlnately. the unrecognized depression remains untreated.

Alexithymia

Dreams

TERMS AND CONCEPTS

Sifneoss coined this tcrm to describc those individuals who

(literally) have no words for their feelings. Lex is the Greek
r~ meaning word. ~he thymus is the g'-Iand thought by the
vnclcnts to he the seal' of the emotions. hence Ihymia. Persons
troubled by aICXilh)lliia. i.ither than recognizing their innermost feelings. bury and deny them only to have them surface
as physical symptoms that seem to. but do not. have ::1 physical basis.

Compensation and Litigation

If the benefits (or potential benefits in fantasy) derived from
staying ill outweigh the bencfits of regaining health, the p'lricllt will not Iikcly gct well. It is gcncmlly recognized in the
healing professions that some patients seem clearly (0 thrive

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Dreams havc been described as-:tilC to,",,,/ mad to the lCIl('CJ1/sciou.... ,o.:ccrtainly. thc dreams ~)f patients oftcn rev~al ('in
their sYmbolism) conflicts. fears. and wi:-ohes tiwI lie buried
outside of conscious'-a\varcncss. They Illay crard). issues <:011stitutiilg'b::uTIers to recovery.

Fear
At a conscious Ic\"cl, fe;.Ir fre<.]uently bespeaks a wish at all llllconscious level. particul<.trly in th~. p~!!i~J}J .. \..Y.h.Q~.ejl~.til.l!lS-;llld
words signalj~JlQUbk..Quamn!~.l!lL!~::~"<tge ..

Functional Overlay
This vcnerable tcrm in the 1l11.:dical vernacular is not part of
official mcdical nomcndalUre. Nonetheless. it is useful in

_____________________________________________..ci.

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I eM 1::1 : .... ::iY(.;HOSOC1AL

393

FACTORS IN CHRONIC PAIN

describing (hose nonphysical (i.c., psychological and emo

Lional) f3clors lhat color th~ way in which patients present
thcl11sch"es. It is also accurate bCC<llIsc it docs not su!.!uCSl :In
either/or dicholomy between physical :lJld psych~;iogi(:t1
symplOllls.

walll and nCL'd til be carcd foro-or lovcd. Thus. the double
Illcssa,::e Ihat iJcmilics the: ~oJ11tltil.er. These patients. in their
passiyit~. :Irc oftcn misllnderstood as poorly motiYilted. The
dinician "h\\uld remain mindful thilt ;\Ctions speak louder
thall \\'\\rd:-.. :tnJ underst:llId that what appcar~ 10 bL: poor 1110tivatil'l1 11l~IY in n.:ality he a powerful (uncollscious) cOlllliclo

Guin

For pr;u":li(al pllrposcs. gain can be thought of as primary.

Se'C'

ol/tlm:\', and Tl'I'Tiary.

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PRIMARY GAIN

Primary gain addresses psychological needs: bcin2 taken care

of while feeling independent. Primary gain is entirely within
the individual. and involves self image and self esteem. Il allows the disabled person to deny passivc dependency. because
the illncss (i.e., the back condition) is forcing the dependency
and, bUl for it, the patient would be an independent and rcsponsible member of society. The person unablc to work because of dis~bi1ity can see him- or herself as absolved of responsibility by the illness, which is not their fault.
SECONDARY GAIN

This term describes those material benclits (special attenLion.

care taking. sick leave. relicf from some if not all responsibilities to others such as alimony or child support payments.
compensation payments. awards. ongoing payments from dis
ability carriers. and the like) derived from oUlside the individual. The ministrations of othcrs to one who is disablcd arc
secGildary gains. Although sccondary gain figures prominently in chronic pain syndromes. it is often not 41S potent :.l
force as primary gain.
TERTIARY GAIN

This relatively new teml describes those material and psy

chological gains enjoyed by those caring for the disabled onc.
The spouse may have a need to be a caretaker. the I.\wyer may
havc a need to kcep the patient disabled and out of work (0
maximize winnings. a doctor may need to keep the patient dependcnt on ongoing care and manipulation (in more than one
sense) rathcr than to teach the patient self-sufficiency. and the
psychiatrist may nurture ongoing passive dcpendcncy for
considerations that have liule to do with the welfare of the patient. Tertiary gain usually involves a conflict of interest. all
issue that behooves all hcalLh care and legal providers to self
monilor.
Motivation
Vinually all patients state that they want nothing more than to
get belter. Most of them do want to gct bettc; and most of
thcm do get better. The rcmaining fe~v. however. with their
ongoing complaints of polin and their problematic behavior.
bespeak a conflict of which they havc littlc if any 'lwarencss:
consciollsly, they wanl to get bctter. but ,,,,consciollsly. they

Parallel History
The parallcl history is th~ r~( ord or important psychosocial
evcnts and circumstanccs e perienced during and bcfore
tho~e lypically indutlctl in the history of present condition. II
When vic\\'cd against the b;lckdrop ,-)f the formativc YC;lrs. th~
parallel history often makes clear the C\'Cllls and circumstances that may bc fucling ;1 chronic pain syndrome ill the
vulncmblc persoll.
Somati7.ation
Somatization is lhe expression of unconscious feelings and
emotions in physical rather than emotional terms. The somatizing patient. believing \vith a conviction of delusional proportion that his or her symptoms arc solcly and totally of
physical origin. typic;;l1ly seeks medical rather than ps)'chi.uric carc.'~ Unfonunatcly this con\'iction often leads the unsuspecting doctor to inappropriate and rather far-nung diagnoses and equally in'lppropriule and unsuccessful treatment.
Somatization Diathesis
C~rtain

individuals. clllotiorwlly sh()l1~changcd or scarred

during their formative years. evidence a proclivity to somalize in the face of strcssful urltow;lrd events or circumstances
of adult lifc. espccially onc~ that awaken fc~lings buried in
the unconscious and rooted in the p.\st. These individuals ;'Ire
said to harbor a JOII!(lt;z.atio/l dial//('...;s. I

RECOCi\ITIOi\
It is proverbially true that if one chinks of the right diagnosis.
onc willlikcly make the right diagnosis. Nowhere is this morc
apt than in the recognition of back pain complicated and col
orcd by ps)'chologicol1 factors. Unfortunately. even tOday.
ill.lIlY textbooks fail to include a discussion of psychological
faclOrs as the)' apply to chronic musculoskelctal symptoms.
including neck. shoulder. and back pain. The aim of this section is to spotlight the characteristics of this group of r~HicIlIS;
to olltline an interview format helpful in identifying the 111. and
to review the use of the Pain Drawing. the Minnesow Multi
Phasicz, and other select psychologic:lI tests.

Red Flags
The following listing of reel JllIg.,-signs. symplol1b-. and
other clucs that alert lhe clinician lO the likelihood (hal psychological and emotional factors ligurc significantly in the
clinical prescntationl-arc 'lrrangcd in groups relkeling his-

Ht:.nl-l.OILI 11-1.1 IUI'l u r Inc "ru'lt:.: H. r'HH.l,.. 1IIIUI'lt:.H v

tory, psychosocial issucs. disturballCl:S 01 mood. and l:xamination findings.

RED FLAGS I (HISTORY)

Vague, inconsistellL and implausibh,' history of illjur~. (l(lell lIll

witnessed
Symptoms that pwlifcratc from (Inc body arca (ll' SY:;ll'!ll \II :;cveral, often culminating in tolal botly pain
Highly emotionally charged pain descriptors: torturing, .;ufrocating, cutting, wrelched, blinding, exhausting, scaring . .;caltlin);.
stabbing, wrenching, punishing, gruding. cruel, vicious. I~elletrat
ing, piercing, terrifying, fearful. crushing, gnawing. !lnunding.,
beating, and the like
Obvious hyperbole in history: "... I couldn't ll111ve .. ,my kg:;
collapsed ... I was numb all over . . I couldn't or can't dn anything ..."
Obvious discrepancies during evaluation: the patient \\ 110 reports
an inability to sit for more than 10 minutes but sits for an hour or
more relating the history
A lengthy history of life-long hard work and responsibility with a
professed desire to return to work. which, unfortunalely. is llOW
precluded by pain
Marked passivity, inappropriate activity curtailment. fr~quelltly
with concomitant weight gain illid marked physical deconJilioning
Accept.H1CC of disabled status: "l'vc just 1cmned to accqll m), limitations."
History that only narcotics afford pain relief. with gradually esca"
lating narcotic usc
RED FLAGS II (PSYCHOSOCIAL ISSUES)

Externalizing responsibility or blame for occupational. r~lation

ship, mood, or financial problcms
Emotional constriction: keeping feelings inside
Tearfulness or weeping during interview
Denial that the manifest somatic problem is in any way related to
life events and circumstances, except to blame life failures on the
purported physical illness: (e.g., "but for my back pain. cvcrything
would be A-okay")
A verbalized fear of ongoing disability. Such aiNu' frequently represents un unconscious wish to be taken cure of. especially in persons emotionally short-changed in their youth.
RED FLAGS III (DISTURBANCES OF MOOD)

Dissatisfaction or frustration with job or anger at a boss

or doctars frequently represents unrecognized (displaced) anger at
parcnting ligures, which mllY culminatc in verbalized resentment
at the way the claim is handled, the way a disability is (not) accommodated, ar the way treatment is rendered
Failure of reasonable treatments, in the face of which patients lIlay
report worsening symptoms. Such failures may reflect resentment
at authority figurcs displaced from parents or supervisors onlo the
unsuspecting and often bewildered doctor.
The doctor begins to sense his {)f her own anger directed at the pa+
tien!. This "countcrtransference" frequciltly signals thc passive-aggressive behavior of a smiling, manifestly compliant. but latemly
angry ar enmged person. TIle challenge for the doctor is then to
rccognize his or hcr feelings to bettcr control behavior. It is :I
grievous error for the doctor!o return in kind tbe anger of passiveaggressive patients.

IV1H.I'lU/-\L

\'i:;itillg Cl1\erg~lll:Y r,"lms ror narcotics. escalating drug needs, inakohul ;lbu'L'. Ill' gaining weight may represellt a thinly
\eikd elliotillnal hun;a and neediness in concert \vith <I proclivity
hl address til;\! lIull;L'r \\ itll drugs or fond

~TL'asing

R::D FLAGS IV (EXAr.Pi,...T10N FINDINGS)

Tht,'alricl! ]lI'<.'s\nl;1111 ,1 walkin~, wilh all llhvio\1sly Ulllll:ccss;lry

I.allc (often carried in lhl' \\T\ln~ hand), a strange limp, or main\,lining a bizarrc po"turl'
\'\)(lanatolllic sens\'r~ lindings. such as glove~slOckillg or half
nndy bypesthesia
\'\lnanatolllic lI\otur tilldings, such :is giveway weakness on musde h:sting or Ol1lOe llr hed walking, or oh~vio\1sly suboptimal grip
alleillpts
Significant diffen:rKt: bet\vcell observed and formally tested
r;lI1ges of motion
Significant difference >d\veell straight-leg raising ill sitting versus
recumbent postures
Inappropriate ccrvio.l compression lest (e.g.. causing low back
pain or causing legs 10 give way)
Inappropriate \vithdrawal {)f exagger:.ned tenderness response on
gentle palpation or percllssion, especially if the paliellt grabs thl:
(',aminer's hand in th~'atrical fashion
1

:"lone of this information is n::ally new. In 1940.

Fctlennanl,l identified symptoms. including dramatic pain descriptors. preoccupation with pain, fcar of increasing helplessness, and lhe utility (i.e .. secondary gain) of the symptoms. that have a "neurotic ring." More recently, WaddcIP-lI.~
described physical signs and symptoms that bespeak functional overlay. In essence. when the examiner encounters any
of these red flags, he or she should document them and make
an anempt to account for them. All too often. they arc mentioned in a medical report. only to be ignored in the discussion of findings. En',-yt!tillg in a comprehensive evaluation
has meaning.

Depression
Eighty percent of persons suffering from depression art?
evaluated by primary care providers: chiropractors, ram~
ily physicians, intcrnists.(' These patients usually do not
realize that they <Ire depressed, because their particular
kind of depression is manifest by lJhvsica! SVfIlO!O!!)S
rather than by a wood r!iI''''''/'WlCC. Back-pain frequently is
an initial manifestation of depression.(The patient whose
depression prog~~-.:~.~~_~()~?~~~~.~,~~I inic'all y cvident YI1~~r
standably (albeit usually incorrectly) concl.uQ.Q.;i-!.b.m_lb_~~
depreSSion was caused by the chronic pail~ Terms such
as dejJressimr-wirhorw71iY7Jres.\!(J!l, masked depressioll, and
paifl w' a depression equil'a/ellt have been used to describe
this particular group of patients. Othcr common somatic
symptoms of depression are headaches, fatigue (including
pseudo-chronic .((ltjg/ie syndrome), weakness, shortness of
breath, dizziness, palpitations, gastrointestinal complaints
such as nausea and diarrhea, parcsthcsias, blurred vision,
ternporomandibul<lr joint problems, ringing in the cars.
diminished libido andfor sexual dysfunction, and gen-

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rKv 1 un,;:) 11'1 \.;nnVI\llv ,...... 11\1

~[':lli/l'd pain (including pscudo-JilmllllY(llgia or filnomyosi-

tis l. It i:-; axiolll;lIic that no person should be givcn a diagnosis()t" chrol/it, jtU;gl/c syndrome'. jil)J'olllya(t:ia. or jibrol1l)'o.'ii/is wilhout 'Ill ~"alll'l1i(ln lhat includes C;\fl:flll psychodia~lh)Slic .ISSl'SSllI.:1lI hy a profession.1I who lllldCl'SI~lnds
lhat d1l'Ollic p;tin alltUm chronic fatigue may be (and not infl'l'qUl'lltly ;lrd lh~ initial manifcswtions of an occult and c1inic;.II, il1:1PI);ll'\"nt th.'pression.
S(llll:tlizil1g/dcpr~sscd individuals (who are usually highly
r6i .. t;llIt 10 psydl{llogic;jl interpretations of their symptoms)
llfh.'u arc so cOI1\'inccd thai their problem is physicnl, nnd offly
physical. that they persuade their doctors of their delusional
misconception. Because th~sc pOltknts have a mood (i.e., psyL'hologiL'al) disorder, thC)' do not get better in response to
Ir~:lll11~1lt dirccteu at a I,hysical problcm, Typically, thcy re
(jllL'SI and rccci\'c t.:.\lcnsion aftcr extcnsion of their disability.
One: ..hnuld beware of the patients who st"lte: "The doctors
jllstl,:an'llind out what's wrong with me," They rrustr;,lte their
~h':lOr~ who, nol recognizing or cven suspecting that they are
dcpr.:~~cd, unwittingly colludc with them. seeking consultalion~ and diagno!'tic tests directcd at discovering a physical
explanation for tilC pain. The astUlc doctor, howevcr, may rec01.!IlIZC carlyon that these patients will remain disabled. They
d~li\'cr a double message: mouthing words about their inde~
pendence, their lolcran~e of pain, ;nd their frustration with
their physical problem. their pussivc. dependent behavior be~
speaks emotional need and dependence, intolerance of and in~
capacitation by pain, and complacency in accepting the invalid status.
The double message of the somatizer is as foHows. Their
words S;'IY:
'i

I started working at an carly age and I have worked hard all my

life,
I havc ~dw:lYs been very indcpcndenl.
I (,'an Ii.Ikc a lot of pain. , , rm nOI one to complain (deni:ll),
I jU~1 want 10 el better so I C<ln h~l\'e Illy life back.
,\11 I want 10 do i<; return 10 work.

whilc their behaviors say:

Becausc I had to fend for myself a~ a youngslcr. I W,lIlt the care
I didn't get (In'".
My p:Jin forces IIlC to be pa.<;sivc and dependent <legitimizing in-

II(JII'

'alidisl11).
1am a victim. disabled and helpless in the face artltis terrible pain.
I need (0 remain disabkd because now I am being laken
carc or.
I don't W~lIH to go back-to work, , , (maybe) ... I want Ihc educational opportunity (vocational n:habilililtionl I forfcited when I
dropped oul of school.

Blumer <llld Hcilbrolln'l described the lypical characteristics of the person with a chronic pain syndrome:
Limited 'formal education
Holds overly strenuous routine or otherwisc dissatisf)'ing job
Has had Ulllllet depclldem.::y needs since C~lrly in life
Began work.1t ~11l carly agc (i.e., had no opportunity to really In: a
child)

Worked at hard jobs a long time before becoming dbablcd by pain

Family role model for pain ;Illdlor di.':.lbilit)' (idcntilicalion)
Often school dropout

These authors cxplain lhat, "by virtue of providing for others

.lHd 110t being fully able to depend on their own parelHs as
children __ .Ihc)' Imd postponed gr;'\Iilic.. ~tioll of such needs
unlil a minor injury provid<::d a mtional and socially acceptable means of depcnding on othcr!' for emotional ,u1d economic suppon:' Chronic (back) pain, in stich inst<lnces. is an
expression of eJ1lOlional and psychological pain, totally outside of the conscious awareness of the patient

Pain (emotional) begets Pain (physical i.e. psychogenic)

Because the pain-prone patient is one who seeks and
usually receives endless nnd costly studies or imenninablc
treatmcnt and doe.'lllot get beller, it is important to recognize
the dingnosis of somatization early. In 1959, Engel't> outlined his understanding of psychogenic pain and its relationship to depression: ",' ,a common error by the physician is to assume lhat lhe patient is depres~~d bcc:!use he
has pain. Investigalion will usually make clear that lhe
experience of pain serves to atlenuate the guilt and shame
of the depression .. :' PsychogclJ.iL(or somatofonn or idiopathic) pai.n.Jather than being a cause is more frequently
a manifestation of depression. This IS to say that pa
tiefi1s whose psychogenIC pain represents depression do not
fe~ch, if3!!Y' depres~~~, Instca~.. they ~x~erience
pain. Engel also recognized that narcoHc addictIOn frequently complicates the management of these patients.
Unfortunately, some well-intentioned but ill-informed
lawyers will object to psychological examination of the
chronic pain patient (in accident-related litigation) on the
grounds that the client is making no claim for psychological injury. Whenever chronic pnin is a manifestation of
an unrccognizcti (i.e.. unconscious) depression or other
mood -disturbance, the patieoJ ..9OCSJlOL_ccn-_kuQW of the
mo~-(fl.'iturbancc,__Thc Illost effective way to prevent and
obfuscate 'accu~;(C diagnosis and impede optimal trc3tm~nt
is t~ preclude pSy"chqLogi~ilt inycstigation of chronic pain
that has failed to improve in response to treatment directed
at a physical disorder.
Substance Abuse
The chronic pain patient frequcntly dcmands, and th~n receivcs, prescription after prescription for narcotic analg~sics.
reporting that nothing else relieves the pain, Such p~Hi~nts
arc at risk for drug dl:pl:lldency and iatrogenic addiction.
The addicted patient invariably denies such addiction. asserting, "I only lake the narcotic for my pain. _. I only take
i( when I reall)' need it ... nothing else (but the narcotic)
helps, .." This lil<lI1Y. or its equivalent. indicates that Ihe
sensatio/l of pain has become a witlulrawal .'iylJl[1(C)JIf
equivalent. which requires the narcotic for its relief. The
patient neither realizes 1101' understands this concept.. il~
sisting only that the p~iii"1 is "rcal." It is. Almost all pam IS

r~aJ. but tilt: sufferer ha~ Illl way of kIH1wing whether il

is physical or psycIJOlo:.:.il"ol Of hoth. Pain is pain. POlin
rcprcsCIllS a final C()I1l11Hlll p:lthw<l)'. Wht:n pain becomes
chronic and inc<lpacitalill~. decimating li\'t:s or workers
and their f'lll1ilicl'. it is thl' t;lsk of the spt'..:ialist to lIIulerstand the diq:rsc factors causing it. no math:r how dirliclih
lhe challenge,

ALCOHOLISM

The child of an ::tlcohoJic parent is. at the- very least, cmotion~

ally shonchangcd. not only by the emotional unavailability
of the parcnt (le.wing residu::tl neediness within the child),
hut also by Ihe negative role model that alcoholic behavior
pn;sc.:nts.
SURGICAL OUTCOME

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Som:ltizatiol1 Diathesis
Becker ' identified a .'ilJllltl1i~(;riml diatll('.'.is in those individu
als who, in one significant way or another. wac cmotion<llly
short-ch.mgcd during their formative years. I(knlifying these
individuals involves looking (,/,. a history of a!Jw/{/OJlIIICf/l.
abuse:, or a!<:o/zo!islIl ill a p;m::nting figure. Because these individu;d:,. in their routh. h~ld to fend for themselves when
they lVere ilJ'r,rcpared to do ;0. they arrived in adult life jack
ing the coping and emotional resources lO m:mage the ordi
nary demands and responsihilities of daily occupational and
social functioning. to say nothing of signitlcant additional
stress. Should such individu:tls suffer lhe loss of a person on
whom they depend. they 'Ire prone to develop physical symptoms lhat garner for them some levcl of c:lr~wking. evcn if it
is not cxactly what the)' need.

Factors Predicting Disability

ABANDONMENT

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Schofferl1l~m <lnd colleagucs 'J observcd (h:lt patients who had

experienced abandonment. abuse, and alcoholism were more
likely th::tn those who had not experienced such emotional
trauma to havc poor results aftcr back surgery. They identified
fivc childhood tr::tumas that are risk factors: physical, scxual,
or emotional abuse, abandonment, and nlcoholism (or other
drug abuse) by or on the P<lft of a primary caregiver. and reported an 85l7c chance of nn unsuccessful surgical outcome in
those individuals with thrce or more of these risk faclors. This
information has clear implications regarding both historylaking and trcatment approaches. Most "failed backs" renccr
unwise diagnostic decisions o::tsed on incomplete (VI" ignuu:J)
psychosocial histories. Frymoyer and Gordon 4 identify poor
patient selection <IS the reason for poor surgical outcome.

Ab<lndonment rakes Illany forms. A parent who. because of

illness or occupational demands. must spend weeks or months
away from the home may well be abandoning his child emotionally. The parent who. because of chronic illness. inllnnity.
or chronic pain. curtails aCli"ities .lIld time \\'illl the child in
effect emotionally abandons the child. The parent who leaves
because of separation. divorce, or de'llh abandons the child.
Loving means /ull'i"g time for. No subs~itu{e. material or otherwise. can compensate when a parent is unable to be with
and {O be "there for'" the child. A child abandoned during
the formmive years is ill-prepared for the demands and respomdbilitics of mature aduh life. The process of parenting
involves the gmdual (not sudden and c.ltaslrophic) withdrawal of caretaking and th~ simultaneous nurture of emerging independence.
ABUSE

Abu~c takes several forms.

motiol1al abuse can occur in the

form of name-caHing or ridi.culing or subjccling the child to a
const;lllt state of ::mxicly in the face of parental fighting.
yelling. screaming.HId inappropriate favoritism. Abusc. how
ever. can also be physical, involving inappropriatc or frequclll
corporal punishment. beating. or actual haltcring. Lastly.
abuse can be sexual. either as a single episode or on an ongoing basis. Adults who were abused as children commonly harbor both unconscious guilt and unconscious rage. either or
both of which can fuel nOl only abusive and rebellious behavior. but also a chronic pain syndrome.

Low back pain typically is a self-limiting symplom. MOSI patients with acute low back pain respond promptly to appropriate treatment and are back at work in short order. In a subset of paticnts, however, pain becomes chronic. The tcnn
chronic back pain was used in the past to describe pain of
more than 6 months duration. but FrymoyerJ redefined
chronic back pain as pain of more thafl 3 mOfllhs duratiofl.
Becker ' commented that. in most cases. chronic back pain can
be identified in even less than 12 weeks. Frymoycr identified
several factors that arc important in predicting prolonged disability after back injury. They includc the duration of the current disability; a history of previous disability; psychosocial
factors; occupation::tl requirements; job dissatisfaction; ::tnd
whether or not the patient has retained a lawyer.
Other factors idcntif'Jed with back pain and/or symptom:llic disk disease that frequcnlly prolong disability or serve
as barriers to recovery include obesity. inactivity. deconditioning. lack of aerobic fitness, smoking and other substance
(alcohol. marijuana. cocaine. legal or illegal narcotic) ::tbuse.
exposure to vehicular vibration, and a troubled family situation (e.g., children leaving the nest. illness. de.uh. marital
discord, divorce. or other losses). A shan period of employment before ::tn olHhe-job injury often bodes ill in terms of
prognosis.

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Examination Format
The cornerstone of evaluation of an injured persoll is an ac~
curate description of the person and of his or her work. Such
a description is possible only aftcr mcdic,,1 and other relevant

,~

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nX\lrd", ilrc rc"icw..:J. and the individual is inlcrvicwed and
cxamill~d.

Al lim~:-. il is necessary 10 interview a spouse or

other family mcmha. The procc~s or c\"<lluation lakes lillle
and ~hould ncn;r bl..' rushed.
Th~ n;\'h.:w of fl'l.:ords is 1110st rc\'t.:aling if it is arranged

,i

;Illd pn=~cl1(cd dm'lllologiGilly. This process may take the

form Ill' handwriuL'l) notes, but a lllOre.: dficicl1l I11CilllS is
lhn)ufh dil:l:ltioll lor subsequent word processor input. A
dnonolngic rC"lc\l,: of the records "ffords the hc.<>1 opponunity
to ull{krSlalld sOllh.'thing of lhe backdrop ~lgainst which an
injured PCf:-:OIl Illusl be viewed. Record review is the task

or a d~\(':lOr and should not be delegated. Sometimes extrcmdy sulHk medical record entries provide vitally important Chl#CS to the comprehensive understanding of an illness
and disability.
A ("(1/II/Jl'elwlISirf history is the foundation on which an
lllltlcr:-'l;lIlding of an injured person rests. It is important to establish r;'ppaTt with the individual being examined as quickly
as po:-.siblc. The good doctor is first and foremost a good listener. The HISk of eliciting a good history is both a challenge
10 and ;lrl opportunity for the examiner.
Imcr\'ic\\'ing is ll. skill. Almost all persons coming for an
initii.11 examinatiolf after an injury (and virtually all those
t.:omil1 for ;, medicolegal e\'aluation) arc anxious. A gentle.
reassuring. kindly approach helps to calm them. Some injured
person~ .Ire angry. It is particularly important that the doctor
not respond (0 them in kind. Frequently. if the doctor simply
listens quietly. the anger dissipates and patients are better able
to talk abollt thcir problems. Many patients, particularly
chronic pain patients. have gone through life viewing every
human being with whom they come in contact as an adversary, These individuals have a way of "setting up" the doctor
<IS an adversary llS well. The doctor should communicate in
word and deed his or her detcnnination to listen to. to understand. and to \vork and collaborate with the patient in the
proce:-.s of hC:Jling, Occasionally. an individual will become
tearful or wccp during an interview. At such times. 'it is best
(0 maimain a brief !'ilcnce while trying to understand what
triggered thc tcars. Remember. everything in such a setting
has mC:Jning. which emphasizes the need for the doctor. and
not a lay "historian," to obtain the history.
An ovcmll structural framework for the history assures
thoroughness and minimizes the likelihood of serious oversight. The follo\ving evaluation format. which has undergone
many revisions. has proven useful.
HISTORY FORMAT

The history format cncomp:'lsses material appropriate for bOlh

chiropraclic as wcll as mcdical or psychosocial evaluation.
All areas are imponam for a comprehensive understanding of
the individual being examined.
J. Ideuti!.villg Data
Namc of patienl. ilddrcss. marilal status. age. occupation. and em
ployer

D:lle of evaluation
Dale of injury. ;f relevant
Job description. inclUding physical demands
Employcr and dale of hirc
Hislory of prcvious Worke~' Compensation claims or personal injury litigation
Time periods mil of work. current income source (ascertain income while working versus income while disabled)
Nole any job or work hid changes bcfore injury
Ask about rumored layofrs or plant closings
A~k aboul an}' suspensions. or censures for unsatisfactory work
pcrfonnanc'~

Reason for evalu<ltion

II. Present Condition

List all symptoms attributed to injury-their onset. frequency. and
sevcrity. Note symptoms present before injury of focus.
Chronologie history of prescnt condition. inclUding all prcvious
IrCiltment methods and responses.
If an injury is involved. a detailed hislory of that injury is needed.
with particular attenlion paid to discovering and understanding the
probable mcch.anism (in tenns of biomcchilnic:J1 forces) of injury.
Othcf\visc. as dctililcd as possible 3. history or onset of symptoms
should be documented.

ll/. Pas/ Medical His/ory

Describe prcvious accidents or injuries. ope,.uions. medical conditions. hospitalizations. and any pre.cxisting disabilit)'.
1\ole current usc of medications. appliances. :md physical therapy
or similar lechJljques .. :~'\ ~v~!! :\~ dini('<!! resp()n~es.
Note prcvious chiropractic treatment with clinical rcsponse.
Describe current and past use of alcohol. tobacco. caffeine. <lnd
other drugs of abuse.
History of current or past psychological difficulti~s and treatment.
Ask specifically about anxiety. dcpression. ilOd suicidnl lhoughts
or auempts.

IV. Review of Systems and Psychological

Symptom Inventory
Ask about general heahh and pose approprii,\t~ly focused que:,lions pertaining 10 the hC<ld. eyes. C'lrs. nose. and throat. as well
a... the cardiorespiratory. v3scuklr. gastroinlestinal. musculoskeletal. neurologic. and urogeniwi systems. Ask a~out sexual flllKlion. In females. ascertain number of pregnancies. live binhs.
illld misc~lrriages or abortions with datcs. Ask ,lOout prcmenstru;11

J,\'lldromc.
Ask spccificail y about depression. sleep problems. crying. difliculty with concentration or memory. loss of energy. casy fatigability. irritability. temper outbursts. physical viL'Ilellce. social withdrawal. dre~Hns. self-esteem. sense of guilt pill' bias. panic attacks.
bypcrventil;ltion. fainling. dizziness. lremors. (,'xccss swe;i1il1~.
childhood bedwelting. history or shoplifting \lr stealing or gam
bling problems. and hallucinations.

V. Chronologie, Educational, alld Work Histor)'.

Ineluding Military Experience
Note schools attendcd. interests. performance. \,,\tracurricular :Ii.,'tivitics. disciplinary problems. diplomas andlL'r lkgrccs. If schO\'I1
drop-out. i1sccrtain why.

NOll' .tll major johs. wnrk d:lll'S. jnh s;Llisfm:tioll. and n:asOIl
for leaving. Ask :.p....:ilir.:;tlly ahoul ... xll'n<kd periods of uncm-

ploymcrll.
COlllprdll'lIsi\"l' desr.:riptiol1 of til\.' w\lrk pl;\Cc and duties, ;IS well
as qualitr of relationships with employers. supervisurs. and

Jc'

<:o-workers.
Ask spccilic;tlly about jllil satisl':lCli(ln.
Specifically d(JclLlll~'nl allY work lash pn:dtldcd by till: physic.L1 or
psydmlllgic:ll (.:ondili\ll\ of Iii.. individual. wilh rr.::.ISOl1S for sm:h
precilisillil.

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\!I. Personal History

Note composiliollufhmlsdtolJ. any rCl'Cllt or illlpending changes,
alld rCI:CII! <.bllhs or scri.ous illness in family or fricnds.
Assess changes jn ;md stability uf living arr..lllgcmel1ls.
Ask about i1H:r~asing l..k hIS. financial problems, and b;mkruptcy.
Check inICrpCrs()Jlal relationships: marit;tl or spousal: childrcn. es
pecially l.:hildrcll by (llhcr marriages: parents: in-laws: and siblings.
Obl"in hi~tory or invC:~lig'Hions and :UTeS(S (including driving while intoxicated), ;\llc.l notc any periods of incarccration.

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Vll, Family History

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Note signi(ic~nt medic'll or emotional problems. specilically depression, ner,'OllS breakdown, ~lcoholism. suicide.

psychialric hospilalizmion. or disability involving

f~mily

m~Jllbcrs.

Vlli. Biographical In/ormation

Developmental history. nOling quality of bond to parents, siblings.
step-parcnls. or othcr~.
Ask specifically aboul harsh or unusual punishment. physicJI or
sexual :Ibusc.
Ask person 10 describe lJIother ... fOllta.
Asscss quality of bond to siblings. parcnls, and other family members.
Determine whcn the individuallcft home and why.
Obtain affectional rclationship history (inclUding history of abuse)
to assess :loy difficul1y in mainl:lining stable and malun.~ intimatc
relationships.
If divorce ha~ been invulved, inquire about alimony and/or childsupport paymenls.

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IX. Social and Recreational History

NOle r.lUgc of interests. hobbies. pursuit of sports. rccrcatiomtl activities Wilh fril.:llds and family.
Specifically dO<:lllllClll any ;;IClivilics Ih'lt the Il:tlienl fecls arc preduded because of physkal or psychological conditions ;Ind the
reasons for such preclusion.
Specific;llly ;;Isk about and Iry to delerminc in dClail Ihe
paticnt's physic:d fitness progr.un, if any. Assess the patient'S initiative, mOlivation. and pen;cvcr.mcc in maintaining a comprchcn~
:-ivc fitness or physical rehabilitation program.

X. Mental Status Examination:

Bricny describe the following: appearance during Ihe inlcrview.
..ulitudc. attention. eye conlacl. posture. now of speech, content of
speech, unusual manncrisms. mo....ements or behavior, and observed as well as reported r<tllgc of mood. Ask about suicidal
Ihoughls or behavior.
Check spccilically: orientation, calculation, digit span, ability to

makc rcasonable judgmcnts. ;.tnd recent and remote memory.

~re partiCUlarly import::tnt in elderly persons who may. because of mcmory difficulties, be unable to comply with complic;\tcd treatment routines.

M:tny of these functions

Xl. Physical Examination

The format for the physical examination is beyond the
scope of this chapter. It is clear, however, that thc corncrstone
of a thorough cvalualion of a person with chronic spinal pain
is a comprehensivc history (which does not neglect the psychosocial arena). and a careful physical and mcntal statliS examination,
Psychological Tcsts
Just as radiography and other imaging studies are diagnostic
tools that work in concert with the history <lnd physical cx~
3minntion to refine the doctor's ability to establish accurate
diagnoses. so also does psychologicaltcsting. aid in establishing ;lccuratt.: diagnoses in the psychological arena. Nothing
from a physical standpoint is as valuable a diagnostic instrument as a comprehensive history J.i1d physical examination.
So also nothing from a psychological sumdpoint is as valuable as a comprehensive parallel history and a mcntal staws
examination. II Imaging, laboratory. elcctrical. and psychological tcsts are important and necessary adjuncts to the comprc
hensive assessment of the paticnt with chronic pain. The psychologist interpreting the tests serves as a consultant to the
chiropractor. much as a radiologist interpreting imaging ~tud
ies is a consultant to the primary practitioner.
Of the hundreds of psychological lests available, only
a few arc of general utility by lhe nonpsychological pro,
fessional with regard to chronic pain syndromes in general
and to chronic back pain in particular. These few tests. however, are immeasurably helpful. They have been described in
detail and discussed by Southwick 1ll and by Bccker and
Smith....)
The MMPI (currently the MMPI-2) represents lhe gold
standard. \Viltsc and Rocchio?O showed Ih.. t u certain MMPI
profile (plottcd on a gmph) is associ~ttcd with a poor result
following chcmonucleolysis. It is my experience that nn
MMPI profile ch~lractcristic of somatization usually is associated with evidencc of a somatizatio!l diathesis in the history
and suggests that a poor result is likely after back surgery for
pain. regardless of thc underlying pmhology. Certainly. an
MMPI2 is imperative in any c.asc of back. ncck. or shoulder
pain that fails to respond to reasonable trc:tlmcnt in a timely
fashion. or onc in which "the doctors just c,mllot find out whar
is wrong," No patient with a "failed back" should havc further
operative procedures without first undergoing thorough psychological assessment.
Southwick"~ dctailed the evidence supporting appropriate
usc of the MMPI. The tcst is used widely and appropriately
so. The MMPI-2 (1989) has largely, if 110t totally, supplanted
the MMPL
In addition to three scales that assess the validity of the individual test protocol. the major MMPI-2 scales include:

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... ,., _, . . . . . . . I V I V, , ..... V ..... V, " ... 1-,... ......

un~

11'1 ...... IOUI'I' ..... r,...ll'l

Hyplll.:honoriasis (Hsl: ahnormal concern over bodily health

Dcprc:-sioll (D): dy:-phoria. wony. discoumgcmcnt, low ::~lfHystl'ria (1-1)'): inappropriate happy :lcccptance of ndversc or
qn:ssful cvents or t'irCllll1st:IIlCcs in general (deni<:t1)
l)s~'dl(IP;llhic dcvi;lIc (Pd): moodiness. resenttncnt. mal<ldjustlUl.llI. ddialll.:e uf authority. anger
~t;lsclilinity-li.:lllillillity(Mf): Aesthetic ,"ocatiomll interests. artisIiI." inlcrcsls. sCXIl<l1 orientation
Par-lnni .. (P;l): pcr~cculion. being easily hurt. suspiciousness
Psychasthcnia (Pt): narcissism. :mxicty. self-concern, self-doubt,
feelings of being forced. constitutional inadequacy
Sl:hiwphrcnia (Sc): alienation. delusions. influence of external
agents
Hypom;mia
t a): expansiveness. irritability. egotism. the other
side of depression

er..

Thes~ descriptors arc simplistic and not intendcd to cncour-

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age the i.llllalcur interprclalion of MMPI-2 profiles. The interpretation of the MMPI-2 requires an extremely broad understanding of that specific (cst instrument. Normally, the
MMPI-2 and other psychological test measures are interpreted by a clinical psychologist with special tr.lining 'and
specific expertise in the area of psychological test adminislmtion and interpretation. Validity scales are built into the
MMPI. Lees-Haley" devised a fake-bad seale for the MMPI2. which has proven useful in identifying patients who may bc
consciously misrepresenting fact or even frankly malingcritlg.~l Full-blown malingering is. in my experience, infrequcnt. A more common situation is unconscious or to some
dcgree cOllscious embellishment of symptoms wherein the
hyperbole is part of the patient's theatrical (i.e., hysterical)
character style. At thc other end of tile continuum is pure som~
ariz-arion. which is almost as uncommon as purc malingering.
Most chronic pain patients represent a mix of somatization
plus underlying organic pathology plus somc symptomatic
cmbellishmcnt, not necessarily in any ccnscious aucmpl to bc
deceitful.

PAIN DRAWING

ers2~ described a means of evaluation in which the patient

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draws. on the front and back of a body outline. the precise location of pain, specifically using symbols to indicatc numbness, burtling, pills and needles. and stabbing. The pain drawing is remarkable in its correlation wilh the history. cspecially
the p,lralle! history. and the MMPI-2. Brown~' concluded that
the pain drawing (along with mugnetic resonance imuging) is
especially useful '1S a diagnoslic adjunct in cases of back and
lower cxtremily pain.

CHRONIC PAIN TEST BATTERY

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I3eckcr and Smilh',} outline a sm.11I psychological lest

useful in chronic pain evalumion. including: (;.t) an
gence assessment (it is imp{)nant to know if <I patient
<lte .md how effectively the p.ltient can reason b::::forc

.. Back home - - -

\Vhal ;.. nnvy:- m..: - - A mother - ..

.. My greatest fem - - .. When I was ~I child - - .. The future - - What pains me - - -

My father - - Use of appropriately seleclcd psychological tesling de-

rives several benefits. including. revealing evidcnce of depression. factual misrepresentation. and the psychological asscts
and liabilities of a patient. In terms of the clinical prognosis.
thcse tests demonstratc the ability of the inol\'idualto benefit
from psyehothernpy or counscling and the likelihood of eompliance with exercise regimens or of persevering in functional
restoration or vocational reh;lbilitation progr:.lm~. The markctplace is repletc with so~called "self-report" test me:'lsurcs. In
general, lhese arc not tests that look bene.nh the surface. but
rather they indicate how the patient wishes 10 be perceived.
They have, therefore. limited usefulness.
Becker ~nd Smith1\l point out that although psychological tests can be scored blindly (e.g.. by a computer or a psychologist who has not interviewed or even seen the patient),
the conclusions are most accuratc when the interprcting psychologist has performed a screening interview and a mental
status examination to provide a backdrop against which the
hard tcst data nrc best interpretcd. The chiropractor who
wishes to use psychological testing for chronic spine pain patients should establish a rclationship with a clinical psychologist who is knowledgeable about chronic pain. somatization.
depression. symptom embellishment. malin2cring. and the
like and thcn work with that individual on
rcg-ular basis.
This working relationship is panicularly cfkctiv~ v,,'hen the
chiropr.lctor and (he psychologist confer to fonnulate appro~
priatc management strategies for each patient with chronic
pain.
Patients, particularly those who may harbor a somatization diathesis. are frequently resistanl to undergoing psychological evaluation. They tend to dislort the mC~\Iling and V~lll~ -.
of such testing with interprctations such as "tltt: doctor thinks
it's all in my hcad," "the doctor doesn't bdicvc me," or
"the doctor thinks I'm cr<1zy." Explaining to the patient
thaI hc or she is to undergo a chronic paill f!wduafioll is
less threatcning to an cmmionally fragile and rigidly dcfended person than is a psychological et'a!tullioll or. worse
yet. a pS)'chiatric evaluatioll. MOSI paticllls readily ad.:nowledge chronic pOlin. and most can accept lhe rCillity that
chronic pain and mood and behavior arc rdalcd. It is often
helpful to review with the chronic p;'lill pmiclll his or her

:1

A piclUre is worth a thousand words. Mooney and co-work-

istering an MMPI-2); (b) self-report measures, such as

the pain drawing; (c) a personality test, such as the MMPI-2;
and (d) projective tests. such as the Rotter Incom~
plete Sentences tesl, in which the patient completes a rull sentence. given only one or two words. Examples from this test
include:

batlcry
intelliis literadmin-

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.....

__ ...._.... _...._-

failure to reg~in health despite reasonable {re~tlllenl, and to

poilll OU! that a chronic pain cvalumion mOlY yield findings
that suggest additional m:atment stralegies. Using patience,
underst::lndim~. and 1.11:1. Ihe doctor C'lIl usu:'llly persuade the
rc~istalJt pcr;OIl to undergo a compn.:hcllsivc chronic pain
c"aluathHl.
The usc of psydlOlogic;11 tcsting as a diagnostic adjunct
in the evaluation of chronic p:lin is :'lcccpled as standard
practice. Failure to consider 'psychologic:il evaluation (in~
eluding. testing) in the face of a rcfraclmy chronic pain syn~
drol11c. particularly before perfonlling inv:lsive proccdurcs. is
llcgligcm"
TREATMENT CONSIDERATIONS

The carc of many paticnts with chronic back pain can be

satisfactorily managed by the treating chiropractor, e:thcr
alonc. or if mcdicmion is indicated, in concert with a
physician, Chronic back pain, especially the kind that lingers or smolders. w:'lxing <lnd wnning with time. can be
cxtrel11~ly frustrating to the doctor. Somctimes "cure" (meaning long-lasting ablation of pain) is not possiblc. When
it is not, the palient should be so advised and assistcd in
establishing realistic goals. This preparation is best done
in a way that cn::lbles thc patient to understand in a posi~
tive light the implications of living with back pain. The
doctor may say, "You will just have to Icarn to livc with
it. rvc done all I can do:' Thc response of the patient,
panicularly one who is depressed. may be 'Tm never going to get better ... I'll have to go on suffering .. , I'll
never be able to do anything ... I will nOl get my life
back." Thesc sentcnces reflcct what typical chronic pain
patients tcll themselves, and illustrate considerable cogn;ti\'e distortion. a kind of negative and defeatist thinking
thai is characteristic of depression, It is essential, to enable
the patient to understand that he or s~e should live (with
the pain) to the fullest, Living with rather than suffering
lI'itll ;md being incapacitated by the pain is the vital con
ccpt to instill.
One talk with a paticlll is rarely. if ever. cnough. Patients
wilh chronic pain arc. as a group. morc needy (i.e. dependent) than most. and they respond best (0 ongoing and repetitive SUppOTt that can bc diminished in frequency as they get
Ihe message and begin to act on it.
The treatment approach to :'l chronic pain syndrome must
be goal directed and time limited. It is also counrerproducti\'c to help the p~ticnt "accept" the chronic pain. because
"acceptance" is invariably misunderstood by the patient as
me.ming ongoing passive incapacitation, helplessness. and
\'ictimizmion, The most effective treatment strategy is the
sports medicine (no pain-nl;) gain) approach of working
through pain to optitml1 flexibility, strength. stamina. endurance. and aerobic fitness. The role of cach and every mem
bl:r of the treatmeTH team must be supportive of such an
approach. Physically conditioned and aerobically fit indi-

viduals arc less susceptible to incapacitating chronic pain

syr.Jromes.oI

Chiropractor as Thcrapistffeachcr
Psychothempy is the praclice of listening to the patient talk in
supportivc, underslanding. and appropriatcly interactive
way that leads to a doctor/patient bond within which healing
can be facilitated .md nurtured. It has been around sil\CC
recorded time, antedating Sigmund Freud by several millen
Ilia, For m.IllY pain palients, especially those who remain pro
duetive. the doclOr may be able to serve effecti\'ely in lieu of
:.1 therapist. Living with a degree of chronic pain means fo
cw:;illg increasingly on the resumption of as many activities of
daily occupational, family. social, and recrcational function
ing as possible. Simply because an exercise or activity (done
by a deconditioned individual) causes an inCrC3s.c in pain is
no reason to stop the activity. Indeed, unless the chronic p:'lin
patient pushes on with an appropriate functional resloration
program. despite some pain. little if <lny sustained progrcss
wift likely follow. Patients must understand this fundamcntal
principle. (Many patients have no understanding of the: con
cepts involved in progressive conditioning or aerobic tmin
ing, and need ongoing guidance and supervision.)
If a chronic back pain patient can maintain;) rcl<llivcly
high level of musculoskeletal function through the ongoing.
infrequent (Le. once a month or with time, only three or four
times a yCo.It,/ C("H:.i~i. , ... Ji.1l a trustcd chiropractor. the ongoing
chiropractic visits require no other justification. Many pa
tients respond positively to ongoing and infrequent supportive
psychotherapy. The parallel is aplo The chiropiJ.ctor with a
healing touch usually knows how to managc th~se challenging individuals, teaching them patiently every St~p of the way.
The proof of effcctiveness is the resumption of optimal phys
kal function.
III Latin. "doctor" means le:'lchcr (hence w(.'rds like doc
trine and indoctrinate). The effective chiropractl,,"'lr understands
that he or she must function as a tC:'lcher to enable patients to
heal themselvcs, Tcnching p~HierHs with chronil..' back pain
how to develop and maimain conditioning <lnd fitness, as well
as how to become relatively self-sufficient. is a aitically im~
portant task of the doctor. Motivation. initiath"t:. and pcr~
severance are vitally import:'lI\t ingredients of sut.:h a program.
The injured worker who stops a cOl1lprehcnsh"~~ physical fit
ness maintenancc program :.\ft('r returning to \\'('Irk soon be
comes a candidate for rcinjury or re-cmcrgence 1.."11 symptollls.
For the patient. the boltom-line measure .."If the effcc
tiveness of a treatment protocol is function: at home. at
\\lork. with the family. and at play. In morc r~::.i~tant cases.
.1 treatment tcam C'lI1 be cffcl.:tiye. whcrein the chiroprac
lor works collabor<ltivcly with the family phy:,ici:.m or the
psychologist or psychiatrist. These providers $hould con
fer regularly to share insights and undcrstanlting and to
coordinate, unify_ and manage;.' care. If psyclh)logic.at evaluation reveals Ihe likelihood of a masked depression or

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p;tin :,... :\ \h.:pn.:~si(ll1 cqll;\'~I~n!. or if the patient complains

\11' in:-'llillnia 1X'~aLJ~~ or pain. a trial of ,ll1tidcpressant I11cdicaliun is \\'arr;lI11~d. Dctaib of '\Heh (hentpy :.IfC he)'ond the
scope of thi . . ,,:hapler. hut lh.:~ have been outlined by Becker'

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and othL'l".'i.
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lllallY patil.'llls who somatii',c can be s;uisracto-

rily 11l,11l:1~\:d t,y the chiwpr:lt"Wf or by ;l chiropr;lctorJf.lI11ily

practiti(llil:J" h:;Il11. some f,lillO make progress. They should be
rdcrn..:d for P'~ chmliagllo~liL' c\'aluatiul\ lind. if indil::HCd. for
smgi!.:al L'\';l!llalion ;IS well. The ('riteri" for sJtisfactory man
agelHem illl-lude:
Pn1gn:ss in llll.:
r~~urn~nl

'1r~lchillgf;.,lr~'Il;;thl.:nilig/li\lli;SS

"t:lh~kks

~ltld

l.:lltll~ss

progralll withollt
date ex-

r~tllrn'lO-work

h;llsions
I'rH~rc:\:. in r~;t(hin~

f:'lch1ry maillkn;uKc

it

pcrnl~lll'lH and

or th,,1 "l;.itll\

401

\.;nHUNIL; PAIN

slatiollary status and salis-

Eith~r

rl.:lurning (0 work on a \u,wined hasis or entcring and com;1 nl>::.llional r..:habililaliol1 pru~nllll. finding appropriOltc
l;ilinful cmplnYlllclll pn:.Hr;tining. ;lIld sustaining work perfllrnl;ll'l"\.'
Disl:ol1linUilli\ln Ill' Ilarcolil.' anall!csil:s. Only in rarc instances
an: n;lfl"Oli(, indil:(ltl.'d in l.:h.ronil" bal.'k pain management. A
small SUbSCI (\f paliel11S funnion more salisfaclorily willi it low
Ic\'eI of mailllen"nce narl.'Qtic th~ln willtout the narcotic.
klclHilicati<1n of such patient' n:4uircs considcmble skill and
expcrience in assess me 111 and manaClllcnl of chronic pain
syndromes and is bcsi Ilnd::naken hy it physici;m skilled in
alg<llugy.
Resumption of family, social. and recrealional physic,",1 activity
appropri;llc for ;,lgC and spinal condition. Ongoing passive dependency. bcspca~itlg psydlOlogic<.J1 regression, is lln<.Jcccptuble and,
in and of il<o;df. is a reason for rdcrml.
At the outset. wilh " chronic bac~ pain patient, IOllg-range gOClls
{rcsumption of most. if nol all activities
daily family. social.
occup;lIion;tl. and rel'rcat~Ol1ill functinn: m;lintcnancc through a
Inunc cxcrci...c :md aCf<\bic fitnc~~ program of filne!>s. stamin:t, and
endurance! and ... /ton-rclllg(' 1;(1(11... {progressive learning of a
homc cxc["(:i~~ and fitness prngr;lfH; acquisilion of skills to enable
a high dcgrcl:: (If self-sufficiency wilh infrequent monitoring:
deprcswcaning fmm rdi~ltlcc Olll1arCOlic ;lllalgcsics: treatment
sion ur pain a, a depression cquh"lcnl. if present; progress in
gellcral phy~ical aCli\"ity Ic\'c1 withnul recurrent sctbilcks. which
indicalc Ihal mllrc spcci;llized Ircatlllclil is indicaled), should be
established \\ Ilh t:lrgel date" to avoid endless prolong~ltion of
disability. Ab(llil 99t}- of all back p:tin patients should reco\'cr promptly. Wh.:n Ihcy do not. S\llllClhing Illay be seriollsly wrong. and thaI something may escape definition if the
psychological dmnain is nOl included among thc uifferclllial
di:lgnosli..- cOIl,idcrali\llls.

ACUPUNCTURE

Acupuncture hi:ls been used by Chinese practitioners for CCl1lOnes. Recent work suggests it may have some value in
chronic pi:lin syndromes,2 4
BEHAVIORAL THERAPY

This type of therapy is rooted in the pioneering work of

Skinner, who recognized that behavior is shaped by its conSt;'
qucnccs. Stembach:2~ describes an approach that identifies:
(I) undesirable (maladaptive) pain beh:wiors that interfere
with the patient's life and constitute barriers to recovery; (2)
desirable (adaptive) behaviors that the patient has but fails to
usc; (3) working with family, reinforcers that encourage the
desirable behaviors (2) and strategies to discourage, if not to
eXlinguish. the undesirable behaviors (I).
COGNITIVE THERAPY

pJ..:lin~

or

This fonn of Iherapy is based on the work of Beck and colleagues.~(, Cognitive thcr-apy helps .he patient to recognize
the cognitive distortions characteristic of the thinking of deM
pressed persons, and to acquire the inner resourcefulness to
overcome passive dependency and the "viclim complex."
RELAXATION THERAPY, BIOFEEDBACK AND HYPNOSIS

Alone or in combination. these methods have shown limited

success. Those patients who mallifc:-.i iilt;: l:ydc illustrated in
Figure 19, I, a fonn of tension myalgia, may respond to a
treatment approach that involves the therapist teaching and
the patient JcaTlling skills that culminate in a high degree of
patient self-sufficiency. Relaxation. accomplished through
medication, biofcedbnck, or selfMhypnosis may increase a motivated patient's sense of self-sufficiency and control while

PAIN

or

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MORE
MUSCLE
SPASM

MUSCLE
SPASM

Ps)'chiatric, Psychological, and Supportive

Treatment j\ lcthods

An in-depth description of lrcallncnt mcthods is bcyond the

scope of this chapter: however. several are identified brieny.
The actual choice of treatment may v:.try with the community
resources that ;Irc ilvail'lblc.

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MORE
PAIN
Fig. 19.1, Pain muscle spasm cycle.

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diminishing or extinguishing maladaptive thoughts of hclplessness and victimization.

FAMILY THERAPY

Rowat and Jcans:.!7 st,He Ihat "learning 10 live with pain is a

family affair." Certainly. when a major wage curner or
provider becomcs dis~lblcd for an extended period oflime.lh~
impact on thc family Illay be devastating. In the worst casc
scenario. the passivc/dependcnt patient can become a virtually helpless invalid. indeed. some chronic pain patients arc
as much of a demand on families as is a newborn infant.
Additionally. most chronic pain patients manifest depressive
spectrum symptoms. including insomnia. irritability, fatigability. lack of motivation. diminishcd selC-es(cem. social with
drawnl. and diminished libido. It is not unusual for families to
collapse and marriages to fail when an overworked spouse
cannot shoulder yct another cx(ra burden. Frequently. Illounting bills lead to bankruptcy and somctimes homes arc lost.
Family therapy can sometimes help the family understand the
underpiilOings of the chronic pain syndrome and to learn
strategies that may avert disaster. The family that learns to encourage and reinforce the patient's active lh'illg and to extinguish Ihe patient's passive sufferillg has a greater chance of
survival.
PHARMACOTHERAPY

The chiropractor should discover what medications the patient is taking. Narcotics, except under special circumstances.
are inappropriate for chronic pain patients and may only diminish energy and motivation. Patients with chronic pain syndromes are at risk for developing iatrogenic substance abuse
disorders. They frequently seek narcotic prescriptions from
several providers. Appropriate team management of such patients designates only one provider to prescribe and manage
pain medications. Ongoing regular usc of narcotics diminishes endorphin production. thereby robbing the palient of
a biologic mechanism intended to help cope with physical
pain. Aspirin is one of the best analgesics in the entire
pharmacopoeia. The practice of taking aspirin with a full
glass of water effcctively minimil.cs gastric irritmion in most
individuals.
The use of (lllxiol.vtics and sedative-hypnotics (benzodiazepincs. barbiturates) is inappropriate in most cases of
chronic pain syndrome. Especially in the presence of dependent 'lOdlor somatil.ing. dynamics. these agcnls lend to diminish energy levels and motivation. lhereby effectively sabotaging recovery cffons. Like marijuana. when used regularly.
they may be associated with the ltmotil'atiollal sy"drome. a
serious barrier to active recovery.
Amideprcs.mlll medications arc among the most useful in
chronic pain syndromes. Insomnia attributed to pain by the
patient often signals an unrecognized depression. Therefore.
in this group of patients. antidepressants are more effective
than sedative-hypnotic medications. Newer antidepressant

agents. including fluoxet::lc. :;~:1ra:iae. <;,,,c i~~~:-~~;:;lil~:::. !~:~\'c

nOI yet been ~(Udied extensively in the trcalmenl or chronic
pain syndromes. but they may prove effective ;.Igainsl pain
that is a depression equivalent. These newcr medications ;ap.
pear to hav~ J more favorable side effect profile lhan the lra
ditional tricyclic compounds.
Mu.w:h' r('laXllfl!S may help whcn idcmiliablc and ongoing
muscle spasm is .\ P:Ul or the (.'lillie:ll picture. This c!;ISS of
medication IS Illost apl)ropriatt.: in acute cases and when uscd
regularly. like sedative hypnotics. may diminish cllcrgy. motivation. nnd initiative. TIlc efficacy of these drugs has bl:cn
questioned. Carisoprodol has acquired .1 repul<Ition as an
aphrodisiac.

Street Drugs. Nutrition, Alcohol. and Tobacco

At[arijllalla has an effect similar to the benzodi'lzcpincs.
\Vhen used regularly. it is a'isociatcd with the af1lOliw"iollOI
syndrome. Alcohol abuse signals a self-destructive behavior
pattern that may effectively undennine the best-intended effofts of the caregiver.
M;my chronic pain paticnts are overweight. It behooves
the chiropractor to teach these individuals somcthing abollt
nUlrition. including lowering intake of dielary fal, and illcreasing intake of fiber, grains. fruits. and vegetables. Telling
a patient simply 10 lose weight is usually ineffeclivc.
Teaching a patient the basics of nutrition in Ihe light of CUfrent knowledge sometimes helps. Refractory patients may
have success wilh a fonnal weight reduction program. The
role of diet in conjunction with exercise in a weight loss program must be instillf'd.
Many patients with chronic back pain have never been
infonncd about Ihe relationship between smoking. back
pain. and disk degeneration." Pan of a comprehensive attack
(Le.. educational program) on chronic back pain should always invohc encouraging the patient 10 stop smoking.
Indced. lhe patient's willingness or resistance (0 do so will
serve as an excellent index of moth"tion. Ultimately. of
course. patients do what they \Vant to do and what they arc
motivatcd to do.

Functional Restoration
Many persons with chronic pain syndrome arc not at all
psychologically insighlful and their care is beSI manag.ed
with (l func~tional restoration approach as described by
Polatin.~11 Such an approach involves careful assessment of
the paticlll's clinical condition. particularly with rcgard {()
flexibility. strength. and aerobic conditioning. The injured worker with chronic back pain usually has restcd for
::l long period and has becomc incrcasingly out of condition with each day of passivity and rcst. The patient mU5t
be taught to recognize decolldirioning. and to addrcss
that state. rather than pain. as Ihe focus of concern. A
functional restoration progwm is most effective when led
by a temn. which im:ludcs the prin~ary provider (dliro-

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4U;;S

pr:h.:lnr. family physician. or internist), the physical and oc1.:Up:ttiOll:11 1Ill..rapi:,t. and the psychologist. Optimal Illan~
agl.'ll1Clll prL'Sllll1l.':\ ongoing tcam conferences, at least by
h:kphollC.
Th(: important ph;lscs of a functional restoration progr.tl11
aflL'r illiti;,l ill-depth evaluation include stretching. progrcs~i\'\,' fl'sisl;lIlCC l'\t,.'rciscs. work simulation :a."ks. and aaohics.
TIl\,' p:llil:lll kant .. wlwt In do on his or her own (without f<lnt)'
111" l".'.\pt:llsivl.' l'qlJiplllCI1l) ,1IId :s monitored until at Ieasl prcinjury (if nOI optima) function is restored. A typic:\1 function:11 restoration program for a refraclory patient (which C;.111
I:lc mndili~d for more ilctive (lr for wcll-motiv4.ltcd palictlls)

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cOl\:"ists

or four phases:

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I. EvaltJillion and tklaiJcd physical asscssment. including

and strength measurement.
Ph:lse II C! [(l nwaks). Supervised stretching. TIle focus is on im
prnvil1~ ;llIY lll<lhility detidts ;lIlt! overcoming ;lpprehension. The
P;\\iCllt1ll1IS\ undl.'r.. . lalld thill hurt docs not equal harm and thilt sucl:~ssfull.:(llllpJctimlof tilt:. program c;lnnot occur without "pushing
lhrough" pain l.'OllSCtjUClit to rCllIobililatioll of tired. flabby Ill11S(:uliltun:. The p:uicnt must be tauglu and. through support and enClIUr;Ij;l.'lIlCnl. llHltjv;lIcU in ,Ill inl.:rcment:lll)' gr..luuatcd home pro~r;lln:l11c palicOl is hest cvaluated weekly.
Phase III (3 wccks wilh progressive lime incrcases).This
c'xcn:isc and rehabilitation program gradually ;md incremcnlally incrcil"'c~ 1I111il function;.1 rcstonllion (or optimal restonltion) is achiC\"cd. The patiellt is repelitively taught Ihe need 10
mainlain gains hln.:ngth. :-;tarnina, and ;Icrohic fitness) madc in the
pro~r.lln, so thilt de:cunditiuning willlUlt s;lbotagc the physical reIwhilitati(lll. The pc:rson OUI of work on temporal)' disability must
understand thai c!'tablishing wcllncs:-; through functional restoration is the ji,..\1 (lml fori'mast priority.
Phase IV. 'n1t: follow-up phase. ~'lost paticnts with chronic pain
l1Ianifest rctunHC)work ;lpprchcn:-;ion and require fiml. dircctive.
blll undcrstanding support. At this stage. it may be appropriate to
ricgotiatt; with the: cmployer if:l residual disability requircs special
:ll.:comlllodation: to pursue job plw.;t.:ll1ent if the patient has lost
cmp!oymelll: or lo pursue ;\ vocation;11 rdmbilitation program if
Ihe p;ltknt h"" rcached ;1 IJefinancnt and stationary status with
residual disability thai would preclude return 10 the previous elll-

Phas~

r;lllg~ of llIo1i(ln

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ploymcnt ~cHing.

Timely identification of those individuals who arc vulnerable 10 develop chronic pain syndromcs. and working with
them to tt:ach and CllCOur;lgC them aboul thc importance of
thcir active in\'oh'cmcnt in and responsibility for Iheir recovery. \viU result in more clTcctivc and faster physical rchabiliunion. Impediments and !'itlllTlbling blocks to rccovt:ry should
be idcl1litkd early on .md <lddrcssed. Thc fundamental importancc or cmpl13~izil1g conditioning (and not focusing on pain)
is underscored. The injured worker must learn 10 work
throug.h the pain with <l no pain-no gain philosophy. The
temporary aggravation of pain when lhe patient \vitll a
chronic pain ~yndrolllc cmbarks Oil this program should bc
anticipated and identilicd as a rC<lson to prcss on. rather than
to slack off. The physically supple. strong. and ncrobically fit
individu<l1 is not likely to devclop much less sustain a disabling chronic pain syndromc.

CONCLUSIONS
It is imponant for the practicing chiropractor to recognize.
evaluatc. {cst. and trcat patients with chronic b:tck pain in
whom psychological .md emotional factors arc adversely coloring the clinical presentation. thereby constituting barriers
to reco\'C:'y. Prompt recognition and comprehcnsive suppon
lye and aggr~~sivc treatmcnt of these Iroub!l.:d indi"iduals
is of ~ign:d imp0rtn!1C"c if they arc to relinquish p;l"i\'cl
dcpcndcl\cy ;md Ill<lladaptivc pain behaviors .1I1d regain a
more :.tcti\~ lifc~tylc.

nEFERENCf:"~

I. Becker GE: Chronic Pain. Depression. ,,"d lhe Injured Worker. Psychia!r
2.

Ann 21:1. 1991.

Ah:xand~'r F: PS)'chosomatic

~Icdicinc.

New York, WW S"onon.

1950.
:t Brown T. \"cmi;lh Jc. Barr JS. Cl al: I'sychological (aclors in low rad.:
pain. N Er.fl J Med 251:12~. 1954.
4. FrYlllu~'\.'r lW. Gordon SL (cds): New Perspectivcs in Low B;]~:" Pain.

Ameri'an A.;adel1ly of Onhopaedic Surgeons. Workshop. Airlie. \"A.

1988.
5. Ford CV: The
1992.
6. Lip(lw~1.;1 7.J:
1990.
7. Frymoycr JW:
it Sifneos PE:

role of somali7.;]\ion in medical pr.lctice. Spine 17:S:-38.

Som:lti7.;\lion and depression. Ps.ychosom.nie:,

I: I~.

BilCk p;lin :llId sciati::;t. N Engl J Mcd 318:291. 19$$.

Shon Term Psychotherapy and Ellloti'lnal Cri:,i:,.
Calilbrid~::. Hal"'.ard Univcrsily Press. 1972.
f). mume~ D. Heilhronn ;'1.1; Chronic pain a,. a \';triant of dcpresslw Ji~~a..'e,
J Ncr.' ~1::::t Di:- 170:381. 1981.
10. Freud S: Strachey J. Frcud A (cd!'): Thc Standard Edition ~,( ~h<.':
Compktt: P;;,yehologic;ll Works. London. 111e Hogarth Pre$~. 1..:):'~.
p60S.
11. S;mdlcr JL Bed;cr GE: t\ddres"ing the rd:!lionship octWCl.'1l b;:.:k r:!in
ilnd diwe'" in your pali~nts. J Musculmkd l\lcd 10:26. 1993.
12. Lipow:-ki ZJ: Somalizali\lIl: The conccpl and its clinical applic~ni('ln...\m
J Psychi;)'lr 1-45:13%. 198ft.
13. Feucnnill'1 JL: Vcnebralncuroscs. Psychos-om ~'lcd 2:265. 1940.
14. W;lddcll G. ?'o1cCulloch Gt\. Klllnmcl. ct ;II: NOllorganic physic:11 $i::r'I~ in
low b:u:f: ;:.::in. Spine 5: t t i. !()SO.
t5. Waddell G. Pilowsky J. Bond ~'1: Clini{'at ;\s-s-cssment anu im"i1'r~'
131i0l1 01 ::bnonnal illness- hcha\'ior in 1\\\\' hack Jl;lin. P.lin 0:.1 I.
1989.
16. EllJ;c1 (;1. "Ps)"ch{l~:l.'ni~" pain ;md thc p;linrronc palicill. Am J ~kd
26:899. ! ~,~'j.
17. Schofferm::.:'! L Antl.... Po'l.ll I). Hinc' R. cl ;11: Chiklhuod ps-y~h\'I,'::i~;11
lr;J.uma C'.:7::1atcs with unsuccc...... rul IUlllb~lr spine surgery. Spin,, 17
\Sllprl,:S:::~.

1992.

IS. Soulh" l~;. 5\1. While A'\: 'Illt: u"e of pS.ydl\llogicilllcsts in llk' <,'\;11113tion of k:bad; p"in. 1 rhlllc Joint Surg lAmI65:560. 19S.'.
19. Becker GE. Smith RB: P...ycholugical fa~ltlrs ill h;ll:k I'~lill. III
Kirk;lIu:.-Xillis WH. BUrlll1l CV led... ): Mall:l;:ing Low B;I~'k P.IlU. :"<,'w
Ytlrk. C::.~~hilll.i\'ill:,>hUle. 1992.
10. Wih.. . c LL Rflcdlilll'D: I'rcllpcr:.l\i\c p~ydH,111~icallesls as rr\'Ji,'h'r~ Ill'
sunc...... I.: ~hcllll)lIudcolysi .. in the lrcallllelll \'1' lilc lowb:lCk "~II,lr\'I\l~'_
J 0011(; J:.;~;; Sur,.: IAml 57:479. 197:;.
21. l.ecsH;.:!~:. PR: A fake bad \(;;.:1.: on lht: ;'I.1~tPI-2 for l't:rs"ful Ill.iury

dailll;lIlt P,yt.:hlll Rl.'p 6S:203. I'NI.

'" Cairns D. R\.hefl'llll J: ;\ sysk'm f\.r c\"alua(in~ ;IlIJ lr<,.!Iill~
dmmic ::-::.~~: Ji.":;lhililY. We...l J ~kd 124::nO. 1976.
2;\. Brown.V The P;)lhtlrh~'sinlogy :Illd Di;I~lIt,~is til' I.ow Ibek P.m~ :md
Sciali(":J ';mcril;;lll .\\.';ukmy <If Orlhllp;\l.'di~ Sur~C()IlS. tn~lru.:ti\'\l;ll
Course L;;;uro.:s Xl.I. 1\11)2. pp ]:0)21:;.
2~. !lhKlIlC~

24. Dcyo RA: Non-opcrnti\'c Irc.;Ilmen! of low oack di~ordcr~. In FrYnlo)'cr

JW (cd): The Adult Spine: Principlo.:s alld PraClicc. No:w York. Raven

Press. 1991.
25. Sh:mbach R: Behavior therapy. tn Wall P, t-.ldnd, R (cds): TC.'l:lh(\ok of
Pain. 2nd Ed. Edinbursh. Churchill Uvlnsslonc. 1989.
26. Beck AT. Rush ,\J. $h;\w OF, cl :11: Co~nili\.:' Tlu:mpy of lkl'rcssion.
New York. Guilford Prc!\s. 1979.

27. Rowa: KM. l;:a...~ :.11:.. \ ,:o::::~.;;:;;;;. .: io;....:,: "I' can.:: 1':lliO:III. f;llllilv.
and health profcs::ion:.tk In Wall 1'. ~kl~;ld R lc~h): Text!>,,,.,, tll" 1':li;1.
211d Ed. Etlinburgh. Chur..:hill LivingslIllh:. 1%9,
2X. Pllblin PH: The rlllH:liNUI rcslw;llillll appa':lo:h to d1f',}Ilj,,: In\\ h;ld.
pain. J ~l\lscu[(\s~d }o.kJ 7:17. 1990.

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Ed

LU PatIent/Doctor interactIOn
WILLIAM H. KIRKALDY-WILLIS

SCOI'I-: OF OLR RELATIONSHIPS

The interaction between medical doctor and patient. chiropmctor and patient. and medical doctor and chiropractor leads
to an integration, a oneness that embraces these three and
their environment. The resultant combinations arc addressed

throughout Ihis chapter. Relationships matter morc than noy

individual factors.
"'n the rcalm of science. lhe unbiased observer record!> tlCIS
from the world around us __ . In the field of ..n. the observer is
involved in 3 pcrsunai assessment of the objects studied ... III
Ihe sphere of religion. two or more people arc im'olvcd in personal intcr;,.ction:'

These words of Macmurryl.2 define the scope of human

relationships. In the work of any health care professional, all

three areas of study-science, art, Hnd religion-arc impor~
t~UH.

Chiropractic embraces all three ,Jrcas, which is why it

IIns so much iO offer.
THE INDIVIDUAL
Each person i" made of four differellt. yet interconnccted,
parts: the physical, the cognitive (logical), thc emotional, and
the spiritual. This image can be illustrated simply by drawing
a circle that represents the individu:ll. dividing it into four
quadrants. and imt.lgining t.l door bet\veen each division to illustr:lle the conncction between the parts (Fig. 20.1). A pr"lctical application follows:
E"1Ch (lilt' (l:'lh~ four p:lrts innuellcc~ lhe others. A hig dillercllcc
is nOlc.:d !Y.:IWccn a disk hernialioll ill a person who is in good
mClllal. cm(,rional. and spirilual heallh .llld one ill .Ill individual
who h;\~ m::nlal or emotional problelll:'. A complete diagnm.is
includes th:: other Ihree component:' ;IS well as the physical
lindings.

The same <lpproach is required for tremment. It is often

easy to trem <:. woman with tl sacroili:lc syndrome who is otherwise in good hcalth. but the s,lIne lre..ltll1ent is diffkult in an
individual who is resentful Loward her employer.
THE INDIVIDUAL AND THE INVIIWNMENT
The cnvironm:::m also can, for conYcniencc, bc considered in
four parts (Fig. ZO.::!): the workplacc: home: social gathering.
consisting of <:.clivities in the elub or the church; and hobbies.
The;,..: is funher interaction between lhe individual and Lhe

different parts of the ellvironlllellt. A simple practical <lpplic~l

tion follows:
'111C diagnosis mllst include 1101 (lnly the phy~ic3l or mental
problems within the individual, but also how the patient feels
.Ibnut life al work. at hOIllt:-. and in the exlernal ellvironment. A
facct syndrome may be a minor problem in ;1 person who is
happy ,It work and ilt humc. A silcroilj;lc syndrome may prc:,ent
il difficult problem for" person whose spouse is ullsymp:lIhctic.
In prescribing treatmcnt, lhc ;Jllswer lIlily be found by illlroducing a change in the workplacc or adjustment to life 111 Ihe home
f:1(hcr lhan in chiropraclic manipulation or dntg. injection. or
olhcr Ihcrapy. The wriler rcc;Jlls the ";Ise uf a yuung mall with
symptoms suggestive uf a cauda equina syndrome wtw rccO\
ered r;Jpidly wben plans were lllade for his mother-in-law to take
a long vacation in iI dist'J1l1 pan of Ihe country.

The wise physician. chiropractor, or physical therapist

sees the patient as someone with four parts to their make-up
living in a four-part ellvironment. Practitioners cannot help
every patient with all possible aspects of their problem, but
they may need to approach the problem in greater detail
sometimes. Often it is helpful to allow the patient time to tell
all he or she wants to say about hil1l- or herself. \Ve should be
<IS prepared to refer a patient to a soci:11 worker. industrial ~Id
viser, or psychologist (Is we would to a neurosurgeon or orthopedic surgeon.
LISTENING: A BASIC SURVIVAL SKILL
A study at the University of Minnesota suggests that 60'ic of
misunderstandings in business result from poor listening.
Eight percent of all business commullications must be repeated. Rarely is morc thtln 20 cK., of what (01' mal1<lgcmcl1t
says understood five levels below. Sixty percent of customers
who stopped buying from a comp;;my did so because of poor
listening, an attitude of indifference to the client. Eighty pcr~
cellt of the day in business is spent in communication. but
time spent in listening is often <It only a 25e;t" cflicienl'Y level. \
Poor listening skills ,Ire responsible for Illany of our failures
and for much dissatisfilctioll felt by our patients.
Fmnk discussion of religion has often heen difficult. awkward. and sometimcs taboo. It has taken lhree or four hundred
years Lo recover from the dicHlln propounded by OCSC;lrles,
who taught that the Mind and the Body :lrc (wo scpawlc entilies in any individual. For mallY years. both doctor ..Ind patient
have felt uncollll'orl ..lbic di~.;;.:~;ssing religious maltcr~.

405

PHYSICAL

MENTAL

llfti,.:.... r is IHIt llH.rd~ ~l\It1t:Ollt: who c.m manage a prohkm. hut

l'lllt' who 111:lirll;lil1~ ({'111m] \\'hell (oping \Vilh a 'mess."
Fn1l11 Ihi:- di:--lU.."j\ll1 of the inui\'idu:'11 anti the cll\'ironllI\,.'IU. il is easy hl ~I..''''' thl' common ground between the busi
lIt'" l'XLTllli\'l' ;lll{! Ill.: kallh em; professional. In helping his
{\r Ii '" pal iClih. Illl' ph~ ,il'iall or \.:hiropral:10r IIllist he prcpah.:U
III d ';d ",ilh tlli ... "1lIt'''''' frl.'qlh.'lllly. T'l rcali!."" thaI physil.."j;lllp:ltit'lll "ilU;lIitlll' 1)111.:11 arc fr:tU~hl with'lhis kind (\1' diflkulty
i... III minilllizc lh.... ,tl'l.', ... c.xpcri .... lll'l.:d by tIll': th .... rapist. [11 additinn. it .... n:lhk:-. him or her 10 ullth..'rsland llHlrc easily the
1IHlugIHS. fcdill~S. ;Illd altitudes of the p;ILiclll.
It is curiolls thaI \\'1..' human hcing.s havc two opposing
f:ll'Ct:-. within tl:-., On Ihc {lilt.' hand, we \\'Olnl ~ bc different.
~1~ll1d out among our fdlows-hrilliam roolh"n player. top of
Ihe d ..lss. c;lrly promotion: 011 lhe other hano. \\11..' wallt to
Illl'rgc wilh the I.'rowd-havc the siilllc ideas and habits and
we;lr the same dothc ..... Tht.'sc w..ming faclors make lhe

EMOTIONAL

SPIRITUAL

Fig. 20.1. Four aspects of personality.

"11)1..':-<'

more l"lHllpk'.x,

or the many \\'ay~ to dcal witllthis mess." the Ill()!'l valllThis attitude is etwnging. however. Many of us now feel
at ease when talking about our world. our universe. and our
Creator. The approach of many. p~lrticularly younger people.
to this subject is often one that differs from tellr.:ts once considered orlhodox. As physici..ms. we need (0 keep open minds
with respect to different ide..ls and beliefs. The good physici"ll1
sits beside the patient prepared 10 listen. rather than standing
over the patient or sitting behind the desk. prepared to make:
pronouncements about the individual's health.

MANAGING SEVERAL PROBLEMS AT THE

SAME TIME
Although a great deal of our work helping people back to
health is quite straightforward. it often can be difficult ancll:lX
our capacities to the limit. Ackhoff. an expert adviser ..md
writer on the subject of business and industrial m..magcment.
commcllled. as quoted by Dixon.~ Ihal problems in these. areas
rarely occur in isolation. In <l plant or facwry. several problems typically exist al the samc time: they arc constantly
changing and intcracting with another.l\ckhofr calls this continuing proccss "mess:' In his opinion. a good chief cxccutive

:,blc is l'-'llghter. H'i," and nol against someone else. often

about something rirJindolls. Wt.'. can ~it beside our paticllts.
chauing naturally, gClling them 10 l<.lugh. laughing \\lith thcm.
~(llllctil1lcS wlH:n llcl.'cssary bt.'ing oursc!n;s the butt of the
joke 10 enhance the intr.:raetioll.

'.,~

liAWTllORNE EFFECT'-'-

Mal1<lgcment at the Westr.:rn Electric Plant at Hawthorne in

the western United St..ltCS W<lS anxiolls to improve the output
of thc workers, They employed ~l team of sociologists who
\'isitcd the plant. !;lIked to tllr.: workers. :lIld inspel:ted Iht..'
workshops. Among other Ihings. they dcci<kd to ilH.:rease the
lighting in several areas. At onl:c. the OUlplU from Ihe worker" ilH.:reascd dramalically. Everyonr.: was dt:lighted. At thb
point. one of the \"i~itors :mggcstell a funher changc., They
told the workers that they planned 10 help thcm further hut
were careful not to ~'IY whal lhey intended to do. They Ihcll
decreased the strength or lhe lighting (0 iI point below till.'
original level. To the "'l1rprisc of the m.lIl,tgcment. the output
of the workcrs incrca~cd still furlher. In fact. the workers h;ld
been innucnc<:d no! by the strength of the light but by the

-.,
HOME AND FAMILY

t
HOBBIES
(INTERESTS)

Fig. 20.2. The individual and the en

vironmenl.

@
tt

WORKPLACE

SOCIAL
(CLUBS,
CHURCH)

.... __ .. _ ........ "",.,

,
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407

IIVI\(

feeling that both m:,magcmcnt and the (cam of sociologists

were interested in their welfare.

In commellting 011 the Hawthorne effect, Dixon nOlcs that

the scientist. in designing experiments, docs his or her best to
minimize or eliminate this phenomenon, which is one kind of
placebo effect. Dixon thinks thaI using this effect forms the
bOlSis of a good deal of his practice and is a central feature of
family medicine. The author concurs in regard to his pwcticc
as well.
OUTAINING THE PATIENT'S CONFIDENCE
The effecI of putting the preceding principles into practice in
our office and clinics is to build up a patient's confidence in
him or herself as well us in the physician or chiropractor.
Our interaction with each patient should begin with a
friendly greeting. a handshake. walking with him or her from
the waiting room to the office. sitting beside him or her and
not behind our desk. These things arc little but very important. and represent the invaluable combinati(;n formed when
Pc.liir.;ilt and therapist work together.
Legend has it that in teaching his apprcmices. Hippocrates
stressed the value of obtaining the patient's confidence. It is
reported that he went so far as lO say that evcn in cases of the
direst of diseases. the comentment engendered by the patient's conviction of the real concern of the physician could be
the main factor responsible for a curC.
Chiropraclors have all advantage in that their particular
skill requires them to lay hands on their patients. This action
itself induces confidcnce. The rest of us should share this ad
vantage. by touching the patiem with our hands during the examination and placing a reassuring hand on his or her shoulder when saying goodbye. In referring to a specialist, onc
patient said. "He never laid a hand on me 10 examine mc. He
came into the room. greeted me brieOy and them asked his
resident to tell him what he had found. Then he (old mc i
would need a CT scan. a myelogram.1I1d an operation. I was
nOI satisfied. 1 said 1 would think it over. I didn't go back to
sec him ag'lin."
HOLISTIC DIMENSION
Obtaining Ihc paticnt's conlldcncc stems from our regarding
him or her as an entire. integrated being. a unilY. somcone of
valuc-the physical, mCIHaJ. emotion.d. and spiritual working
in combination. The tem1 draws attcntion to an imponant fact.
already considered to some extent: 'IS we look on our patients,
set Ollt to diagnose their ills. and attempt to treat thcm. we
must think of them. '1l1thc time. as a whole man or woman in
their own p::lrticular environment. In so doing. we try to get
alongside the paticnt. with or almost ;1 p"lrt of him or hcr. 10
help solvc the problem.
HOW SYMUOLS AND METAI'HORS WORK
The use of symbols :md mClaphors has a powerful effect on
the patient. They help the patient overcome the feelings of

ios:. of wl&ulctlr.::-:' ;'IIIU unelh';~:-, iv:-:-. ,,;' ... ouirol. vulnerabililY,

and isol::uion from friends. relatives, ::JIll! colkagucs.
Symbols and mctaphors ..II'<:: vcry pcrsonal. E~ICIl illdi\"idu<ll has thc ability 10 m"lkc his or hcr own symbol<;.
Somctimes. cxh:rnal CVCtHs o\"er which wc sel.:1ll 10 ha\"c 110
control I1wkc ~~ I1lbols for liS. Groups or pcopk ;111d rwtions
also havc their:-~ mhols. A symbol often. pcrhap:- alway'" \,.';11'
rics I11me weiglu than logic.
The situation in which we lind Olllsd\c, IS not .l!\\.l''
friendly. Friend:,. acquaintances. doctor:-:. nurses. cven l:hin l .
practors C:Ul disturb the working of our symbols and
metaphors by their .mitude. their thoughts. their words. and
thcir actions. All of us call rccall examples of being abrupt.
unkind, or unfeeling in treating a p.Hient. Reminding ourselves of sucl~ occurrences cncourages us to do better in the
future.
TIle following scenario oCf.:urrcd in a major tcaching. hospital. Cystoscopy W ..1S to be performed in a large room with
bright lighting in lhe presence of several uoctors. /lllrSt:S. ::llld
orderlies. The patient was taken to the room from the ward
without any prcopenllivc mcdication. He had to get himself
across from the stretcher to the operating table. His legs \\"e-rc
placcd in stirrups. all of him in full view of all persons in the
room. The surgeon then injected .1 local .Ulcslhctic pt:r ure~
thram. A few minutes later, the cystoscope WtiS passl:.":d. a
painful procedure. This experience of both pain and embarrassment affectcd the patient adversely. IC:lVin a pcnllant:1ll
scar, with fear of and dislike for the urologist. A few changes
in procedure. a few minutes of explanation by the surgeon the.::
previous evening. and some arrangements. for more pri\"~H':y
could have made the whole proccdure less traumatic both
physically and symbolically.
RESTORING THE PATIENT'S SELF-RESPECT
Fortunately. it is usually not difficult for the caring phy:,icbn
or chiropractor to help tile patient regain his or her feeling of
wholeness. belonging. and \....orth. The physici::lll or chiropractor can listen carefully ::uld with concern to the patienl's account of the assauil on his or her dignity. Some sanlpk cxchanges follow:
Hc or she can then S.~IY "1 agrt.:c. Ihis is thoroughly bad. k(~
,\'hal we can do about it together:'
The patient can be se~1l as oftcn as is nccessary l(l help him l'f

sc~

h~r

fcel happy. free frolll cmbarrolSSmCnl, .llld al case again .

The praclitioner can put him- or hersclf in the p'lticnr's Shl'C:'. ~:IY
ing "Yes, if that happencd to me I would be really mad."
The practitioner can say. "After what you have told mc. i \\-l'uld
be reluctant 10 undcro cystoscopy. I r.:all illlilginc h\l\\ YllU
fclt...
Another paticnl s'lid. "Once I had" catheter passr.:d by a r\lufh. inexpericnced a..sislal1L It WilS vcry painful. In my C<lse, I \\"~l:' wid
not 10 be a sis,",y. I decided lIot to go to that surgeon evcr :lfain 1111less driven 10 il." Thc physici;ul replicd, "I'd lll'lkc the S:UlIt.' d..:ci
sinn myself."
A physician s,lid to;1 p"ticnt. "Yes. SOIllC years ago. like y<,u. 1 had
(Ill one occ'l.~lon to I;Ike ,Ill my clolhes ol"f mid wail l"or Ihc dO~'lOr

\\il;iL' ~hln<..lill~ ill l"r\l111 ,Ii" j;, . . ,'I' ~i.\ 1ll1'1l

seemed to be ~njoyin); my pn.:l.!il.'allll.:I1I.'

ami \\'(1111\.'11.

Tlwy

All of these silllllliolls sound ridil,:ulously Silllpk. Till'

reader mav think thaI the\" an.': IHH 1\l..'II'l'u1. I hclil:\'c llh'~ :11\.'

cxtrCl1lcly irnpOrt<lllt for ','llsllrillg it l~rlJilrlll illll'r;ll'lip!l 1'1.'tween p~l{icll( and phy~i(iall!l... hir(lpr;l\.'hlr. Ccrwinly. tk p:!.
tiClll call do some lhillp rill' tilL' dOl..'!\lf \)1' l'hiropr;ll'!(lJ": !~.!\ .
in!! a h:lth berm..:- thl..'ir :Ippllinlllll'lu: w;lshing Ihl' (.. . \...\

Ih~rollghly: and

wc"lring dCOIli tll1tlcrw\'ar.

PREVEl'TION: I'!W\IOTING IIEAl.T11

The most important mcasurcs for the flHurc ..In: ill thl.." 1'1.':11111
ofprcvcnlion. Fortunately. individuals now invol\'ed in 11I"~llth
care arc concerned with the promotion of active he'llth ;1I1tl
110t jusl with the <.:orrcction of a disease process. This n\~l.'l1t
lesson has been lcarned mostly in the lieltl or sports 1llcdil,,:illC.
The resl of us owe a debt of gratitude 10 the pioncers in lhis
field_ Our mono should be "health through activity'"
Thc 100is and resourccs nccded for disease prevention are
well known. \Vc need now to reline ::Ind develop lhl.'lll.
ChiropraCIOr5 and medical practilioners teaming to \'.. or" 10gether in harmony is probably the most signili<.:alll advancl.' in
[he field of musculoskeletal illncss and tre::Jtmenl. These professionals havc diffcrent yet complemcntary skills and allitudes. For the last 25 years of practice. my work in incrc:t:,ing
cooperation with chiropractors has turned oul to be of great
benefit to chiropractor. physician. and palient. and W3' of
great assistance in teachim! and in resc'Jrch_ Whcn chiroprac;or and physician work together. almost in symbiosis. the rcsuit is something of far greater power than the sum of the two
working alone. An analogy can be helpful. The power re:;uhing from fusion of interests on the spiritual pl:.mc is comparable to that relcased by the fusion of hydrogen :.Homs on the

Fitnl'ss Cl'ntcr
I:\"\.n sm;lll Nonh Am;.'ri.:an citi~s ha\'l' on~ or t\\"o litness
;lnd large ci,ll..''' have many. Thb type or vcnture is
lIsu;dly fUll by a lr;lill:..'d tlH:rapisl or exercise physiologist.
Thl'ywlrl. startl.'d fnr Ill-.' henclit
IIH\~C cngaged in o.Itlllctit:
;ll.ti\,itil... Ill' :.11 kiml-.. ;,' hoth prnm(ltc litl1ess and help the
rl.Stl!1l1i\11l or minDr l11tl'l'llh\~kcklal illjuric~. The dielll
;1l1L'Il(b ;11 his or hl.r ,'\\ 11 Qllitiol1. docs his or her own
work-oul. ;Illd ;lsb 1'(11 hdp alld ;td\'ice as I1cce:-.sary_ iviany
dliropr;ll'{\lrS :Ind Slllll:..' physiL'ians usc thc litllcss center
tIl Suppkl11Cnl wh;lt thl..'~ GIll do for the patient in their or~
li(~ :lnd wh;lt lhe pali;.'1ll can do .11 homr.:. They refer the
p;tticlll 10 lhe lhcr;lpi~t in.':harg.r.:. bcing careful to kt tile
lalll.:!' know by pholle or wrillell IH)\e the nawre of the
prohlem. with l)Crhap~ "Ollie sugg.estions as to the type of
L'xl.'rcis(' li!,dy 10 bL' u,cful. The therapist has free rein to
dirl.:<.:t and advise the pJticnt and to control his or her activity.
While the patient i~ allcnding a litness centcr. the health
care practitioncr ~lIld IherJpist C.1Il have frequent dis<.:ussions
about lhe progress made. The chiropractor or physi<.:ian sees
the patient at regular intt:fv.lls. Somctimes. thc professional
personally attends the .,amc fitness center. \vhich provides <10dilion;J! \';dLJablc <.:011l<l(;t wilh both pmient and demollstr;ltes
Ih:.1t Lhe doctor does the things that he or she ad\i~cs patients
to do, E\"l~ry chiropractic or medical orticc should have access
to such .1 supportive progmm.
Coulchan 1 outlined the dimensions of treatmcnt outcome.
The doctor-patient illlcractioll is expresscd in thrce W:'lyS:
(I) focal. the treatmcnt method: (2) symbolic. r6ulting from
both cognitivc and affectivc intlllences: ;lIld (:.) behavioral.
ag.ain from these two intlucllI:cs. The routine of the fitness
(,:enter affords <lll three. It pro\idcs the incenth'c to develop
both the physic.lI and the spiritual well-being of the client.

Cl.'llll.r~.

or

physical.
Sometimcs the chiropractor takes the lead nod sometimes
it is the physician. Each should leam from the other. Th~ chiropractor can help lhe physician by making treatment simpler
and more cost effectivc. Quick. almost immedi:.ne intcf\ ention by thc physician makes things bcltcr for both paticnt ~l1ld
chiropwctor if somelhing suddenly gocs wrong in the management of a disk herniation or spinal stenosis. or sudden de\'e!opmclll of cauda CqUilHi syndrome.

Back School
The availability of Ihis f:.lcility is essential. The physician or
chiropr:'lctor should be <lblc 10 send .1 patient at any time with
dday of no morc than 2 or 3 days. A back school In:Jy be
staffed by physic~i1 and/or occupational thcnlpists. sometimes
with volunteer help. or by two or three chiropr:'lclOrs. II may
be in the orlice of a chiropractor. physical therapist. or physician, or in it gymnasium or hospital outpaticl1I departlTlcnt In
many instances. educational alh-anccs from the back ~cho()1
bc:nclit the COllllllll11ilY. The back school has bC~1l disc.:u~~cd
cxtensi\'cly elsewhere.

EIOlstic Uodysuit
The ratiol1;.J!c for wearing an clastic bodysuit for the prevention and tre.llment of 10\1. back pain is similar III thai Pllt forward by athlctes eng.tged in many different kind:-: or sporting
;lctivitics: downhill lind cross country skiing: bt'bsledding;
water skiing: and sl:uba diving. among other things: c1:'lstic
trunks or suits arc often worn by footb;.tll. tcnni~. and baskethall players <tlld by cycliq~: wdght lifters wcar a ~imilar garment. This type or garnlc_nt suppons trunks and r~"'is (focal).
gives conlidcn<.:c .md cnour.mce (behavioral). ;tnd expresscs
~hc idea that the alhlete i\ .. triving for on~ness.lllldy. mind and
spirit combined and intcgf<.ltcd (symbolic)."
Physician and ,hiropf<.lctor~ have been slow to grasp the
f~lCt that an el,lstk body\uit is not a rigid corsel but something
thilt cnhanc~s activity exactly a~ the corresponding g:lfIl1ent
do~s for the ~lthlele. \Vc need to r~think this means of making
l.'xtra provision f(lr prc\'cntion :lnd treatmcnt. In thl.' conlext of
doctor/p:.lticllt interaction. it i~ the symbolic aspc ...t that is the
l1\ost cogent.

..

,.:J.

I ..

,?

).

r\,

ASCENT OF TI II', SI'lkITlJ,\L

1\ series

,
j
~

Il

Religiun and Healing

Abdul Baha writes. "Religion and Science arc the two \\ ings
Oil which man's intcl1igctlcc can soar to Ihe heights. It if. not
possible 10 fly with one wing alone. With the wing of religion

'llooc an individual \\!ould fall into the quagmire of supcrsti~

I ,i
i

or steps lead upward from what might be cOl1~id~r~d

the purely physical (if such .1 stale cxi~{~d) to lhe COlllpkh:ly

spiritual (something 1101 seen in this "-orld). In our w()rk as
hc"hh can: pracliliona5.. we arc conccrnt:d with the sp:.'(trum
Ihal Iic:'\ bctwccn these 1\\"0 extremes.

,1,

)I
I

409

' v v ' - ' I v n 11'lII:HI-I.L.IIUN

lion. \Vitlt the wing of science nlonc he or she would 1'.. 11 inw
the despairing slough of materialism.""
Edison patented 1093 invcntiolls Olnd turned the iJl\'cnlions of others into a success. In 1879. after many unsuccessful attempls. he made the first electric light bulb. His tenm
produced latex from Goldcn Rod aftcr examining hundreds of
plants. When asked whcrc his ideas C41me from, he used to
smile and point 10 the sky.
Quite ordinary men and women like ourselves belie\"(:: in
the existence of a God who is all powerful and prepared under
certain conditions to intervene in our affairs. provided thi~ intervention docs not compromise our frce will. We seek this
help through what we call "pw)'cr:' It i~ wise to do thi~ lllorC
often than we do.

l\k.iI:alirm. r('!a.wtiol1. am! ;IIWgf''-Y ("1Il be a part of

H;\ck Sdllml or they call be taught individually. both with
gl"l.';II b:..'ndil. An illlcgral pari of thi:, proCI.'SS is how to
t1l;U1a~1.' :'Ircss. This subject is discus:,ed at length by
Z'lhollTl'k. t,
l.;'.\/' (.r the ilJlOgil/Clrio" should h~ cuhi\all.'d. Sanford"
tdb 11(\\, .:.hl.' was able w help a SlH,lll boy with a ':'l.'riol1s heaft
condition. She lIiscon:red that he \Va:' fascinated hy foothall. Sh:.. ,aid. "Let's pl;l)' <l gamc." He nodded ,lIlll agreed_
"Billy. illl~l~ine lhat you arc playing football and lhat you arc
getlinf! beller and hcacr <it it. Onc day -your team is playing
agail1~t Ihi: best l~am in (he Icuguc. You pl;:l)' so wcllihat yOll
score more g.oals than anyone else and win !.hc game for your
sidc. You hear some of the onlookers say -'Just look <It Billy.
110\\1 fa~t hI.' C<1I1 run. how well he tacklcs, how strongly he
kicks the ball. We' d like to be likc him. He IlHI:,[ be so fit <Iud
well: Bill\' was thrilled'" Sanford continues. "Can you make
a picture ~f that in your mind three or four time:, 1.'\'1.'1")' day:'
Once again Billy. nodded vigorously. He did this every day.
After a few months. be became perfectly fit and well again. no
problem with his heart, He later bc,ame <I great football
player.
The IIISIitutl' for the A(/V(lllCellleIlf of Hili/Ifill Bdwl'i()r, anolher resource, is in Stamford. Connecticut. This. organization
of psychologists. psychiatrists. and other practitioners plnns
seminars and mcclings dealing with the psychologic and immunologic aspects of both \vellness and dise:l:'L'.

Puhlications

Either/Or: Both/And

,!

,II
1

)1

,'

!
I

Somcthing is lacking in the way we think. Perhaps it has

always been that \\'~IY. In most situations. we think in terms
of either/or. The ehiropraclOr or osteopath thinks in h::rms
of manual thcrapy. thc physician in terms of medic.lIion or
surgery. In S;'lskatoon. the process of chiropractors and orthopedic surgeons learning to work logcthcr \Vas at lirs! p~inful
for both sides. Out of lhis elTon c"me a "both/and" tlpproach
resulting in a synthesis of both disciplines. something new for
us. to thc benefit of bOlh ourselves and our patients.
Turning to consideration of the physical and the spirilUal.
we encountcr the same difficulty. r\'1~ny spiritually minded
health care professionals sec no need for anything other lhan
physical and material methods of treatment. Priests and ministers who have ;,\ concern for healing often tend to lhink in
spirilucli tenns onl)'. The best approach is a synthesis of the
two. Intermediate steps on the journey from the Phy~ic ...1 to
the Spiritual contain clements ofholh, <.lnd are mentioned only
briefly.

Othcr Rcsources
/Jack sc.://Ool. already mentioned. deals not only \vith material
facts but also with the interaction of instructors and clients
.1I1d with the \vhole group ill the class. Discussion of their
problems dming breaks is as important as <lny instruction
g.iven.

Siegel \\TOIC of lessons learned about sclf-healin~ from a Sllr~

geo;'s cxpcricnct: \!"'ith exceptional p;,llicnts. ' : Hi:, approach
combines orthodox medicine with Ihe spiritual. The Americ<ln
Cancer Society Il:lS produced a pamphlet cll1itl~d Say it \I;tll
the Hcart to help thosc'suffering from callC('r. It. is full of
helpful ~uggcstiol1s and empha:'izcs the imponan... c of lhe patient's .lititmlc <lnd feelings. Another book b~ Simonton.
M<tlthews-Simonton. and Creighton <lppc<tls t:'ljually LO health
care profcssion.I1s and patients with cancer.l.' ThL' underlying
philo\ophy is th;,11 we arc all rt:spollsible for l)ur l)\VII hc"lllh
and iIJnc~ ... cs. and thaI we particip,ltc. cOllsl.il,.)lI=,ly or unconsciousl~. in crc;lling our own physical. clllotilmai. and spiritual health. The ktlO\\'lcdge gained from n~ading this book
can abo b~ applicu to the management of many ~)[l1cr cOIluilioll~. b;;: Ihey physical. emotional. ;lIld spiritual. \ Gt'uillg Well
AgClin j, also ;\v~lilable in videocassette.

Power or Prayer
M;'II1Y of liS believe that the natural indwdhng defenscs
a"ainq forcil'll
c invaders and disease, incllldill~ Ibc immune
s;slcm. wcre giycn LO us by God as part of our ~makc-up: lhat
our CIl\"iro111l1cnt contain~ many resources for hl.'aling. sllb~
stal1c.:c~ like pcnkillill and digitalis: and thai h~;l!th care professionab ;lIld (lthers have their source of tr;lining directly
from Him-it is no accident that hospitals :lnd dilli,s had
their origin in lhe mona~tcric:' of the Middk .-\;;e="

h is not too !.'!.r~at;l strell'l1 pf the i1llagillatinn to believe in

the existence of~lI1 all~po\\'errlJl king, prepared uncler certain
circulllstances to intcrvcnl' ill \)\ll' ;tllail's. Again. wc seck this
help through prayer. It is l':l'~ to ignore thl' l..'.'\istcllcC of a
power "reater than ourse!\'l', \\ hell till' Still j, .;hining. Thl'n
our bomfmav well bl' -~{)Ir. nur ':l\'ior the computer. Ol:r illSpi.
ration gained from though!" (It" "<..'.'\. Wlll'll ill health and disaster loom ahL'ad, \n,' ;1I"t~ lllPrl' indillClf!o h\\l]..: above and hl'yond oursch'L" for help. hlrlllllate is !hc man or woman.
health care pwrl'" .. ional or p;l1il'l\!. who seck, lO take advantage both of the natural pro\'isilltls for health :\Ill! well ness and
of those from lhl' supernatural realm.
One exalllpk makes the POllll morc dear. '~hc people involved were lOugh sturdy lishermell. The c.iptain and four
members of the crew of a sm:dl craft Iivcd for II days without food in a rubkr rart after their ::r9-llleter fishing boat sank.
They werc evclHually rescucd. When ljuesti(\I1ed later. one of
the crew said. "We did a lot or praying. I Jclinitdy belicyc
that God was watching ovcr us. Every timc \~'e made a stupid
mistakc or something went \\Tong wc would just slump our
heads and stan praying hcavily-and bingo something would
happcll. Wc did a lot or soul searching and now I think wc'rc
going to cnjoy the simpler things in lifc. Inswad of shootiJ'lg
for the stars we'rc going to sit down and smell thc flowers."
The samc sort of rcyclation can occur when somcone is
suffering from severe low back pain. at a time when both patient and doctor are at wit's end. A priest in the Episcopal
Church developed severc back and leg pain of sudden onset.
He contacted a friend who in !Urn called his friend. an ortho
pedic surgeon. The surgcon examincd the man and thought he
had an acute L4-5 disk herniation. This suspicion was confinned by a CT scan. Members of the priest's church prayed
for him that night. On his next visit, the surgeon prayed for
him as well. with some reluctance (surgeons do not usually
pray for priests!). In the middle of that night. thc patient' woke
up and realized all his pain had gonc. From that point, he had
a rapid and unevcntful recovery. Thc priest later said that he
had experienced two miracles: the first, that a surgeon had
visited him in his own home, and the second. the healing of
his back.
SUMMARY
Interaction betwecn physician. chiropractor. and patient is
both fundamental and complex. The resulting relationships
arc the phenomena of most importance. They depend on
something more than science alone. The raw materials of
which they arc built come from a variety of sources:
A careful study of science and its br:lllchcs

humanities
Philosophy
Mylh, lhc story with a meaning'
Behavior, symbol and Illclaphor

TI1C

The combination or these sources with the grcatest significance arc those with a strong symbolic content. GOOD' rela~
tions stem from our seeking the best for onc another. The
search Illay involve us in efforts to understand aspects of a
person's psychc thaI range from slight differences in dress to
grasping the nature or an individual's reaction to a situatioll of
life and death. At timcs, it is not difllcult for the discerning
physician to empathize with the distress felt by a patient. sh'lring the symbolic contt~llt and the behavioral aspects of the situation. The practitioncr must shift from time to tillle from
close identity on the stage to standing back in the wings.
In lhe process of travelling with a client from a state of
distress to one of complete well-being, we should be prepared
10 seek help from other sources. Complete rapport between
the physician and the chiropractor is of greatest significance
and also is rewarding. The convergence of ideas and beliefs
held by students and teachers from two different backgrounds
produces within them the stimulation required to conquer new
areas in the spectrulll of musculoskeletal illness.
Given the large a nUlllberof different approaches to spiritual healing. it is essential to respect beliefs that arc different
from our own. It is good to be aware of the presence and in- .
volvement of the Creator in any and every scenario in which
client and helper seek health and wholeness. This statement
docs not imply that we arc always talking about such awareness. \Vhen we ourselves do not have access to the "throne of
grace:' we should feel free to refer the client to someone clse
who has. The One who sits on the throne is able to come
"alongside" us just as we arc taught to come alongside our
clients in their need.

REFERENCES
I. t\1anllurry 1: Re;mm ;ll11d Emolion. London. Faber and Faber. 1935.
2. Macmurry J: Cre;l(ivc SocielY. London, Faber and F:lbcr, 1935.
~. Blanchard K: Listening::1 Basic Business Skill. In.side Guide. Nc\\"s1eller
for C\I1;ldian Plus. Toronto, Grant N.R. Gcall. June, July and August.
1992.
4. Dixon 1": TIle philosophies of family medicine (editorial) Can Fam
Physici;lll 35:743, 1989.
5. Chapman-Smith D: Rdleclions on the Hawlhome cffccl. Chiropractic
Rcport (editorial). Vol 4. 1989, P I.
6. Dix(\1I T: In praisc of lhe Hawlhorne Effecl (cditorial). Can Fam
Physician 35:703. 1989.
7. Coulchan L: The lre;lllllet\{ act: All analysis of the clinical art in chimpr:lctic. J l\-Ianipulali\'e Physiol Ther 14: I. 1990.
8, KirLlIdy Willi" \VH: Energy stored for aClion: The clastic lwdysltil. In
KirLlldyWillis WH, Burton CV (cds): Mmlaging Low B:lek Pain. New
York. Churchill Livingstolle. 1992.
9. Abdul Baha: P;lris talks. London. Baha'i Puhlic Trust. 1973. r 14.'.
10. Zahourck R: Relaxalion and Imagery. Philadelphia, WB Saunder.s.
1988.
! l. S,mfonl A: The Healing Light. New York. B"llanline Books. 19S.l.
12. Sil.'gcl US: Love. ~kdkil\e and 1'vliraek.s. New York, Harper & Row,
19S(I.
1.1. Simonton OC. Mall!ll.'wS S. Creighton J1.: Gelling Well Again. Nt,\\,
York. Bantam Books. t980.

Ll

Place ot Active Care in Disability Prevention

VERT MOONEY

The difliculty of defining and treating a sort tissu!.: in.iury to

the back is well known. Nonetheless, the.: primary thcr;lIk~Ulil:
focus is now changing from relieving pain to rcswring function. The ability (0 measure fum:lional capacit)'. cspct:i;dly for
the returning worker. becomes im.:rcasingly illlpOrWIll.

MEASlRING FUNCTIONAL CAPACITY

Most back injuries. whether industrial or n,:crcational. occur
withom :t verifiable sile of injury. No rcpcal;:tblc. valid lest is
available to pinpoint the location of the painful soft tbsue in
jury. It must indeed be <I sort tissue injury. bCl:ausc radiographic and bUlle SC;,1rl changes arc consislclllly nbsClll ill
what has been classified "motion disorders of lhe spine." i.c ..
p05tinjury back pain. Degencrative changes may be seen radiographically. but these findings arc nonspccific. In no study
h.lvc these changes been corrchllcd with specific back pain.
Without specific nerve root signs. therc arc no reproducible physical findings. From the chiropractic and physical
therapy \iew. the previous statcmcnt is incorrect. but currelll
Illcdicallheory holds finn to this tenct. Because of this difference in opinion. the consensus report of the Quebcc Task
Forcc on Motion Disorders of the Spine 'vas forced to classify
the back ailment strictly on the basis of pain location and its
duwtion of compl<lint. 1 This document .!lso proposes that no
mattcr what the soft tissue injury, problcms typically resoh't.:
within 7 weeks. If spontancous recovery docs not occur. the
problem should be defined from a multidisciplinary perspective. Intensive investigation of cause should be initiated early.
before a long delay allows thc burdens of deconditioning to
emerge.
Because the specific site of injury is unknown. palliative
care was considered appropriate. Until the last decade. rest.
physical ther~lpy techniques that reduced p'lin. muscle relax
ant medication. and analgesics were the standard of care.
Certainly. manipul~l[ive care can speed the rate of healing. but
Ihe mechanism is nol known,1 The emerging concepts or
sports medicine. however. Icd us all to realize thai soft tisslIt.:
injuries arc not bcst treated passively.
injuries to extremity joints. gradual progressive exercise programs to enhance
the organizalion of scar repnir in the strained connectivc tissues have become the standard methods of care. A combination of exercise with treatmcnts such as the :Ipplk:.uion of ice
to reduce the pain reaction is now recommended for ankle
strains and simil,lr injuries. It is therefore reasonable that
exercise is equally appropriate for individuals with low back

ror

injurics, No matter where the soft tissue injury--disk, facet

joints. Iigamcnts. or muscle tendon junction-progressive exercises Sllould be of I]enefit. Anolher importtlnt concept is that
when ex.ercises an~ used as the Ill<ljor trt.:atment tool. thc measurement
fUllctional capacity replaces the patient's assessment of pain as the b~I~\iS for evaluating progress.
Spons medicine cxperience also showed that rest produces dcconditioning of cardiovascular as well as peripheral
lllusculature. Similar information began to emerge from the
space program. in which the reduction in physical stress associmed with gmvity-rcduccd spilce travel produced measurable deficits in function: ' The space travel model also revealed not only that the absence 'of physic'll stress hinders (he
healing of injured soft tissue. but also deterioration in function of otherwise healthy tissues could be expected 10 foHow
prolonged rcst. It is rationaL therefore. to lllrn to thc measurement of function as a starting puint in an appropriate exercise program. We nced 10 cstOlolish the currenl baseline of
function. Aerobic testing can supply baseline of performance
(Fig. 21.1).

or

PERFORMANCE LEVELS
Objective measurement ufo function is accomplished fairly
easily in thc rcalm of sports testing. Performance 1c\'e1s in the
athlete arc measurable. and norms against \vhich to asscss
performance can be readily cstablished. Athletic pcrformance
is a summation of many physical charactcristics. including:
strength. endurance. neuromotor control. <and Illoti\ation. To
make the best lise of pcrfornwnct.: measurement. specitic
components. arc identified for lesting. Furthermore. no one
(est Ciln reliably predict IOta I performance.

R~HlgC

of Motion

Earl)' in the analysis of performance. range of Illotion was

recognized as a measurable entity. and the 'lbscncc of normal
range was llsed as a possihle predictor of delicicm performance. Range of morion of the extrcmities is nicely measured
by goniomctcrs (lnd thus became a standard of physical thcr"py assesslllent of extremity fUllction; the validity nf such
measurcment can be verified in the opposite limb. For the
back. however. r.mge of motion of the hips l1:1d to be separated rrolll that of the lumbar spine. Thus. in the bte 1960s.
sped lie discrimination of IUlllb~lr range W<lS cSIOlblishcd using:
inclinomcters..1 This method of evaluating lumb.lr capacity is
411

Fig. 21.1. Aerobic lesting using bicycle ergomelers is a relatively

inexpensive measure of pertormance. Consistency of elfort and
attilude toward physicallunction can olten be detellTlined by evaluating aerobic perlormance.

now standard. ~ccordillg 10 the AMA Guidelines for

Impainnclll."' In facl. the delineation of lumbar r.mgc is the
only objective measuremcnt of function for thc assessment of
spin'll impainncnl in these guidelines. This measurement
does not give a tolal picture. but no other functional capacity
tests for the spine have been judgcd reliable C1nd valid by consensus. Also. some clinicians believe they can recognize intersegmental vari~tions in motion. but such a finding is not
Illcasurabh.:. 1
Rang.e testing is insufficient to evaluate the functional cap'Kity of the cxtremilies. A signilicant innovation in the late
1960s was thc dcn~lorlllcnl oftMe capacity locontrollhc vari~
uble of speed in muscle function.] This isokinctic testing <.II~
lo\vcd an individu<J1 (t) cre'He as much torque as feasible.
while allowing forcc to be mcasurcd throughoul the range by
controlling velocity. This type of measurement proved to be
an excellent guide for sports medicine physicians trying to
evaluate the rdmi\"c strcngth of ncxors and extensors and status of rehabilitalion after injuries to various joints. The lise of
isokinctic dcvicc~ ..\S tr;tining/cxcrcisc tools has come into
question. howcver. because the incompletcly controllable imp;tct forces may cause ""Idditional injury.
Not until tlu.: early 19S0s WilS the conccpt of isokinetic
testing .applied 10 the b'lck. Using converted extremity equipment and normal subjects. the first study was conducted in
Japan in 1980." Although the invcstigators did not have a
mcthod ef normalizing the torque curves. and the equipment
required that subjects he recumbent for testing. several points
~lI1ergcd that arc cuntinned by current studies. In normal subjects, the extensors are s.tronger thun the flexors of thc buck.
~llId the differencc is more signific'll1t in mcn than in women.

Age definitely innucnces the strength of trunk muscles: older

subjects arc notably weaker than' younger individuals. The
relative strengths of extensors and ncxors, however. remain
the same during the aging process.
Smidt el al (also using convcl1ed equipment) took measuremcnts while subjects were sitting.;'1 more realistic posture
in terms 01" o;lck performance.') TIle results conrmn~d th'lt
men are sig.nilic~mtly stronger in torso muscul .. ltur~ 111<111
women, :ll1d that the cxh::nsors in normal individu'lls an: signitkmllly stronger than the ncxors. As in most of th~ early
studies. the number of subjects was small. Furthennore. factors such as fitness and patient size were not considered.
Nonetheless, the sitting posture could be of use in isolating
trunk musculature from hip musculature.
Mayer ct al lO performed the first major study using equipment specifically designed 10 test b.tck performance isokinc(ically. This group compared significant numbers of subjects
(125 normal and 286 chronic back pain patients). The patients
were tested while standing, which probably permits a more
realistic cv'lluation of lifting performance. The investig<ltors
also used the weight of the subject as a method of nOnllalizing the data (torquelbody weight), making comparison among
subjects more valid. Again. extensors were stronger thun Hexors in normal subjects, but extcnsor musclcs proved significantly weaker than flexors in individuals with chronic back
pain. At higher speeds. torque production was signitknntly
less in individu<lls with bClck pain thml in normal sub}:cts.
The study also dcmonstr.lted the e) lrCllle variaoiiity of
initial evaluation in back pain paticnts. Consistcncy of performance in spite of pain. however, can be expected whcn the
patients are fClmiliar with the mach inc. The study showed that
pain docs not limit consistency when the pnticnts me making
maximal efforts. The equipmcnt bec.lIne av'lilablc- as a
mcthod for idcntifying willful submuximnl or mislending performance on thl"' part of the patients. The concept that only
maxi'!1a1 effurt could provide consistent performance \vas
proposed in this study. This theory assumes 110 perfonn;mce
fecdback to the subject is being lcsted. It also assume:;. an accuratc mcasuremenl tool.
Another variation in the objective of back musck performance was the asscssment of trunk rOl<ltory perforll1~uK'e with
isokinctic torque measurcment cquipmcnt." Torque measuremcnt was ~Iccomplishcd with thc subjcl:t siuing. RaIOltional
torque in normal subjccts was about 50t;.,. of extensor torque.
Torque production W"IS signilicantly decreased in bal..k p.tin
patients. to about 65% of extensor torque. Patients \\"~r~ not
tested lIntii lhey hud achieved normal r..mgc, which w;\::. ~as
ill' defin'lble using this equipment. The authors of thi:, study
also mtel11plcd to COl11p..lrc myoelcctric performance with dymimic pcrform;mee using i:mkinetic equipment. but they
could make fcw correlations. No study has yel been able to
use clcctromyogmphy as a specific predictor or discriminator
of individuals with low back pain.
All of these studies involvcd the lise of cquipl11l..m from
Cybcx (Ronkonkoma. NY). the only manufncturcr (..If sll('h de
vices at that time. Othl..:1 tnanufacturcrs have emerged since

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413

operating at the same lime, comparison from one day to

alloth~r and from onc individual to 3nGther is morc difficult
111;111 with isokinctic equipment. Nonetheless, norlllal Icvcl~
of function have been rcponcdY Once again. women have
luwer torque and velocity measures than men. One of the
most ill1port:lIH contributions from studies w~ing lhi~ equip
lllcllt is that speed of perfonnance is a major discriminator be
{ween individuals \O,:ilh back pain.l-l Investigators lIsing (hi:- .
equipment have also observed that with increasing fa~iguc.
muscle substitution and greater deviat.ion in the arc of mol ion
occur.

Fig. 21.2. Example 01 a strengthening circuit manufactured by

Cybex. In the far rig f)! corner is the lumbar testing machine for
evaluating sagi,Wlllexion and exlension isokinetic lorque.

Ih-.: lap,ing of SOIllt: Cybt:.x p;ltcn1s. which h.ls led to a virtual

L'xplo~ioll ill lht: lllark\:'ling or l'unL'lional testing equipment.
In addition. mallY manufacturers supply exercise eqllip~
11lt:1\l modeled 011 tht: origin<ll Nautilus equipment designed
~O y('ars ago (l':ig. 21.2).
:'\ limitalion or all the carly studies was lhat the individual
was constrained to the ~allle position on each occasion of testing in :1I1 l:llorl 10 achicve rcpe'll'lblc dm.1. Each of us has a
spt:ciflc stralegy 1~lr lifting and lowcring thal is based on our
unique configuration of hiolllcchanic<ll factors. When
strapped illlo a silting or standing. position. we do not lift the
way we normally would (Fig.. 21.3). Another isokinctic tcst
i.lllows the pmiclltlo lift in any posture desired. This simulalcd
lifting t<1sk was performed from a slanding position. In the initial repon of this tesL 10\'..- back pain patients could lift only an
average of 67C;f: of Ihe value liftcd by normal subjccts. l:
Again. at higher speeds. pmicnts performed poorly in comparison \\:ilh normal subjects. The equipmcnt seemed 10 be
sufe. and the re~ults of isokinelic pcrform<Jllce testing were
more consistent than those of single position isometric testing
using the same equipment. Patients tested isometrically ill
incompletely isolated postures sometimes complained of
pain. whereas thosc individuals tested isokinctically USU~llly
t1id no!. Finally. a poor correlation existed between isokinetic performance and i\OmClric performance. Isokinctic testing was therefore advocated .IS <l safer. more reliable means to
test lifting pcrl~mnance. h had the potential to provide specific numbers ill !erms of torque and work pmduction. but
with the equipmellt u~cd in this sludy. anatomic isolation was
poor.

Such evaluation of lateral bending and rotation simultaneollsly with llcxion and extension is a unique property of this
equipI11cnt.l~ The point is that different systems of measurcment can provide alternative perspectives on human performance. It Hlso underscores the emerging awareness that onc
specilk me.lsure cannol totally summarize or diagnose with
certainty the incapacity resulting from soft tissue injury in the
back.
Various other methods can be used to evaluate free lifting.
The subjects arc tested in such a way' that they can lin or
lower <lny weight lhal lhe computerized equipment defines.
They can lift straight or in a twisting mode to \'arious heights.
Numeric representation of performance. graphic feedback.
and .1 printout of performancc arc available.
Simplcr mcthods of cvalu:ning free lifting involve having
the individual lift graduated weights. Perfornmnce is then
me.lsurcd in terms of increasing amounts of w(':ght !:ftcd C';cr

Isodynamiclisolllctric Testing
An alternative !o isokillctic tt:sling is a computt:rii'ed system
l'lbcled isodynalllic. Manufaclllrcd by Isotcchnologies (Hillsborough. NC). this constant~load device simultancously measures change ill torque and vdocity in all three planes of molion (silgilt;ll. frolltal. and tralls\'t~rsc). With ~o many variabks

Fig. 21.3. Device manufactured by the Lordan Company with an

adjustable platform allows testing while sitting or standing.
Unfortunately. stabilization of the pelvis cannot be fully achieved.
Also, intense. variable resistance concentric and eccentric exer
cise is not available.

With these design characteristics, the equipment has proh,~11

to be extremely reliable and repeatable in testing lumbar
strength (Fig. 21.4).20 This equipment can also be used for ex
ercise training. Because of the intcnsity of the variable resistance exercise, full potential for strenglhening C~lI1 be reached
with only one or two sessions per week. in 3ddition. strength
ening correlates significantly with dilllinish~d pain complaint.:!1

f,

PAIN TREATMENT

Fig. 21.4. Design of this equipment completely stabilizes the

pelvis so that testing accurately documents lumbar extensor mus
cular strength. Also, variable resistance concentric and eccentric
strength training is provided to the lumbar extensor muscles. This
equipment provides the most significant am\?unt of isolation. and
thus. specific training of any device currently available.

time. For safety and to avoid overexertion. limits on perfor

mallCc can be identified. For instance. in the Pile tcst, 5- or
lO-lb weights arc added ill 30second intervals. and the sub
jeet lifts and lowers the weights four limes in 30 scconds. If>
This lype of tcst provides an alternative to methoJ:i icquiring
expensive equipment. Normal standards and comparisons of
the performance of back pain patients against such standards
for thesc tcsts have been recorded. An improved weights in a
box test, known as Epic, has been developed that defines
deficit rclative to normal ability.17
Allhough isomctric testing was the first functional tcst
mcthod with which to assess lumbar performance and thcn
compare it with the expected performance of worker. this single-dimension'method has not maintained its primacy .in lum
bar assessment. l~ In simple. unconstrained isometric testing.
the posture of the tesl.subjcct is difficult to cOOlra!. In addition. the significant weak link cannot be easily identifiedunconstrained isometric testing depends on arm strength.
trunk strength, and leg strength, but standard test methods
cannot readily separate the contribution of each of these
factors.
Another isometric lumbar test. the Sorenson test, requires
th~ subject to hold the trunk parallel to the floor while the
torso is unsupported. In industrial populations in Denmark,
the inability to hold such a pO!'tufe for a minute or more cor
rdated with an increased incidence of back injury. I') This find
ing implies that strength has something to do with back pain.
New equipment has been developed, however. that speed'
iCi.llly segregates lumbar isometric performance from that of
the arms and legs. This equipment. made by MedX (Ocala,
FL). identifies isometric perfofllwncc at spccilic equidistant
points in lumbar range from full flexion to full extension. The
thoracolumbar spine is totally !s~b!ed from all other an<llomy.

Given our improved ability to measure strength. we must

recognize our inability to locate specifically the soft tissue
site of injury in back pain. Quantitative assessment of func
lion secms (0 be the only way to obtain objective data. This
concept is not totally accepted. Hasson and Wise criticizcd
earlier investigators for not dividing patient groups into diag
nostie categories; howcver. the diagnostic catcgorics they
suggested arc non verifiable. Le., ~acroiliac strain versus facet
syndrome versus disk pathol.ogy.1~ This problem is identical
to that which plagucs the treatment of chronic back pain: most
of the sourccs of pain arc non verifiable. Pain in the back usu
ally is withoUl representation of specific nerve root dysfunc
lion. The role of deconditioning-the impairmcnt of physical
capacity that may result from prolonged pain~limited bell..1 \'
ior--eannot easily be evaluatcd with a simple physicJI examination. Such barriers to undcrstanding have led to the deve!
opmcnt ef pain clinics with .1 focus on the perception of pain
f'lthcr than on the sources of pain. Behavioral control of pain
has been the project in these centers. but restoration of functional capacity and return to work have not been mC:i.lsured
goals.
The focus on treating the pain alone has led to a general
suspicion. particularly among third-party payers. that rchabil
itation for chronic pain may be ineffective and in fact m:.lOY
be no beHer than a placebo in attaining specific societal goals.
such :-lS return to work.~1 Fordyce and colleagues noted that
pain clinics tend to treat the experience ofp<.lin but not the disability associated with pain behavior. Pain often is associated
with the deconditioning syndromc. and technology now allows us to measure this extent of deconditioning. III the case
of the back. objective lumbar function testing has been of
gre<lt value in Ihe trcatment and rehabilitation of individuals
with chronic b'lck painY
It is a great improvement to base evalmltion on fUllctional
and strength testing rather than on simple :'Iltcratioll in the patien(s repan of 1><lin funclion. With this morc objective
methodology. the focus is on returning the patient 10 work and
normal life activities. But how C;.lIl we lise this improved ability 10 measure to enhance .lctive care?
REHAUII.lTATlON

One 01" the most imponant areas of community knowledge

has emerged from the availability of widespread observ'ltion
of sporting evenls. With lelevision covewge. man)' more people wilness injuries suslained during various professional

~ptlns. Tk~

abo obsern:: the rapid r~lum of this athlctc to acwithin -'L'veral day.. . or wecks after ~ignificant injury.
Thus. thl.' rr..,;t1ily or cl"kcti,'c can.: in SP0l1~ medicine is rcacl~
ily t.,:\idenl h1 the publ;t.' 'II large.
What ;1;"(' lhe priuciples of SpOilS Illl.'dicinc'! Put simply.
pm~fL'~S in tre;\(lllCIiI is b:ls~d on measurcd chanu.cs in fUllction. Thl.. ;Hhktt.,: vicws discomfort as im:!c,"ant in~'crms of reltlrn "ur hlll..:tlUIl. Moreover. Ihe c<lsily understood principks
or stlff li:-:-'ll( repair arc .. pplied 10 these athktes._Gr:ldu:ll progrc:\.sivc I.:.\l..rciscs Ih;lt challenge thc sofl ti"sues consistcntly
;!Ild progn..':-.-.ivcly constitute a rcli'lblc ther;lpeut;c l11;l11CU,"cr.
This pnll.:r..':-" is the way we all learncd (0 trem a spr<1incd
ankh.::. Tral1:-.fcrring thcse principles to otha joints, including
the bat.:k. b~;;implc. Are these principlcs applicable to industri;1! injuri6 as wcll'!
J\ reasonable approach 10 the injured workcr is to consider
that illl.li,iJu;s! an inuustrial athlete. The l)fOj~ct is to convince
Ihat indi\"idu;t1 th.t( the principles are just as applicable to his
or IlL'r injury as they were to the injured mhlcte they saw on
televisiun. Outcome in lhe treatmcnt of any joint. including
Ihe h'lt.:k. can be measured by using various tests of function.
As de:-:cribed previously. exccllent cquipmcnt is aVl.lilnblc for
lllc;l:\.urin~ qrcngth .1Od "cndurancc in a rcproducible. objectivc scnse. It is <lbo possible to idcntify It::\"els of consistcnl
performance and effort on the part of the injured individual.
The injured worker must want to oct txttcr for the treat1l1Clli progr;sm to be of benefit. Certainly. most people truly do
\\';Ill! to gCI better and to avoid pain anti disability. Their desires for recovery arc usually enthusiastic if the tre.Hlllent is
initialcd early. With prolonged delay in rational tre<llmcnt.
howe vcr. f<lctors of deconditioning of the soft tissues. as \\fcll
a:-: of the psyche, cmerge. Habituation to pain develops.
Perhaps some pleasure with absence from work may occur.
Under these cin.:umstances. significant social disruption also
can occur. Litigatio'n perhaps can develop wherein the suel'r..':--~ftll litigalion depends on proof of sc"crity ~md levcl of
pain and disability. Once thcsc psychosocial problems are: invol ved with Ihe rep<lir process. chances for success arc con:--iderably Iimitcd.
Even under these circumstances. hO\llCver. modern techniqucs offer a tool 10 urge the deconditioned worker back to
he;lhhy behavior. Thc progrmns arc gcnerically known as
work hardcning ('('IIle,..... Hereto. the earlier the disabled
worker panicip.ues. thc more sllcccssful the approach" What
:Irc Ihcs~ principles?
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QUEBEC TASK FORCE: PRINCIPLES FOR

EVALUATION AND TREATMENT

dr~ssed

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Certainly. the back injury problem is one that has been adby many experienced c1inici.lOs and scientists. A wide
~lfra)' of concepts and various areas of cmph.lsis havc becn reponed. A:-. mentioncd previously. a consensus of these COI1CCPIS is now availablc. In 1987. a document was publishcd
stoning tho~e principles dcemed most appropriate for the ev..lu:ltioll and treatment of back injuries. The projcci was initi-

aled by the Canadian Inslitule for Workers Health and Safely.

Thus, the Quebec T~ck Force on Spinal Disorders was convcned. Included in this task force wcre a wide arTay of experts
in mcdicine, law, and therapy.2s
This extcnsive consensus report identified various factors
that would increase costs, e.g. exccssive, unnecessary diagnostic testing. such as magnetic resonance imaging. CT. and
c1cctromyogrJphy withoUl clinical justification. Surgical in(ervclllion with lillie c1inic31 justificalion also was .. oted. Oneof the most important factors in increasing costs was the usc
of ineffective physical thcrapy techniques, such as ultrasound.
The usc of the therapies was "hit or miss" in large part because few objective data wcre used to support the benefits of
.my type of treatment program. Finally, the report noted that
cmployers often arc reluctant to allow an employee \\'ho is
still having pain to rcturn to work. This siluation led to prolonged treatment .1I1d. of course. cnhanced legal costs. Delay
in receiving effective care ,vas also noted as a factOr in driving up costs. What is effective care?
This repon revealed that most complaints were nonspecific in that no anatomic ..:au~c \,.uuld Ix: identified (0 explain
the patient's complaint. Even though thc source of the probIcm was unexpl<lined. however. bed rest turned out to bc an
inappropriate form of treatment. This study also reported that
surgery alone is not predictably effective in treating back
pain. Associated with this concept is that the dccis.ion to usc
surgical care should be made only after thc patient has particip<1led in an active rehabililatinn program and has demonstnned lack of improvement. It was 'llso noted that residual
chronic pain was not a contraindication for return to work.
This concept was further reinforccd by an excellent prospectivc study that documented a greater than 80% rate in the ability to return to work for chronically disabled people even
though they had some residual back pain. Z('
The task force also found that the majority of ('osts associated with back disorders are incurred by 10 to 1.5'7c of the
patients with symptoms lhat have lasted longer t.han 7 weeks.
Thus, lhe concept proposed from this consensus. report is lhal
scven weeks is the time at which a problcm i~ considered
~hronic_ Chronicity may be defincd as the time at which a soft
tissue problem no longer can be expectcd (0 he31 spontancously. This document also idcntified the milcsh,...ne of acutc
injury as 1 week, and subacute injury from I week w 7 weeks.
This differentiation is valuable in that if onc expe':-ls spontaneous resolution of a problem in the acute and subacute
phase, developing a morc vigorotls and cxpcnsi'-e treatment
plan during that phase is inappropriate in most (';\Ses.
There is somc support for the: concept rut forth by
McKenzie that a mcthod to prc\'cnt the back injury from deteriorating into a more significant problcm can ~ imple~
mcnted by a spccific exercise program that eVaIU;l{eS physical
maneuvers by which the pain is (:(l;l1lged. Studil;.s h:t'"C shown
Ihat if this program is initialed within the first ..1 wccks. excellcnt or good results C.1I1 be t:.'\pcctcd in 9};(""(- \,... 1' Glses: if.
howcver, the progwlll is inilimed after 4 wCt.'ks. the pcrccnt'lge of success drops to abollt Sock .~?

A relatively simple exercise progm.n1 was documented by

Choler ct aPR At this acUlc and subacute phase. some methods in the form ofhcat or cold likely arc useful: however. the
literature includes no justification. as supported by the
Quebec Task Force Study. that other techniqucs such ;;'s
diathermy, massage. and repeated hot packs offer any benefit
to enhance the rate of recovery. It must be emphasized that
treatment is to a nonspecific problem. and the only definition
of improvement in the McKenzie concept is centralization of
the pain to the mid-low back. I r the pain progresses funher in
a peripheral manner. the therapist must recognize that thc exercise program proposed is inappropriate. The exercise may
be extension. nexion. or sideshifting based on what happens

~'

to the pain. At least, this type of program has the benefit of

some relatively objective measurement of progress. Indeed, a
method to measure progress should bi! at the core of (Ill eDident. efJecri\'e rreatmtllf plans.

PROVIDING CARE IN TODAY'S HEALTH

CARE ENVIRONMENT

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The reason for interest in the sports medicine approach. i.e..

measurement of progress by some objective maneuver. is the
mattcr of reimbursement. As the health care system begins to
look for greater efficiencies, it is apparent that more docllment:.1tion as to the levcl of dysfunction is the basis on which
reimbursement is more likely to be provided. The system responds more specifically to paynlclH for IIlcuit.:;,11 care that is
focused on documenting how (he parient is functioning beuer.
rather than how they might be feeling better. Il is apparent to
the providers that even though the patient may feel better
briefly. no benefit has been served in tcrms of reimburscmcnt
for medical ClIrc without long-tem change in function.
Documentation of progress is lhe essence on which billings
are reimhurscd. Lack of measurable progress is the documentation on which lIseful medical care for soft tissue injuries has
ccased. This is essentially a sports medicine approach. It is
unlikely that the future health carc dollar will pay for maintenance level care for benign. nondestructive disease.
A plan of care that reflects this attitude is noted in
Table 21.1. This treatment guideline has been accepted by
scveral preferred provider org,lIlizations in the SOllthern
California area. It speaks specifically toward documeIHalion
of function.
In indu!'trial back injuries. experience shows that the patient seldom arrives at an appropriately oriented trcatmcnt
program wilhin thc first scver;;l1 weeks. In those patients for
whom treatment is delaycd. somc dcconditioning occurs. In
this group of patients. and those that have not improved in the
McKenzie type of program. one may expect <l relative loss of
range and strength. The reality of this phenomenon is documented by the fact thot an ICD-9 Code 728.2 makes aVililablc
a dctlnition of deconditioning by the diagnosis of muscular
wasting and disuse atrophy. This diagnosis cnn be objeclively
demonstrated by specific testing. Therefore. a treatment plnll
that strcngth~l1:'i i:iC soft tissues and can documcnt lhe benelit

Table 21.1. Treatment of Medical Bac;<,

Prot~cm::;

A program 01 progressive ex:ercise should be initiated after no

more than 2 to 3 days of bed rest. Passive melhods (either ice or
hot packs) are only useful as an adjunct to exercise, Other tech
niques are not appropriate.
An objective, reproducible functional assessment should occur if
more tpan 2 weeks of treatment are required.
Most patients need instruction on appropriate exercise but do not
need a lormal program of physicallherapy. When physical therapy
is indicated, rll)r~linn ~holJlrl nol exceed 6 weeks and frequency
should not exceed three treatments weekly.
Diagnostic radiographs are seldom appropriate initially and, with
rare exceptions. are not appropriate at intervals during lrealment.
Unless neurologic function has deteriorated or progressive exercise has failed. specific diagnostic techniques (e.g.. CT scan. magnetic resonance imaging, bone scan, EMG, nerve conduction studies) are not appropriate.
More than 75% of employed patients with medical back problems
relum to work within 4 weeks of.on581. Careful re-evaluation of the
treatment plan is warranted it the patient has nol progressed significanUy in 4 weeks.
If treatment lasts 6 weeks, the patient should be evaluated by an
appropriate medical specialist. The evaluation should include objective measurement of funclional status. reassessment 01 treatment goals. and confirmation of appropriateness of treatment.
If the patient has not return":!d to work within 3 months. the patient
shOuld be referred to a specialized center for computerized reassessment and care planning.

of treatment by objective testing is justified. These tools were

described previously.

SUMMARY
Active excrcise programs arc effective in disabilit)' prevention. It is important to separate the concepts of impairment
and disability. Impairment is the physical we~lk link(s) that
limit function. If we can isolate anatomy suffkiently. we
should be able to test thc deficit ;;.lOd evaluatc progress and
treatment by further testing.
Disability, on the other hand, refers to thc limits that prevent retum to thc previous level of function. In addition to lhe
weak link" is an array of personal and human factors thm
create disability. including age. sex. educ;.uion. secondary
gain. and overall attitude. Some factors of disability may involve acquiring b;'ld habits such as substance abuse, obesity.
marital and family upheavJI. and anxiety and depression. All
of these f<lclOrs seem to be enhanced by diminishing physical
activity. Physical activity th.u is focused on improving
healthy behavior is the anecdote to these disabling problem$..
Frequently. coaching in positive health habits is llecess;'lry.
This coaching docs not necessarily rail into the patient com:
realm of any specific clinician; all practitioners \\'110 come in
contact with disabled patients need to focus on these positive
faclOrs. Active exercise. not preaching, seems to h.lve th~
greatest opportunity to effect a significant change.

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HEFERENCE.,,)

wo, LcBl:lIlc FE, Dupuis 1\'1: Scicnlilic ;'rpmach Hllne assl.'ss

lIlelll :md lIlan:lgcmCllI of ;u:li\'ily-rclalcd spinal dis(lrdcrs. Spine I ~:S t.
19K?

1. Sril7,cr

(J
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I'rjll~'jpk~ and Practice. New York. Raven Press. 1991, pp 15811605.
Lamh I.. Johnsull RL. Sl. Jens PM: CanliO\':lscubr conditioning during
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En~dha;: :\L h.-d): Guides-Io the E\'"luatioll of Pcrlllallcm lmp;,irIllCIlI.
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<ii,,:lm:m R: "chimpra":lic approach in biomedical dil'mdcrs \)( the lumb:,! -",'111\' '1Il1l p\=h'is. In I-Jaldcmall S (cd): Mot!.:nl Developmellt!' in the
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l11isloc H, Hislop HJ. MofTord M, CI al: lsokinetic contraction: A new
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Ilasue M. Fujiw:lr:I M. Kikuchi S: A new mcthod of 'lu:llltit:lti\'c measuremenl of :lbdomin:ll :lfl(l b:lck Illu~clc ~lrength. Spine 5:143,1980.
Smidl G. et :l1: Muscle strength :11 the (nmk. J Onhop Spons Ph)'5 Ther
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:o.1:l)'cr T. Smilh S. Keele)' J. et :II: Quantification of lumbar function. !'an
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10:765. 1985.
~h)w T. Slllilh 55. Kundrd-<ikc G. el :II: Quanlilit::Ilion o( lumbar (UIICli,ln. l~an J: Prdimin:uy data all isokinetic 10NO rOlation lesling will\ myockt:lrit: sp'-~tr;11 anal)'sis in norlllal ami low-b:ld: p:iin subjecls. SPIIlC
10:912. 19K5.
Kishino N: QU:ll\tiliciltion o( lumbar funt'li\lll. Pitn 4: lso111elri, and i~\l.
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Sceds R. Lcvinc J. Goldberg HM: Nonnative data for is()st:llion BIOO.
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tion B-IOO. J Onhop Spons Phys Ther 10:121. 1988.
l'arnianp\Jur ~-l. Nordin r.t Frankel VB. el 'It: Triaxial coupled 1~(Jmctric
lrunk mcasurcments. Presented al Orthopedic Hcsc,tH:h SOCiCl)' Meeling,
Allanta. January 1988. p 379.

"

"

16. Mayer T. Kishing ND. Nichols G. ct :II; Progressive isoincl1\'ll llfling

evaluation. L A standardized prolocol ,\lid nonnalive dalaba...e. Spine
13:993. 1988.
17. Alpert J, M:llhesOll L. Beam W. et ill: 'nle reliahililY allli v,!Iidil}' or
two new leSCli of maximum lifting cap:lcity. J Occup Rehahil I: 13.
1991.

IR. Chaffin DU. 1);lrd; KS: A longitudin:ll study {If low h;lt:k (uill :IS ;Issud
<lh:d wilh lll:cupatiun:lt wci!;ht !if1illl; f"chlrs. J
lod I-ly,;: ..hsu;.:
10:5 n. 197 J.
19. Bit'rin~-Sml'IlSIlIl F: Physical mC;lsurCIllClll." :IS lisk indicators fllf b\\"
It.1ck trouhle over OJ OIlC ye;\r period. Spinc 1):-15. 1984.
20. Gra"cs JE. Pollock ML. Carpenter OM, Cl al: QU:lIllitali\"C: aSSl'ssmCIlI uf
full range of mOl ion isometric lumbar cxtcmion strcngth. Spine 15:2l.'i9.

"Ill

1990.
21. Gr.wcs JE. Pollnd ML, FOSler D. ct ill; Effcct of training frcquency
:lnU spccilicily on isometric lumbar c:\tcnsion strength. Spinc \5:504.

1990.
22. Ha....son SM. Wisc D1): Instrumcnted teluing of thc back. Surg Rounds
Onhop 10:28, 1989.
23. Fordycc W. Roherls A. Slcrnbach R: 111e bcha\'lorJ.\ managcmcnt of
chronic pain: A response to critics. Pain 22:113. 1985.
24. M:I)"crT. G:Hchell RJ. Kishino N. el :II: A prospcclivc shon-Icnn study
{In chronic low b:lc\.: pOlin p:ltiencs utilil.illg no\'c1 objt.~tivc (uncCioR:d
mca.<;urelllenl. Pain 25:.53. 1986.
.
25. Spill.Cr UO: Thc scienlilic apprc,xlch 10 lhe a.<iscssmclU and managcmenl
of acli\'icy rdOlled 10 spinal disorders. Spine 12: I. 1987.
~f. M:l)"cr ,,.. G:llt:hd R. M;sycr II. CI :II: 1\ pro,"pcctivc 1WO YC:lr study of
functional restor:\tioll in industrial low bOlck injury. J.-\~1A 250:450.
198-7.
27. Donelson RG. Sitv;\ G. Murphy K: The centralization phcnomenon:
Ils uscfulncs'\ in evaluating :1l1d lfe,lIing sciatica. Spine 15:211.
1990.
2S. Choler U. L.rsson R. N:u.:heIllS(lll A: Back p'lin attempt at ;I slruclur:ll
lrealmcnt program ror paticnt.. with Ill\\" h:ld: p:lin. SPRI Report ISS.
Soci;ll PI;l1Icrings-och R:ltiollaliscringsimsiHII Rappon. Slockholm,
\985.

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Index

I
i ,
,

Abdominals
exercises
crunch, JO';
lkad but;
description. 300. JOI
illuslratiun, 347, 382
isolllclrk.

306, JOi

SI:lbiJi~\ioll, 303-304,

304-305

gymnastic: tM11. 307, JIO-11 I

ohliquc. wcal.:llCss cV:llualions. lOY, 110
Abnoflll;ll illncss bch;wior
chronicity 'lOd. :!5
l1eltncd. ()
cffcCI on ncurolllusl.:ular system, 18
indicalions fur, 6
nonorganic ",i~I)"', 6\)

pain and, 17
Waddell's si);lls, 73
Abuse
cmotional, 396
sC."U<l1. 396
subs!;Jllcc. chronic p;lin patiel1\s :ll1d. :W5~3lJ6
Accelcraliondelckration syndrome, rehahilita
lion l11anaemcl1l. 378-379
Acromiocl:l\'icular joint. traclion-rnohiliw
tion, 2/';
Active carc, (S('t' 01.1"0 jvlanipulatin: lherapy; no:
habilitation)
for disability prcn:ntion, 411~ 16_ -116
nOIl:'ipcl.:ific b:lck pain. 300
passi\'c care and. l.:omparison. 1.":-1
role in rchabilitation, 32-3.\. 13
sci:l\ica.360
lre,l\lllenl .11:1Is. 33
Acti\'e prept.lsili\millg. ddin...'u. 2\):,
ACli\'ilies of daily li\'illl;
evalu;itioll \It". t)3
improper ;md pml",.:r po\ture
c<lrrying it...' I"s. IS}
dressifl~. 18S
dri\'ing. /77-/78
gelling in am} ()Ul or bl:d. 188
ironing. 186
overh~:ld r...' :Khing. 182
pulling,IS.J
pushing. ISo4
risin~ frolll ..::hair, /.'W
:-itting. 167. 17.'\-17fJ. 179. J..1I, .m.;
:-kcpill!!, ISO
AcupuIKtur~. dlrtlllic p:lin tll.:atUlenl. HlI
Acute p:lin. ,,'!In-nic pain 'llld. tf:ll1silinl1;11
sIers. IS
,\dUUClvf:referred p:,in. ~51)
!'c1f-streh:hin~. :!:(,l. 262

lhig.h
illhih;led. eV;llll:lIillll \If, IOi-:
muscle ilTlh;ll<lnc~. 9S-9IJ, 100
pnslisollictric rclaxalioll, 259-261. 2M
tighlncss c\alu;ttiol1. 98-99. 100. IOZ
trigger p(linls. 259
Ad~l1osill": lriphnsph:lle, roli; ill111usculm ninlf,K'
tions, 50
ADL. (5c'c' Al.:li\'ilics of l..laily li\'ingJ
Acruhic c:lpal.:ity. erfccl 011 lifting. capaCil)', 1..1-l
Acrobic condilioning. for atltktcs. 3..18-349
i\crob;c procc>.~es, locomotor syslem. 48
Aerobic tcstin. fur p:rforl1lam.:c Ic\'c1 d~tcr11lin:I'
lions, 411~11, -112
Arf~rcllt libcrs
mech<lnorcccplOr, p;lin cre:llion. 2.\.-25
nociceptor. musdc h)lJC :lIId. 2(J
spinal sl<lbilil)". 17
Agg.rcssivc carc
carly retum \(l work. 7.165
cx'lIllPlc.~ of. <>

Allodyn;:l
dclined, B
symjlWIll". 23
mo\'emcnt p:Utcms
chronic p:lin and. 25-26
erfcc( on mowr S)st~lIi. 30
lJ)usl.:ul"r imbal;ll'Ices :mu. J I
IrCal1ncnt for. 31
Amotivational s)"lIdrom.: . .\02
An:lcrubic capacil)', cffl'cl on lifting c<lpacity. 1..t4
All:laobic prtKc:-ses. 1tX:1I1110Wr sy!\lelll. 4S
Annulus
descriplion, 3..1 I
injuric.... 10. 34}
Anii-inllamm<llory lU~dk:\lions. low back pain :.1lc\'i3Iioll.3':5

Alla~d

,\RCON ST. /-17

Afln "b<.Im;tloli. ill p;ltil'nt with shor1ellcd upper
lrapczius. 135. 135
Aniculol1luscular :llllJllitllde. (SC(' Flc.'(ibilily)
Asymlllctry. pOSluwl llllli....
id~ntirying. 3:\1-.'.': '.
palholo,gj(,.. 331
physiologic, :n I
Athleles. (SttIII.WI Sptln~l
lum!l:lr spine injurk,.
:lcruhil.: (,.:"tJlldititll\ill~. 3.\X-341J
:Igcrdated facl(lr~. J.\:!
ll:tl<lncc r.:'turalioll.

,,"'9

ht:d 1\:'1.

J.I{.

. . \)/1111\(111 'ymlrtllll...,.. J..15

comdin:ltilill. ~'\I)
diagno,i:-. 3'11
injury JlIech:mislll~. J12

lI1:lnagelllcnt guiddincs, .]:.:>

Illl11opcrati\'e care. 3~5-3~6
patient history, 3-1..\
physical c;.;amination, 34.\-315
predisposing f;H:IOr.~. 341
rehabilitalion prosr(llilS. 3.48
spmltl)'lolisthcsh tx:curn:llC~. Je
spondylolysis OCC\lrrCllce. 3..l:!
t01ll1.: sll\:lIgthening pro!!r:lIJ1s..U6-J-li
ATI'. ISt'c' Adclllisine triphosph:u':J
U;lh~

l.:<ln)'ing, cum.:ct mclhod. ISJ

dl:lIlgin!; slat Ion hClghl. 185
pUlling in car. IS~
[bel.: p;lin, lllw. I.St"( Low h:l(:~ p;lin I
Rack P:I;lI CJ:lssilk:lliun Scale. description, 65
B:Jck relief. 1.":6
Ibel.: school
b<lck s:tfety trailliu:;. 1;7, 160
back tr:tining and CxeN."isc pro~r:llll:'. 156-1:'7
California, 155
Canadian Back E~dlU.:ali(lll Units. 1:'5
company interview. 159-160
curriculum. l5X
disability prcvcllIion. X
formats. 157-159
injury response lraining. lSi
principal goals. 15,'
prog.r.llU promotion. 159
purpose. 153-154
rcquil\:lllents for. 158-159
safely orientations to indu~try. 1:'6
Swcdish. 155
(J:lI:mcc b:llls
dcscriplion. 320
purpose. 326
Balance sh,'lCS
dcscriplion, 320. 323
guidclincs for using. 3D
il1uslrati(1ll.321
standin~ 011. 327
Ballel. low back IlImh.lr ~pin .... il1juri~:,. 350-351
Barre's test
devicc for. 335
illuslr:l1ioll.330
Harrier phCllilll1CnOn
illustratioll. 19,'\
rn;lllipulalivc ther:lpy. 19S-1(1)
palpaliull Icsliug
connccti"c ti~~uc, lOU
pressurc aprlic:ltioll-:. :!Ul. ~Ol
shifting :lIld Slfctching las...i:l, ~lll. 201

skill. 200
flllll;lion,. 19IJ
,un lissue p..in S~lldHlllle:,. :tl.:
prolei,'lin~

419

..I.

Ba~cball, lumbar ~pinc injuries, 353

Bcd, gcning in and out of, propcr fonn, 188
Bcd rcst
di$advantagc~, 346
low back pain allcviation, 345
Bchavioral t~crap)', chronic pain trcatm<:nt, 401
Biarticular mu~c1e~, tr.lining specificity for, 51-52
Bias sourccs, 011 pain mcasurell1CIl! quc:>liollnaircs, 59
Biccp~ fcmoris, (St'" also Hamslring)
functional an'ltomy, 120
gcncral charactcristics, 120
postisometric rclaxation. 259. 260
shortcned
body contour changes. 122. 122
body statics impairmcnt. 120. 121
disturbcd motor pattcm~. 122./22
Biochemical mediation, (See Infiammation)
Biofcedback. chronic pain trcatment. 401-402
Biomcchanical coupling. effect on lift-Iowcr
tasks. 144
Body contours
changcs in
shortcning
biccps fcmoris, 122. 122
piriformis, 124.127
quadratus lumborum. 128. 130
stcrnocleidomaslOid. 137, 137
tcnsor fasciae latae, 124. 124
upper trapezius, 134. 135
weakening
glutcus maximus, 120. 120
rectus abdominus. 133, 133
inspection of, 113
Body oUllines. (See Body contour~)
Body static~
abnonnal. 116. 197
case study
back view. 140, 141
di~turbed statics. 142
front view. 138, 138
sidc vicw, 138-139,139
diagnostic critcria. 117
disturbed
description. 116.217-218
in musclc dysfunction. 116
pelvic di~tortion. 221
normal, diagram.~ of. 115
visllal impeetion, 113-114
back "icw. 113-114, 1/4
front view, 1/5
side view, 114. 1/4. 116
view from above. 115
Bone, immobilization effects. 15
Bone scan
indications for, 342
low back pain diagnosis. 341
Borg verbal r.lIing pain ~eale
dcscription.61
illustration. 63
Bradykinin. releasc Juring ischemia. 19
Briuge e:>;ercise, 295. 374
description. 300-301. 301
Bnl.~hing teeth. improper and proper posturc. 186
Cardiopulmonary sy.~tem. immobilization crfen~. 15

Care standards
low hack pOlin, 34-36. l61J
reimburselllent for. 37
C'lrpaltunncl s)'1Idl'Olllc. IhnJ,t Illanipllla1iI1l1'.
215.216

Ctrr)"ing. corrcct posturc. }."'',I

C.lse management
gencr.l1 principles. 3;;S
for nonspecilic back pain. 3M)
pain and disability quc,tionn;lirc usc. (II). 69
Cat cxercise. 187. 383
Ccntral controllllcchanislll. tScc Fecdhlrward
mcchanism)
Ccntral intcgration
exteroceptivc infonllation. 329
visual input disorders. 329-331
Ccntralization fl?spomc, in derangcmcnt syndrome,247-248
Cerebellum. movemcnt control
involuntary. 26
voluntary, 26
Cervical extension. disturbed movcment pattern,.
due to shortcncd upper trapezius, 135. 136
Ccrvical extensors, post isometric rel'lxatiol1, 206
Ccrvical fascia, barricr phenomenon. palpation
of,202

Ccr.'iealllcxion. (Sa also Seck l1exion)

disturbed movcmcnt pauerns. due to shortened
sternocleidomastoid. 137. 137
Cer.ical musclcs. (Sec alw ~eck musclcs}
postisomctric rcla:.:;ation. 271-272
refcrrcd pain. 271
Cervical spine
dynamic tests
illustration, 238-239
1:;peS, 238-239
joints. referrcd pain. 78-79. 79-80.175.376
loading of, McKenzie approach, 237, 237-230
mobilization techniques. 2/2
position of, aftcr side bending, 217,218
postisolllctric rel'lxation. 379
rangc of motion tests, 78-79. 79-R0
cxtension, 237
flexion, 236
protrusion, 236
rctr'lction,236
static tests, types. 239
traction. 206
Ccr.icobrachial syndrome. ctiology, 376-378
Ccrvicolhol<ldc outlet syndrome. thrust lll;ll1ipuI.nions. 215. 2/6
Chair
proper posHlre, 178.178
technique for rising from. /89
Chiropractics
back school
back safety training. 157, 160
back training and exercise progr'lllls.
156-157
California, 155
Canadian Back Education Units, 155
company interview. 159-160
curricululll. 158
di~'lbility prevention. 8
formats, 157-159
inj~:ry response training. l57

prillcipal !!\lals. l:'i~

!JHlgr;11ll rrPlll111ioll. 159
pllrpll.'l,'. 1=',~-151
rcquiremcnts for. 15X-159
sat"cty llri..:nt;ltinns tll industry. 15(1
Sw.. di,h. 155
dlll\lli.. !Jilin p;lIicnls
Cdll<.:;ltiolJ Ilf. ,j')
motivalioll ul'. JI)
trcatmcnt ;lrpro;Khcs, .j()O-...j(}1
manipulativc therapy
harrier ph..:nomellol\. II)X-199
hcnclils of. 222
facct joint ~Ylldrol11c. ~6X
for low h;lck p;lin. 7. 36-.~7. 1(15,359
McKenzie approach and. 225. 2:'10-251
recovery r;ltes. 166
thrust. ~13-~15. 217
oflic.: pwcti.., c,. }X4,-~H5
pain ;md dis;lhility questionnaire me. 69. 69
patient sati,Jactinn ratings,
subluxation. defincd. 22
Chronic pain
;ICllte pain and. transi1ional '>lCp~. 18
ddined. ~%
disability and. )1) 1-)1)2
dnlg usage and. 402
ftlnctional re'>loratioll programs. 102-403
lifestyle changcs dllc to. 39
movelllel1! pallcrn ;lltefiltion~. 25-2<)
p;ltients
motivation increases. 39
rehabilitmion education. 39
psychogcnic di;lgnosis .md. 5. :195
psychological tcsts. 398-399
psychosocial faclOrs
alcxithymia. 393
compensation, 392
compliance. 392
deprc.ssion. 392
gain. 393
litig..nion,392
reporting to third pari)" payor. 38
risks for developing, I (I 1
sellsory motor slilllu];llion. 321
device.s ilnd 'lids
halance balls. 320
balance shocs. ~20, 321
Fillcr. 320, 321
minitr;llTJpoline. 320. 32/
rocker bo;ml. 320.320
twister. 320
wohblc board. J~O. 320
indications for, ~21. 321
mOlor leaming slages. 319-320
.~hort foot
(Jc.~cription. 322
exercise program, ~22
fOntl:ltion of. 323
half step forward stance. 323
illustration, 322
passive Imxlclill~. 322
sllhst;ll1cC ahusc ;1I1d. ;'9;'i-':W()
syndromes
charactcristic_~. 39;;
prognosis. 35. 16:'1

__________________________d.

Chronic pain--{,"O/1/iJll/cd
tesl hallt:ry, }99-4fX)
trt:atlllel\t
.ICUptllKture, 40 I
behavinr;llther~\py, 40 I
biofeedhack, 401-402
cognitivt: lherapy. 401
family therapy. 402
~')~IL,. }:{. ..:no
hypnosis, 401-102
pharmawtherapy. 'HJ2
rdaxatiol\ therapy. 401...4 02
Chronicity
detinet!,25
risk f;l(:tors. 34, /66
Cognitive therapy, chronic pain trt:atlllenl. 401
Compression injuries, in alhletes. }43
Concentric conlractions
deli ned. 50
training spt:cificity. 51
COIll,:llrrent \;llidity. of pain queslionnaires. 60
Conncetivc lissuc
lesions of. palpalion lesting. 200. ZOO
osteopathic cccentric muscle energy proccdurcs. 258
Conservative care. (St'" also Passive care)
aggrcssive. 36. 165
low back pain. 6-7
nonspecific back p'lin. 360
primary gO;:JIs, 32
rehahilitation and. comparison. 3 1~32
sciatica. 5. 360
surgery and. comparison, 5
trealment methoJ.~. 6
Constitutional hypermobility, symptoms. III
Construct validity. of pain questionnaires. 60
Cuntr;lcl-renex technique
lower seapuhH: fhators. 28H, 29/
middle trapezius, 2SH. 290
principles. 254, 258
shoulder joint. 2H7. 288
Contract-relax antagonist contraction. 25H
Convergcllce. defined. 24
CR techniquc. (S('(' Contract-relic x tcchnique)
CRAe. (Set' Contr;lct-rclax antagonist COIItractioll)
Crcep. ti.ssue. dellned, 16
Crilcrion v;lIidity. of pain qucstionn;lires. 60
Crossed .syndromes
diS!;11.97
lower
illustration. 28
posl\lral signs. 363
pelvic. 106
proximal. 97
Curvc rcversal
detined. 23~
l.lbslructions to. 232
Cut;ll1eous hypocsthcsia
detincd. 23
symptoms. 23
Daily acti\'ities. (Sn' Activities of daily'
living)
De;I(I-Bui' excrcise
dc.seriplioll, JOO. 301
illustration. 347. 382

Deconditioning
altered movelllent patlems..\ 1.3 J
charactcristics. 13
defined. 402
joinl hyperscnsitivity. 21-22
llIuscular imbalances. ~ I. 3 J
neurophysiologic clements. 17
pain relict. 167
pathophysiology. 14
Dcprcssion, chronic pain and. 392. ;'(l.:~.w5
Derangemcnt syndromc. lllcc!l;l1lic;ll :md symptomatic rcsponses, to loading. 2-1'2. 246-~50
hehavior nomenclature. 24X-249
behaviortoJlogr.lphy-dcfonllity nOI11<.'nel,,ture.249
manipulative therapy. 250-251
p;trtial pattern.s. 249

Descartcs. Rene. view.s on pain. (}

Desk. proper height, 167
Diction.try of Occupation:ll Title
functional c;lpacity :Ind worl\ capacity eorn::lations,93
joh listings. 93
Diga,~lricus. postisomClric relaxation. 208
Disahility pronc palient. protllc. 36
Disability questionnaires
pnin measurement types. 5H
reliahility, 59
types. 58
validity. 59-60
Diserimin.mt validity. respomivity. 60
Disk
biochemistry. immobilization cffeet.~. /5
hernialions
description, J71
ill'lstmtion. /76
low back pain and, relationship. 3
spontaneous recovery. .3
illustration. /70
intervertehral. injury mechanisms. 3B
spinal ncrve TOots and, 170
syndromes, rehahilitation management.
]69-:nO
Disk eXlmsion. surgery for. 5
Distal crossed syndrome. charaelcristics, 97
Distr,lction force. joint surfacc separalion
and,2/5
DistraetioflS. as abnormal illncss beha\ior
sign. 73
Disturbed hody slatics
descriplion. II(l, 217-21~
in muscle dysfunelion. 116
pelvic distortion, 221
Disturbed l1lovemcnt rauans
asscssrnell! of
normal, 117. 1/7
shortened muscles. 117-11 g
weakcned muscles. 117-118
dlle to m\lscle dysfunclion
biceps femoris. 122. 122
gluteus rnaximus. 120
stcrnocleidoll1as\(lid. 137. /37
Di'l.l.iness ,Iisordcrs. 3X;,-,i:-;4
Dormant lIluscle. 29(l
Dorsal fascia. harrier phc11l1l1JCnon. palpation of.
201. 2a!

Dorsal h,'m scn~iti/:lIi(lI1. ~~

asso..:i:~l<.'d ncural dl;lIl~"" :'.'
caus,". ~3
ddin,:d.14
p;lin ;~:ld. 17
pallw:i1ysio]ogy or. 25
DOT. IS,.,. Diction;!ry of O,,'I:l':lli(1:l:d Till<.' j
l)\luhk k,: raise. f(lr p.... h'h: ,!:<.'n~\I1I''I. .\(J
n,,\\,af:cr', hump. !7lJ
[)y.Shlll'li(ln syndrome. Illc(harlIL'al ;tI1d ' : mpl(lmalic rc';:,onses.
IO:lding. ]':2. 2,14-~.l(,
classitkations, 24:;
lI1anipulativc therapy. 250
EecclIlriL' contractions
defined. 50
training specificity, 51
Education programs
B:lCk school
Cl!iforni::. 155
Cm;ldi;1l1 Back Educalion Units. 155
origins
154
principal goals. IS]
purposc, 15,\-154
results. 154-155
Swedish. 155
history of. 154
patient. (Sa P:nient education)
Elbo\\". extension tests. for hyperl1lohilil~ e\'allla~
tions. //0. III
ELC. {Sa EPIC Lift CapaCity Tesll
Electromyography. muscular imbalan<.'e J:lla.
26-27.27
EMG. (See Electromyography)
Endurance training. effect on ml1sck. 4~--19
Engram. defined. 26
Environmenl, paticnt and. 405-406. -106
EPIC Lift Capacity Test, description. jJ<.}
Erector ~pinae
hypertrophy. 107. 368
inhibited. cv;l1uation of. 109
po~tisomelric rd:lxation. 268. 270. :;, :-0271.373
referreJ pain. 2(1:-;
sci f-jXlstisometric rcla\~ltion. 27:;'
selfmetching. 270. 27/,373
shortened. tcst for. 370
thor;;cic, 206
tighmess evaluation. I(}O. 10-1
trigga poi illS. 265. 367
Ergunomics. wor\.;s\;ltion
eh;;ir ~ellil\gs. 167. /79
computer, /7Y
headache rdict". 375-376
ERGOS work simulator
lk,uiption. ln
illu'\ration, 1.17
Exer~i'C. actin:. j\lr low back pain. ~
Exercise hall. (Sa Gymn<io,tie hall \
Exerci~e seien~e. lllCO[llolor pcrforl1lan,.... physio
logic categories . ..\7-49
Exerci'es. (S('(' also Trainingl
abdominals
crunch. 301
dead bug
dcscripti(lll . .100. 30/
illustratioll. 347. 382

,0

or.

Excn::i:-e:--'nUlfillll('t!
isomelric. 306. 307
SI:lhiliz.:llion, 303-3Q.1, ](N-J05
gymnastic ball. 307, .lIO-.HI
chronic paill al!c\i:l.Iion. 39
cOlllpliealing factors, 359-360
cndurance, erfect on muscle, 4S
force, effecl on nHlscle, 4t\
gymnasllc h,ll1
b~I'::':

,,:oc:c!:.

~I~.

3/5. 37-1
hridgc, 307, 3M-3/O
dorsal cx.lcnsion, 3 [3, 3 J.J
fronl rolls. 313, 3/4
iIImar.nion. Jo.'~-3/2
lumbar clttcllsion, 31), 1/-1

scc-saw,)11.3/3
shoulder rehahililation. 381-38~
squ;l{S, 313, 3 J3-3/4. 374
"sullCrm:tn:' 309. .lIZ. 374
types. 306-.:\07, 309
imprtlpcr form
hC:l:d rorw;mj posture, 187

low hack h)"pcrelttension, /85

politural faults from, .MI
waisl slumping, 187
kneeling
dc.~criplion. 30J

or.

l::'.. tn ....F1..' ll\lll'. S~-S3 . .';.J.

h'IIII,11I11':. SI..';1
hip Ikwr. SO-XI.,'\1
kllt't' 11..'\11111. S:!. 81
pdvil: 1111. Sl,: ,)y, ZI),,-}IJI. ';,';2
I\.'t!th fClllnri ... XU-Xl. ,,1
Sl\kll~, S.'. ,<';5

pl'llll;lr. U3
pn 'pritlCept i\"C. .l2 'J
ml:llurs Icst, 33-1-.1.;:'
:-pill;11. .l\2

3'N-.'30

lllamlihlliar inlerft'r":Il..l' .H.'i

musdc 1011<:, 330
orttltlplics contrihmi\1I1", Y;7
pO~lural swaying..';;0
l)u~lUr:l1 tr.linin!; pl;U(llflll..'.11\.;j,'\
-.tahillll1\elry
t.baiptioll.337
Rumberg's quotient..'\.\7. 337
ue;l11ncnl follow-up..'.'6
Fittcr
d..:~crirli(Jn. 3~O . .1:26
illu~tr;l1i(\Il,

32/, 327

FOOl

27,28
tr.lining eneels. 27
r::Ili!!-uC" curve. illUSlr.ltiOIl. 17
I:CE. (Stt'.Fllflclional cap;ld:y evaluation)
Fcedhaek Illcch;lnism
hdlavioral syslems and :\pproach, 47
descriplion.47
llItJ\'t:Illt'1lI eorreclivc Iev::!s, 47

Flexion
prolonged. crf...'C1 on lifting injury. 167
vulncr.Jh1c positions. 171
Food in lake, musclc dysfunction, /97

dorsillcxion, for hypcnnobilily

c\~llualinn~.

111.11/
proprioceptive rcccp\()r~. 3~O
Foolball. lumbar spine injuries. ;;51-;;5~
Fol'\;c, dclinilion of. for tr:lining l,lad delcrminali(ln~. -Il-i
Force lraining, cffecl 011 lIlu:-ck. 4S-t9
Forceangle curve
fle~criDlion. 51
illu!'olration,52
Force-velocity CUf\C
de~cripli()n. 50

illllstr:l\itlll.51
impMwnce to rehabilitation. 51
1Jlccl!;lllislilS of. 50
For""ard bending. Ic~t. for hypcrlll\lhiliIY.
II J, III
Free lifting. cvalll;llioll of. 413
FS. (.'iff; Function;11 ~I:lhilil.;lliun)
Fukuda-Untcrb!:rJ;cr Stcpping Test
iIIuslrilliOll,332
pathologic asymtnl.:lry, 331
Function;tl c:lpacily
cJl:tcrrtal dcrn,md and, rcl:llio1lship. IfI, /68
work capacity antI. corrclmiuns h~'I\\'ccn. 9J

-----------------------

(.-

lk-,ihilil~

20+-205
face \"alidily. uf p:till qU~lionnaircs. 60
Facel joim l;yndromc
dl.":!'cripliOll,366..)67

char:lCtcristic~.

l'\l":l'llCcptivl. J2'1
llJ,lIIiplllalillll
.~.~2 '.'.'.'
I"SIS. 3:\5-3;;(>. }.'5_.1.'"
1,,:uIIIIl10111r. 3J>.~".;. 333

\'i~u;ll.

1:IIIKliulI;11 \;lr.I~lty c\aluathlll

alll1lill; .. II~III"n ,It. 7-1-7:'i.
l:ill\lj'llllll'nb "i. 1-1.,
lTili..;11 f;l~'I"t, Inl". 75
liIllLlitlll;lltl"b. 77
l\lll'''lI!(l~h,kl.d t"L1l1,liot\:t1 :1'1"'..,1'. 75
'lh.k..li\', qll:lI1l11i:lhk 1\:sIS

IIll'1Ih

Fk:o:ihility
dclincd. -Iii
lo~ses in, low hack pain ;lIld, 15
tc,IS of
~;I~trocnell1ius.S::!-~O. )j.J
hamstring. 81. ~ I
hip Ilcltor. 8Q-8I,l'i1
knce. 82, tiZ
qu,ldriceps, S2, 82
rcctus feJl1oris. 80-81. 81, 110

hllllt"ocl(\(1f:'al,3-12
Fast-twitch fibers

h'lal 1"I"";lillll. illll~Ir.II"'Il, ,SO

Fihnlhb"l~. .'il:;lr (llflllal1\>Il, I.'
Fihll!;l. 1lltlhiliZ;lIilln I,,hlliqu,'. : /4
Fill,' 1'I)~lt1r:l1 sYStl'lll

illustr'llion.303-304
locomotor system rC:l.Cti\'ation, 53
pro~ralll erc;llion, criteria. 52
role of muscular qualities in. 48
singk knee and double knee. /87
Extcnsor:>
cervical. postisomctric rdalt<1tion, 200
"nee, mechanism disorders, 382-383
wrist, postisonlclric relaxation, 204
External dem:md, functiona: c:lpacity <lnd, relationship, 16, /68
External stress, reductions in. 36
EJl:leroccp{(JO', function, 329
Eyc. Ill(WCmCn!s of. fIOslisomctric rcb.\<llioll ;lIld.

di:lgno"is. 3
palho!clgy, 345
rchahilitationlllanagclllcnt. 36l-i
Iriggcr points..M7
Facct joints, oricn!:llion of. 341
Fadlit:ltcd scpncnt, defined. 22
F;ul1ily thcrapy. chronic pain IrC:ltmcm, -102
Fascia
!:lan-ier phenorncpc1ll. ~Ol. ZOI
Cl.":rvical. 20Z
dorsa!. ~Ol. 20/
ghue;ll. ~Ol. 2()J

i:..:";,-,,, ..... ,IIU<.:,ii... ,,'l11. ,k..,-riptillll. ..\(I_.J'

111 lIltlllOIl
(t'rvi..',,1 .. pint', iX-7\). ill_SO
hip rolall{111. X~. 82,'.;,'
lumh:lr ~plll~. 76. 77
th(\r;I~'k "pm,'. 7X. 7.'\
lrun" rut:llllHI. 7:\. 71)
ptl rrost'. 7-1
qualiliahlc IC'I-.
hip ;,h{\m;titlli. XX-St}, WJ
hip t',\l..:n .. loll. 91. 1)2
ncd-; 11c.~i\lIl, X7. l}()
Ollt' k~ "l:lIldill,~ 1..',,1, x.;,,vJ
pd\"ic lilt. Xli. ,'';N 3,';1
n:Spir.llion ,"nnrt.lill:llilln. XX-S9. IJO
shuuldcr ;lbtJUl:tiOll. X.'i. ,'\.'01
sqllat .\lfCn~lh, S-I-S5. 8i
Sl:lntllil kn..:clicsi. X3-S-I. ,VI
slenlf.x:lcidlllua'luid. S7-KX. YO
tnlllk IIc.\ion, X7. WJ
lrunk sid..: rai"ing slrcnglh. 'JO--9 J. 'JI
rall~e

W(lrk c:lp.1cil> and. 93

FUlIl:lional ddicit,"
Illw h;ll:k p:lin :mt!. rcl;ltillll.. hip. IfI
tIU;llItilic;l1itlll (If. fum:lilln:ll (;Ip:ll:lty C\';IIU;I
linn, n
IrCalmC1lt tlf, 7~
Funeti(ln:11 pro.;:rt..... qll:lluilic:uion. -',Ii
Functiollal r.mgc.l.'if'c' Tr:linillg r:logc)
Functiollal rC"llJr:lIi'lll
chronic pain and, -1{)~-4U~
[tlCOllllllor -,y .. lt:1Il
lI1UScul,lr illlh:llanccs. ~62
p:lth(lkine,ology.3h2
pa:icnt da..,ilic;ltiull. 361
sl,in.. 1 !'o1;.Jhilily. :'I61-:HI2
lIlullitlisciplin;.Jry
indlcalioll\ ..\2. J6
SChCIll;llic. Ij
p:llil.'lll SCkClill)l. }.'i.'i
secondary
"'lll\llltlllt'fll~ 01', .'01, IS
(,;IP:~l'iIY c\'aIU:llioli. X
lIlutur sy:-h~lIl rc!mhililalioll. X
palient Cdut;.lion. N
p-"'ydUNl(;ial f;ll"lurs idt'ntiliGllillll. S-t)
FUIl..linll:l1 -",lahilizOllillll
dilliGl1 applic;llicUl ..2t)(,_'21)7
....\cf,i"c chcd:li~t. J 1(1-317
cxcr'!.'ise If:llmn;!. 295
factors Ihal arkcl. ]/)(,
cxercises
ahdlllllinal .... .103-JU\. 304-31J5

funcl;llu:11

.. ~

423
Functi'1ll3! '!<lhil!1.;,'i"Il-.,''I!il~:,/
hicycle. 315. 3/fJ
brid~l:. J()(}-JOI. 301
"dl:ad bUf:' 300, 301
SYllltlJ~tic hall
\1;lt:k str.:lch. 31 J, 3/5
hridl:'l'. 307.309-3/0
dm:>al ":.\Icll~iun, .\1 3.31':
fWlIl rolb-. 313. 3/./
illll.~lr;l:i(ln. 308-3/2

lUlllh;lr .:xlcnslnll . .' 13.3/.1

~csaw. .lII. 313
shnulda rch;lhililalion. J8J-3~~
S4U:lls. 313. 3IJ-J /4
"sur::m1:ln:' 309. 3/2. 37-1
tYll<:S, 306-307. 309

,i
J

I,
i
-~

~]

).

~
~

"j

1
I

*~J

,I

I
~

I
~
~

iI
i,

I
I

Cilul<:U:- 1lI..'dilh
l:Killtalll'IlI\dull'jll\:-. !I)(I. :!lJl

Fill"'r Il~~'. J~;

t'tll1<:tiOll. 102
'1;lhilil.alillll c.\..r..I'~'; ..\OtJ-.'U5 . .WI ."'.
(iltl1l'u.~

lIIiuilllll'

flllH.:liol1. IO!
rdcrrcll p;,in. 175
slahili/.;uiull c:\~n:i .....s. JtMI-.\tl I. 301
G\.J1f, lumhar spille injuri<:s. 55.2-:\5.;

1Il1lhili/alillil I'roCl..'durc:<.. JlOSli:<.omclrie rebx-

Gravity

alion.

pullcy.315

Gr.tvity inloler-mee.

squats. 305. 306

styrofoam. 306.306-307
go,lls of. 291
principles. 293. 295
routines. 296
spinal position. 297-298
training range, 294-295
Function;I) tesling
funcliom.356
lunge IC~L 296
purpose. 356
I),JXs.297
Gain
primar)". 393
secondllry. 393
ler1iary.39.l
Gail
evaluation of. 97
hip extension cvaIUalion!'i. 101. /05
:<.lilllCC phJ.St:. 197
swing phase. 197
Gail :1IlJ.lysis
hip movcmenlS. altercd
alxluClion. 363
cx-Icnsion. 363
neck flexion. 365
purpose. 30
rcspir.llion. ahcrcd. 366
seapulohumeral rhYlhm. altered. 365
1m Ilk nexion. altered, 3(..1
lrunk lowering, 366

Ghneus ma.'(imu;;;
funclion:ll :l/I:11omy. lIS
gcna'll Ch,Hilclcrislics, I' 8
poslisoll\ctric rcl;lx-ation, 2(1)

clTcet 011 Ir;linint: lll,al d..:lcrlllillalilll1\. J~

usc in poslisnmclri;; rdax.uillll. 20:'-21)-.

171

iIIustr.II;OIl, 176

i....;\.
, .,. .=*-----:--------------------------I

Il~

\.

\, .

~:;s

Gynmastic b:tll c~cfcises

bolC!.; slrclch. 313. 315. 3i.J
bridge. 307. 309-JJ()
dorsal cx-tension. 313. 3/./
e.>;tension.349
fronl rolls. 313. JJ.:
illustration. 30.'~-JJ2
lumbar cxtensiun. 313, J 1./
pdrti;ll situps. 3~Cj
scc-saw. 311. 3/3
shouldcr rchabilil<ltion. 3S 1-382
sqU31S. 313. 31.1-314. 37./
"supcnn=tn." 309. 3/2. 3i.J
Iypes, 306-307. 309
Gyrnn:lstics
lumbar spine injuries. 350
spina bilid:t occurrence, 350
spondylolysis incidcncc. 350
Hamming. (Set' Cltso Dicep~ fellloris)
improper cll;erci~e proccdure. 372
po.~liso1l\ctrie rclaxalion. 258-259. 259.373
refcrred p:lin. 258
sclfstrelching. 259. 260..i73
.\llOrh:n::u. tcsl for. 370
lightncss C\':tluation. 99. /01-102
lrigger points. 258
fbwthor!lc cffcct. 406-407
dclillcd.59
in pain diaric~. 63
HAZ. (Sn' Hypcr..llgc~jc WlIes)
HCild I1cxi(ll1
ahcr...:d movement. 365
inhillitcd muscle!' cvaluation. 102. IWi
in palient with ~hnr1encd slcrnoc!cidof1l;:-YJitl.
137. lJi
HC:ld poslure. J7IJ
Hcad:ldlc
ahnormal rcspirOllion and. :>7(1
manip\llalivc Illl:r..lPY. 2n-~23
rchabilil:llioll Jllilnagcll1l.'lIt. ~7U-37 I. 3i)-37b
types. 370
J'lcallh chills. chiropraclors ;md. rclmjoll'hlp.
360-361
Hernialiolls. disk
dc.~cripli(lil.

~8-1-285. :?X6

flIl:i1iotl. r,mge (If m(llillllleSI.~. 82. 8?-s.~

}1}6

i
1
~

Hip
"bdlKlillll
all.::r...d p:l1Ierns. ~63-J(w. 36-1
("1".Irdill:llio!l I<:st, :-;9, Y!
!i~l:llle ...... .c\;llu;llitlll. 1)1). 101. /05
;uldul'l:on. ligllll1<:s~ C\:IIUalilln.lJlJ. 100-101
e~I\~n:-II'U. (S{'c nix" Bicep' lel1lori,1
:Ilh:rcl! p:lllems. :\(1.\ 3(j3
l'(II.'Hlin<llio1l1cst. 91, 92
for gail cycle cvaluation. 101. 1(15
Illll."dc contr;lction. 122
in p:llit:nt wilh shortcned quadr.tlu!: IUl\1borum. 128. 130
hypcre.\ICnsipll lest. 371

Gothic shuulder. de'crilllitlll. 109-110

lightl1cs~ c\";dU:llilln. 10./

trigg.er point!>. 2H'Glenohumcral mOl ion. :<'c:lpulohumcr:,1
rhyllHll, 3foiU
Gluteal fasci;l. barrier pheuCllllenon. palp:lli(lll of.
'201. 201

It.,," t'>;l.:k p:,in OIlld. rdalil.n.;hip. 3

sl',onl;lIll.'OIl" rCl'l\\ay. :;

kneelin};. 303. 303-304

lumbopch"ic.298-300
lunge. 305. )05
11ron.... 30i-3o:!, 302

G;l.slrocllcllliulo
f1c:<ibilil)' ICqs. 82-83. ....ol
jX1;lisoll1clric rdaX;lli(ll1. 284. 2!H
rcrern:d pain. 2S~
sclfslrelching. 2M. 1.'\5

".'11' 'Iretdlin~. 26.". 1.6S

.'l'lhili/.;l\illn c.\er~i~cs. 3U 1_.llJ.;. 30~ _}I,.;
\\'cakcncll
hody ll\lllil\\' dlau~c~. I ~O. J2/J
Ilisltlr11o\:d Il1OI"r pallerns. I ~H
d.~turh ...(l :-1:IIK.';. liS. J1'1

1lip n....\\Or'
Ikxlhilily lcst. SO-SI. ,~I
ll1(lVelllenl pallern ilnpairmcnl
pinformi" shortening. /27. 128

lemm fasci;u: I"lac .o;horlcning. [24. 125

fK1Slis(llllctric r..:lax;111nn. 262. 263
.o;llllrlcned. It:sl for, 3fi9
tighlllC~\ \:\"alu;,tiot!. ~S-99. fJ9-IOO
Hip internal Wl:llors. !l(lslismnclric relaxation,

267.268
Hip joill1. f'K"ll"II111Ctric rc!:lxali(lll,
History. pdticllt
cffect on Ireatlllt:nl plan. J~4
form~l,

,in

397-39:\

for low back pain c\alualioll. 344. :-5i

p"in drawing. W9
Hoffman rcUc:'\: :Icti\'ily, 254
Hold-relax lechnique. prindrlc~. 254_ ~5i
HR lechnique, {S('c I-!oh.lrcla.'( tcchl1iqu~l
Hyperalgesia
dclincd. 23

secondary, (Sa Refcrred p:lin)

symplOrns. 23
Wllc.. .. skin drag di:lgn(l~i~. 198.200
Hypcrmobility
:lsseS~ll1cnl of. I I I
con!>titutional. III
dCl'cription. III
cvalwlllvc IC~IS
c!buwextension. 110
fOOl dor~inc:\ion. JJ1
forward hCllding les!. III
thumb hyperlell~i()lI. J10
H ypcrlonu.\. 2{W
defincd. 113
vi.\u:ll impcclinll rllr. 1I(i
I-Iypcnruphy. cfecl(lr spina..: muscle.. , /0-. 3(iS
l-Iypllo~j:-. chronic 1};.IIl IfC;lllllcnt. 401-t(l~

Hypcr.lll;csic

Hypoc~lhe\i;l.

ddincd.23
symptom...

CUI:JJ1C\1\IS
~:t

Hy~lJ,:rc\is

dclinel.1. 1(1

illustration. using slrcs!J"tr.tln CU(l'~'_ J:;lIluscle injury du<: to. 1(1

lBQ. {St"(: 1II11c."s Bch"~'i(lt QUCSliollll;lir..'
IliopsoOl\
lh:xibilily tesls, Xl

..

"."

I~,'<.l~

".", """
]1ostisometrir rdaxatioll. "2(11-2(,3.
263,372

:r,:

rderred pain. 173. IN. 261

sclf-strctching. 263, ](,3. 373
tightncss cvaluatioll. %. 9'1
trigger points, 2(,2
trunk (uri up cvaillatitills, 102. /(/5
Illness Bchavillr QUL:stilltlll;lire. ,kWI-il'tl\\I\. (,I)
Illness hchavi('rs
abnormal
deli ned, ()
indications for, 6
pain and, 17
Wadddl's signs I'f, 7J
normal. 18
psychosocial indi(es
Back Pain Classilication Scale. (15
Illness Behavior Questiollllair"" (1<)
nonorgank signs. 69
Sitkn",ss Impact Prohk,

()I)

rok in patient eV'llu'llion. 57

ImmobilizatiOll
biochemic,,1 changes. l.J
low back p"in <lll",viatioll. 345
musculoskcletal. effects of. f.J. 17
negativc effects. 13-15. 15
Impingcmcnt syndromc
description. 380
scapulohunwral rhythm, 380
Industrial Case History, 160
Inflammation
in joint, ncuronal cvents. 22
mcdiating factol'S, 18
soft tissue healing. 13
Infraspinatus
postiso!lletric relaxation, 208. 2B2, 283
referred pain. 283
trigger points, 283
Inhibition, musclc, effect on musck fmigability.
19.21
Injured worker
risks for injury. 161
total management guidelines, 162
Injury
lumbar spine, (Set' Lumbar spine)
mild to moderate, trcatmcnt stages. 37. 3.'N
modemte to severe, trc;llment stage.~. 38. 384
severe, tre,Hment stages, 3."14
subacute phasc. 34
Injury prcdictors, 161
Inspection, visual
back view
lower extremity, 114
spille. 113
uppcr eXlremity, 113-114
from view, II ()
purpose. 1IJ
side view, 114, 114. 116
vicw frOIll above. 116
Imerva1 .s~ale. of pain measurement
description. 58
example. 58
Intervertehral disk. injury mechanisms, 343
Ironing, improper and proper posture, 180, 371
Ischemia
caus('~. 21
c1"(el;t (Ill lIl11sde tunc, 19

llaillic testing, Illlllhar

1~I,illl..'rtial. isometric

~pill"'.

-11.,-114

and l'I'klnelic. n'nlp:tll

SUIl. J50
l,,'ith.'rli:ll testillg
\kfllld, 145
m;l\III11ltll ;lr~'qllabk\\"I,:I\\ ;IP!'II';ldl.

[.-IS

h"kinciic t,'"sting
,"I'lh,'pl illln,duclil'l1. I:"
d,tin,d. 145
i','m,tri,' ;lIld i~oilh.'nl;d. ,'llllp;lri,ol1, 1511
uno lirt. 1-18
lUllIh;11" spin~', 11 ~
r,'luhilityof. I-IS .. 112
1~1'11l,tn..: ":('lltr;I":li(ltI~

d,'llll,',1. :'i0
tlallHllg SIl<:citicity.;=; I
hom":lrI": stn.:ngthL:llillg, ill llL:ulral positioll. 346
J~\1l11,'tri~' testing
(klill..:d.145
,k,;,:,iptl(ln, 146
isokinL:lic and iSI,inl.'rlial, ..:omp;lris\lll. l,'if)
rdi;thiJityof. 14(1
safct~ o!'. 146
S(lr..:nSllll t..:st, 111
Ja\'din throw. lumbar spinc injuries. 3;=;2
Job di~"l1isr;ll.'tion, questi(lfln;lires, 7-1
Joh~.

DOT

dassiti":;ltion~.

9.'

Joint mubili/,atiol1. description. 209-211

Joint receptors. stimulation of. effect on mtlsdes.
19,21
Joinb
afferent excitation studies, 22
~eni..:;ll spine, rderreo pain. 7B-79, IY80,

/75.376
dysfunction. 2 I-22
myofasciJI trigger pIJints ;Illd, differential di,
agllosis, 366
facel. 341
fixed (Je:"ioll, contrihuting factors. 23
functions, 45
imlJ1obilil.ation cllects, J5
inflammation, neuronal events, 12
lumbar spine. rden"ed pain. /75
IllU'Clcs and, functiona! illler;lctions. 30
recl..'ptors. (."'(i> Joinl receptors)
sacroiliac
;Idjustlllents pr, dfect on rellcx r",sp(lnse~. 4 7
mohilil.ation techniques. 210
Jumps
description, 323
illu>,tration.315-320
sensory motor programs. 323
Kincsiophohia.295
Kinetic chain, functional pathology, 3.W
Knee extensor.s, lllcchanism disord~rs. 3S2-}X}
Knee l1c,xioll
flexibility, objcctive quantiti<lhk t,'SlS, S2. 82
tightncss evalualion. <J9. lOr;
Knceling exercises
description. 303
illustration. 303-304
Kypho~is, lllobilil.atlon, 2 J3
Lactic acid. production. 49
(...It pUJl,dowll, improper form, !YO
Layer syndromc. illustration. 2<)
LevalOr scapulae
posiisolllctl'ic n::laxation, 27-1, 27)-;'76
rcf<.:rfcd p<lilt. t7l, 275

~clf-~ln:tdlillg, 275, "27(,

tightn",.\s cvaluation, %. V8. lO8. 109
triggcr poinls, 275
LIDO lift. is,lkinClic testing, /,18
Lifestyk, p;tlicill. ljllestionnaires. 74
l.il'ting
dctined, 14.1
!l;lIId PO~ili(lllil\g, 144
hl\\~tillg ;lIld. cOlllp:lrisoll, 1,13
fr"qUL:llcy linlit;ltions. 144
"'lcGill's rules. 1(}7
1~'..:lll1i(llIeS, 16()-1(}7. 181--182

vcnical displae"'lIlell1. 144

Liftillg ':;lpacity
factors th;lt affect, 14.'-14:'i, /-/5
sll'l.'llgth tl.'Sls. 92-93
~'\ll1lp<lri~on of.

150

typcs, l~;=;
WEST-EPIC test. I_P}, 1-1V
II.'sting oL 143
Ligaments
imnl\lhilil.atiol\ dfects, /5
stre.\slstrain curve, 10
Li~tl.'llillg, a'S component of p;ltient care, 4(l5-Hl6
Load
.:ITcd on Hlllsde fatiJ;ll<., 1(1, 17, 19
Illlriwlltal displ,lcem~'nt, 143-144
Loading
amplitude, 22:-;
dynamic. 22:-;
frequency,22K
intensity, 228
m",chanical responses
properties of. 2~0-2~3
syndromcs
der:lI1gelllelll. 2-12. 246-250
dysfunction. 2-12. 244-246
po.stural, 242, 243-244
111<.l\"t.'lllelll planes. 22S-229
posture, 229
sour",,,,s. "229
spin:l!' 227
st<ltic, 228
symptoll1:ltic

re.~p(ll1sl.'s

p;lrametcr~

or. 2.'()"2~J
syndromcs
d",rangelllenl. 2-12. 246-250
dysfunction, 2-12. 244-24(1
postural, 2-12, 243-244
Loading strategy. COlllr(lIlent.~, 229-230
Locolliotor system, (S('(' also Molor system)
chain reactions in. 359
ll)wer crossed syndrome . .'62-363, 363
uppl.'r crossed syndrome, 364-3(,(1
dysfulletioll, 196
fUIKtional restoratitll1
nlllSClilar illlbalanc~'s. 362
path()kine.~ology. .'62
patient cla_ssilic;lti,)l1, 361
."pinal stability. .'61-362
fUll~'ti()ns of, changes in, 196
fUlll!amcnt:ll unit'S
anatomic cOmpOl1<::l11s, 45
fUllctional c01l1pon~'llts, -15--4(}
IlIl.'chanical cOllll',lnell\s, 45
motor control
kedb;lck,47
fc'l.'df(lrwanl cOllln,l ..1(1----,17

425

,1
J ,p,.,tll,llllr ' ) ,Il'lll .. , ";::,::,,,,1
Illll,,'k ... 1111' 11 ... 1\\-

... 'lIll;'...lh>JII~I'\>. ",.

d~,flllh:ll"th. )~-~_;

..\... l\i".: ;111.1 ll';tlllin:: ,'r... '.:rll1lilllh. )~

l~ll,

1.,l,

;lll::k ... tH,\'. ~ 1

n'I".Il~ . .UT . . :. ~n~:'il

111,'1\11' lIlIll_ ..1'1

-5'
.;! ';;2

1'.lllh,k H'""l"I,,~~, .:1':

I'h~,"",I'l.;!I\ 1111;1111 ...,
1l1ll_(lIbl'. .IS

tlf;:;lIIil', .IS
':'~"":"I

:-trulHlr;llllalh"I\,~~. !'}- -19X

1.\111~ loop n..'lk\.-17
L'lr.lt',i,' ptlsilion. f'}t,
LlIW h;I\:1( p;\in.tSt" ,Ill.. 1.lImh:lf "pilll:J
;l(!i,,' l:\~n:+.c h,'I1..:lll_. '\
hinp,~dlO_'lh:ial ,ll'pr, ., .. h. \j
,";tf.: '-':lllllanis..\.'-.~(,. ii,"
,';1 .. ..: llI;lI\'I:':'::IIIClil

pnl:;lul",,,. JI.16
rql<lrl 01' lilHlin~,.
\';1\,-,,-,, "f. 17U-171

d:l",ilil;lliIlIlS.

3.~(,

(O"b ;t~_~o,:iall'd wllh. ,J

comp,;u:-:llioll. Y. .:
n:ducliol1:' ill. 15.1-155
di,\gno~is uf. 3:!
aglrc1;}ll'd I'Klnr...~..t~
hun..: scali. 3.11
disk hcrni:ui,lllS ;Illd. r;:J;,lillnship..'
cxer,;i,;:s fnr. (Sn' E'<:rcl,csJ
f:u:lorlo lhal pn:di..:t. .W(,
funclional diSl1rucrs. 6. l:i
high risk p;llicnls. IMI
manipul:llin: Ih",r;tp~ re,uh~. 7
mi=,uiagnnsis
prc\":Jknc..:. 3. -I
Mruclur.11 di:I~lliNs. ]-1
symplom r":cllfr,,,ncc. 3
mislIlanagemcnt
o\crus..: Ill' surgery. =prol(lng..:d h",d r.:'1. .1-5
p"ychogcnil' ,li;ll;f1O'l" 5-6
lIlusck "lr.:nglh ;llItl. rd::tiollship. 15
nonspccilil:
C,I~C rnall:tg":llIelll.

3"(1

sources of. 36
prc\"akncc (11'. 1:'3
prevcnlive 11IC:lsur..:,
b:lck sch~xll. ISn' Bad.: wh('(I!)
cla,\i(" j,OdY.SlliL ,\lJ:-;
litll":SS cCIII..:r. If!X
psycho..ocial pn.:dilcctmn. IJ
qualilY ("an: appwac!H:'
primary ctlllscr\';lli\l: c;m~. b-7
rril1l:l~' prLv",nliun. (,
SdU:lllalic. 6

second:lry fUIH-'linnal rcslllr:llillll. 7-1-:

Quebec Til..k Furo.:c. 3(j1
",ilh radicular symptoms. L'arc .,I;H)(l:mh. 3-l-35
rc:con:~'. faclOr:- lil;11 illay pn:dilt. 31
recurrence risk f:u;lun. 15
rcdUl;lioll IIlctllll(b. ,lrl;ss/\lr;lin rsl!ucliclll.
16-li

(
(

\.

... lral,~i,:, ..;3. 11-1. -J /(,

trunk 'lr~'n;:;h':llil1~ llnt<!I~lIlb ..~..t&_.t17
I.Hwo:r (." .......c:J ... ~lld"Itlh.
Illll~(r:lli(ll1. ::'"
IltlSlllr:.tl ,il=u,_ 3(13
1.\lw,,:rs:-.1r':lllily
h'llly ...1;llic m~a'iUr"'IllCllts uf. 11-1
sn"'nJ.:ltl.... ning of. 347
1.11\\.:rillg
ddill\d. 1.1_~
lifting :l1ld. i,CHllpMisoll. 143
frt:qut:n(:~ limitalions. l,j4
l.umhar disorder... surgical trcalllt~f1I. 5
LI1I11t'tar hypcrlordosis. 141
LUlllll;lr lordo~j~.

_'('-,n

lolb,n";lliv..: l';lr,. (,-:

\.

'UIKlur;,l p.llhtlllll;il..' liHdll1l;.....~-1. 13

lI<:;lhlll'nl f" . I... .13. ~(,_.~i
;1!;:"fllhm.35

1l;llHlll:: 'l'll'i1i,Il~.

l..... r,..:pllnllll\llpl.

rl'~nhllipn p..:rccnl:lgcs. 7
n:lttm II' .1'1,\c clllplllym.:nl p.:h~nl:lgcs. 3. oJ
"'1"'"1,\'1:1":'1. '.'>C'I' I.lilllh:lr srm,:. ~IXlns ;l11d)
... t;lhilllll1~lrl' dala. R(llllb~r{s qUlllit:IlIS.
,\.'1..;.17

106

Lumh:tr spine. (See II/SO L(lW b:Kk pain)

alhlelcs and
;It;mhk conditiollin~. 348-3.19
age related f:1Cwrs. 3:;2
b:ll:lllce reqcration. )49
!x'd rest. )-l6
common ~yndrol1lcs. 345
coordination. 349
diagllosi~. 341
injury mccho.nis1l\'" _~C
m;lOagcmcnt guidelines. 353
nonClpcrati\"c care. 3.15-346
p:ltient hi~to~. 344
physic;]1 c.'taminalioll. J-W-3..t5
predisposing faet()~. ~.I1
rehahilitation programs, 348
hiulIll'Ch:mi.:... J4J-3-4
11isk pres'ur.:. /76.
dynamic tc'l<.
illustration. 2-/0
IYllCs. 2':'(1
injury mechanisms. :U.'
is\lkinc1ic lcsting... I ~
joims. referred pain. 175
IH;t(lin~ or. \lcKcllzie ;Ipproach. 237. 237-2JS
IIltlhilizaliclIl proCl.:duro:s
poslisolTlctric rclax:lthlll. 285-286. 286
self stretching. 2S6. 1.... 7
1H11\(11l<.:r,lli\c Ire;lltltcnl plan... 3SCJ
radiugraphic imaging Il.:hniqut:. 219
r:lI1ge of mr,IIIOJl tests. 76. 77
cxl':lhion. 137
lkxion.2)7
side-gliding Iclt 238
sidegliding ri!;hl. 238
rhythmic U(lclion
pril/le. 216. 2/7
slIpim:.1I7
sp{)n~ <lml
11:llIel. 350-351
b;lsen:Jll. 353
fool hall. 352-353
goll'er,,35>353
gYlIllla.. tic... 350
j:l\'dill throw. 3:'2

pole vaulling. 351

lennis.353
water sports. 351
weight lifting. 351
static lest..
illu~amtion. 2-/0-24 I
types. 239
lhrust manipulatiolls. 213-215. 217
Llll1lbodorsal fascia
muscle control <If. erfe.:! 011 srillal Slress ill
juries. 3-12
Icars of. 345
Lunge coordin:uion lcst, (Sec Sland to kneel t..:st,
Lunges
description. 323
as funclion"l r.mgc lest, 296
illustration. 314. 374
sensory motor programs. 323
Slabiliz:ltion exercise. 305. 305
Mandibul:lr interference
cffcct on po~tural system. 335
testing procedure, 335
Manipulative therapy. (Sa a/so Active care)
barrier phenomenon. 198-199
benefits of. 222
facet joint syndrome. 368
for low back pOlin. 7. 36-37. 165.359
McKenzie approach and. 225. 250-25 t
rccon:ry mtcs. 166
thrust 213-215, 217
1\-'lanualll1cdicine. (See Chiropr.Jctics)
~hnll:ll r~sist:lllCC techniques
choice of. therapeulic goals. :!j8
clinical :lppliCalions. 255-256
f:lcilitation techniques. 256
goals of. 25,5
neuromuscular basis. 253
postf3Ciliiation stretch. 25.1
procedural sleps, 257
postisomclrie relaxation, (SCt' PostisOmclric relaxalion)
proprioceptivc neuromu;..;ular facilit;ltioll.
253-154.254
purposc.253
w;:tys to maximize. 257
M:Jsticatioll. muscles of
dY!ifunClion. 197
postisomctric rcla,,:Hioll. 20t
MAW. (S('c r-.bximum aeccptahk weight)
M:udmlllll acccptOlblc wcip.IH. iSllincrti:L1 test
ing.148
McGill P:lin Questionnaire
description. 61
p:lin diagram SC(lre~ and. c~'rrL'lali()l1 between. 61
reliabilily.61-62
validity. (l2
!,lo'leKcIl7.ie :IJlproach
eriteri... 225-227
t1clin",d. 225
. manipulalil'c Ihcr(lr~' and. 22;'
rncclwnic,tl and symptolll:\li,' rc~r(J:1SCS. In
loadillc.
c":r\~c:Ll spine studies. .23(>-.237. 236-137
dyn:lmic 1ests. 237-2:W
lumbar spine slucJies. 23"7. ::37-238
pallent history. 2J5-2~6
poslur;11 ;lI\:Jlysis. 2;16

II
1

,\

\kKl'lll.it.' :ll'prl\:1..:h-nmlillunJ
SI;,tic Il'St.., ~37-2.'R
,~ndf(lrnc

r:tllCm."

dinic:!l rca,oninl: ;lnd 11lililY. ~ll

tkrangcmClll. 2-12. ~46~2:,n

dysfunclkm.

7r:. ~.I.t-2j(>

Il\l...lmal. 2.J~. 2..1:\-244

,ul\lIliary. ~J2
P;llhtl;lIl;I!U"'~ :U1.1.

226'

:1 ~"lcrinri aPJ'n'~lch. 22(,

n:hahililalioll :lIld, 2:;1]."2

Measurement ,\':.k,. Ill' pain

hi:L"; sour........ ;q
dc.;niptiull. ;'0:-type.". 5S. 58
\kch:lI1ic:llly il1l!,\:dcd cild r:lIlgc

tlclllH:d. 2~2. 2.~-l

Ilh,lrUCh:d. 235-

rC';lrh.'IL'd.2..1-2.'.1
~rccplilln.

233

1\'kchaunfcct:pwr :Jffcrcnts. pain Cfl.':tlioll, 24-25

\ktlicinc b:.tll, (St'(, Gylllll'I.'lic hall J
MEl', (SC(' lvhl."ck energy proccdurcq
MEr. (Sl'(' MIN:!.: Encrg.)" 'I\:chniqtlc)
Mctaholk c:lpaciIY. cllcl:1 on lifting c:l.p'H:ity. I.tJ
MClaC;Jrpophal:lOg<.'~1jllint. manipulali\'e (her
allY. 115
Mkr()f:lilur..:. ()\:'lJm:I1I.:C~, 15-16. 16
:"lilit'll")' PO~IUfo:. i/7
Minilrampolin..:
de~riplion.

J2(1.

32~

fuur point kneeling. J2N

illu!'tr.uion. .121
walking on. 32i
r-.'lilll1e.~ola Mullipha~ic Personality Index
chronic pilin predictions. 398-399
pain dia!;r;um .:md. corrcl:nioll hctwecn. 61
!'calc.~. 399
l'\'linnesola Multiphasic Personality In\'cmury. :L"
dis."Ihility pre<liclOr. 9
MMPI. (See Minnc~ola MlIllipha~ic Personality

Inde:-;; Minnesola

:-'\ll\O:llICllIll:lltCnI."
.11t...r..:d
l'hrmli" pain
~5-2(1
efkt.:t of chroni l' pain. 25-26
Il\u~ular imh;lbIK'e :llld, j I
Ir..:allllCIIl for. :II
l'nmpk:c lIS

.m",

di~tu'l'lcd

~1r.:Kclll.i.: RI..'IX'. _'~')

suhjecli\"c

conservative 1r'::'Illl1cnt ;md. comp'lf\!>C'tn.

.ll-:l2
fU11llalll':lllah. ~55-35~
:-'hllelllclIl correclion, kvcls (If. 47

\'luhiph;l.~ic Per.~ol1.aljly

II1\'cl1to1)')
Mohili;r':l!ioll
joinl. 209-211
cer\'ic.t!. 212
C()l1lITlamk 210-111
sacroiliac, 210-211
kyphosis, 213
ncuromuscul:ll" techniques. 210-.211

sidebending, .2 1l. 2II

Modified 1l10111a~ Ie'\!. SU. 93
~'1ood dislUrbanccs, chronic pain and. 39.J
Mowr cnlllrol
defined. 24
feedback mcchanism ..17
fecdforward mech:mism, ';(1----17
nCllromuscular ~truclllr.:s :md pathways. 0/6
symptoms. 24
Motor learning, concepts of, 319-320
ro.-lotnr pallcrn.~ ..(SI.'I.' MO\,":l1lcnt p:rttcrns)
MOhlr syslem. <Sl'e oho Lt}ColTlOl0r sy."tel1l)
cVlllponcnlS of. 25
dcclmdilioning ~ynttwlne. 13-15
rehabilitatiun
aClive :10(1 passi\'e t:ar..:. 32-34

:lssCSSlllent of
mJnllal. 117. 1/7
shonencd musdcs. 117-118
wcakened muscle.~, 117-1\8
due ttl l1lusde dysfunction
biceps fClIIori:>.. 122. 1'22
gltllcus lIla:-;imus. 120
.~tcmockidoll1astoid. 137. 137
dieet on skills. 358-359
Movcmcnt rl:'llles. loading :md. 228-22')
~1o\'cnlents

control. reeducation, ) I
involulll:lry. cerebellar error conlrO!. 26
\'oluntary. cerebellar pathway.... 26. 46
:-'IP. (See Myofaseial pain)
MPQ. (5('(' McGill Pain Quesliollllairc)
MRT. (Sa Manual resistance techniques)
~1uhindi.lumhar. postisometrk rcla:l;mion.

~71.

1i2-273. .213
:-'lusclc. (Sa aha specific mllsclt"sJ
contr.lction...
accelerations in. 320
energy sources. .J9. 50
functional conditions for. 50
joint protection, 319-320
function . .:5-4(1
ease study .:mulysis. 140-141
imbal;mcc. (Set' Muscle imbalance)
illllllobili7.:llion erfects. t5
inhihition. 19.21
joinls .md. functional interactions. 30
Ienglh
effect on muscle ~pindle impulse fre
quency. 19
hip alxluction. altered. and. 363
hip e:-;lension. altered. :mtl. :\63
neck flexion, altered. 365
rcspir:ltion. altered. 366
scapulohulllcral rhythm. altered. 365
leSlS of. 30
trunk flexion. altered. )(,.1
low back. (Sec EreelOr spinae)
motor units
ddincII. 49
tYllCS :Iud characteristics. .19
pain cycle. 18-19
pha.... ic. 26
poslUrnl. 26
~honenecl. disturbed slatics. 116. II R
strength, effeCl on low back pain recurrence, 15
~lressJstr:.lin curves. 16
tighlncss
spa..~llI'lIld. differential di;l~l1usis. 97
lrealment of. 97
trigger points, 28

wasling.21
we"kne.s...
anhrogcnic. ~9

disturl'lcd statks, 116-117

stretch. 28-29
tightness. 2R
trigg..:r roint. 29
Musel..: dysfunction
types. 255. 255
\'isu.lI inspecliun
h:1Ck vicw. 11J-114
e;l~': study. 1.J0--141
Muscle energy procedures. 253
Muscle Energy Technique. 212
Muscle libers
fasttwilch, 27
slow twitch. 27
stiffness of. 254
Muscle iml'lalancc
:Jlten:d movement patterns and. 31
analysis of. in standing position
from behind of patient, 106. 108-109
from front of patient. 110-111
dinic:!! features. ~6-30. 362
compcnsalOry actions. 116
consequences of. 29
defined. 97
cx;mlplc of. 30-31
inhibiled muscles. 97
c\'alumion nl.:thods
head flexion. 102. 106
hip exten!':;on, 101. W5
push up. 102. 105
shoulder abduction. 102. /07
trunk curl up. 102. 105
seientiflc evidence for. 362
tight muscles cvaluation
erector spin:lc. 100. I()J
g<lstrocncmius. 104h<lmslrings.99. 101
hip ne,~ors. 98-99. 99-/00
iliopsoas. 98. 99
levator SC;lpu!:le. 98. 9R, 108, 10<)
pcctor.J1is major. 98. Wi. 110
pirifonnis. 100. tOJ
quadt:ltu!': lumborum. 100. 103
r..:ctus femoris. 98. tOO
~(lleus. I()..J
sternocleidomastoid. 98. 99. liD
tensor fasci:lc btue. 98. 100. 110
thigh adduClors. 98-99. 100
triceps surae. lOt. I().I
upper lr.tpczius. 98. 9."1. 109-110
Muscle qualities. of locolliutor perfnflll:lme. .ts
Muscle spindle
effect of rnusl'k streich on. 50
impulse freqth,'nt:y. muscle length in:!\!
ences. 19
Musdc tcnsion. 19
c1assificalions.155
mechanisms ilwtllved ill, 20

treatment fer.

~55

MuS'.:le lone
organ of. 19
rol<ltors test. 33J. 334-335
r-.'1uscultY.'kclet:l1 function

cfl\:l.:\

UIJ

liftill~.

145

"

\~;
,.
""'10,

\J

"

..$

427

''''Vt:.A

~ 111,~uh"i.,,,kl;d hllH:lillll-., ";luWI'II

.." :lIII,llh>n I,'.b. 71 7~

I..l'~ .1'I'o:,:h,

75

:\l\I"III,,,\..ckl:ll paill s~lldr,'m~,. lllll'lllllptil':lt<:d

,,,l'lli".'ll'" ll\:IIl:lgl'lIl\:1I1 ;,:ul,ldin....... 36

:\111',"ul'h\..d.:t:,1 slrlll:llIr...... \'\k'nlal {klll:llld ;IIHI
11l1l,II"11.l1';tp:Kily. rd:llllllbhl!,. Iii
:\ 111,,11\, '1.1>:11\. PO\ti"'IlWlt'h.' r"i.: x;llion, ].oS
:\l~.'l;l"r.,l p:UIl "'yndrtlllw. 1;,':,1I1II.'nl. ]9:". :;66
:\'~'\';Kll" f,'lk\ ..17

NI >1. 1.\,-," :'\,.... 1.. !>i..;,hility Illdn I

N,'d. Dr",l-lIlly Illd....\
,'r..'all<'l1 uf.lIt")

d..\"fll'Il"ll. (IS
illu"lr.llnlll. tiS

;\,..'cJ.. 1l,",iOIl. (Sa olso Ccni,";d (k.\i.1I11

:lltef..'1! ,"ourdin:lli(lll. 377

:1111:1','"

llI(l\"l:lIICllls,

305

.. lrt:llglhlll;ll~ c.'\CrL';scs.

3.'\'

l..''-h. ~i. lJ(). 9:!

N..:d.. lIIu_..:k:-:. (Sn'ol.WI Cl::ni"::llll1ll.~dt::-::Sl\.'r

n"..:kid'llIl;t:-:lOilil
do:..:p
pr\lprio.:qllnrs ill..\20
li!=hlnl::." c\"alualitlll, 9S. lJ<I
p\ISIUral dl":(I:-:, IiI)
n:.~i~lanc..: ..:x.:n:iso:s, .17 I}-.1Xf)
Ned: rdkxo:s. mO:;lsuro:mcllt (lL 3.11-.1~~. 332
Nc!=ali\'~ work. tr:lining wilh. r1~k (If injury, 51
N..:uromuscular len:-:i('11
..:ausr.: tlf. 21'
cxampk.. ol'..?S
N..:uro!lluscul'H Will.', n(l(.'iccp\l\c slil11ubtioll. 18
NClIron~

iI
.,

I
I
,i

,.J

t'

::A

motor. r,,;cipf()c<ll inhibition uf. 2i

wide d~nJmic ranfc. Ih:Uro~lhic pain ;md. 25
Ncurop;l\hic pJill
C:luse" of. n
ddincd, 22-2:3
lleurochemislry uf. 2-l-2:,
p;ltho.lnJIOll1lc chal1l;c~. 25
simil:lriti(.'s tI.l olh..:r condition'-. 13-24
Neurophysiologic rt:actiofls. li'-~ue Slrcss. pOlin
cycle, Ii-IS
No:uropla~li<.'it)'. rcf..:rred pain ::nd. 2..1
No:ulral po"ilion isometric slrengthr.:nill,!; ..'..1(,
Nocir.:cpwrs
irrit'llion of. crfccl Ull muscle tonc. 20
I)aill gencr;ltion. :\0
N(lll1inal data, in paill measur":Hlenl st.'aks. 5S
Nnllopr.:r:ltivc can.::
for low bJ.ek pain. 3..15-J.t6. 35"
neurologic delicil incrc;t'es. 3":6
NOllorganic sigll~, of abnormal illne~s bL'ha\',
ior.69
Nono... idat;vc llICt;tbolislll. (If mu,cle ..:,ll1tr:H;
lions. ,11)
N\lll~pr.:dfic back p:lin
t";J~e management. J6(}
p,tlknt cla'silic:l1icllls, J(II
sources of. 36
N(Jrmal i1lJles.~ bcli;lvior. th~uc protecticII1, 11'
NUS. (S('t' Numerical Rating Sc;tle)
Nucleus pulposlls. 171
description. 3~ I
Numcric:L1 Rating Scale. p,lin intensity I\l~'asure
lIlenl.61

(k'uIOll1ulor input. to fine poslUral syslem

';tw of scmicircul.H can:lls. :\:"0. 333
prism Iherapy. 332-3:n. ,U3
01:1', (Sc'/' Opcrati0l1011 Lift T;l.~k)
On..: leg ."landill!= lest
dcscril'ti(ln,
Illuslratinl\.86
Operational Lifl Task. isoinertialll,,,ting. 141)
Ordinal scale. M pain lllC;ISUTClIlellt
~kscriJllioll. $80
cxalllplc.58
Organic qllalilic~, of lot"()lllotor p.:rforl1l'lllcc. 48
Onhoplks. dfect on lillc poslur:ll SySt..:lU. 337
On!Jo."t;llic pl,)~\ure
;lsYll1mo:tries oj
p:l1lwlogic, 3.11-:\32

S"

phy.siolo~k.

HI

line poslur.ll system. 329-330

fineness of. 330
O.,t":(Jjlmhic myof'lsd.l! rdc:lsc ltlCtlllxl, 256
o.sw~stry Low Back I'ain Inc!;::x
descriplion.65
ill\lSlr.tlion,66
Oulcome assessmcnt
d":\'c!opment of. n
f:lctors lhal 'lfrecl. 1(.1-162
functional change docuOlcntillion. 37
Ovcrhead re:lchint;. IS2. 371
Overpressure
defined,228
usc in dynamic and slatic t..:sting, 239-240, 241
Overrc:lctlon. a~ ahnumlal illness bchal:ior
sign. 73
1';110
acute. chronic pain and. transitional steps betwcen. IS
:tvoidance n'rSU.f confrontation of. 38
tJarricr phenomenon. 199
chronic. (5('(' Chronic pilin)
cortic:lli7.alion of. 25-26
Ildincd.57
c.\aggcrated perceptions of. .J8
intcnsity SC'lleS, 61. 62...(;3
l(lCallOIl of. measurcment modalilies for. 60, 6/
Inw tJ:lck. (Sr'l' Low txu:k pain)
museu!:lr rcactions to, 21
rnyofasci'll. 195
psychogl::nic diagnosis :llld. 5-6
queslionnaires. (Sec Pain questionnaires)
referred, (S('C Referred pain)
relief posilion. 196
Slrolin and, rcJiltionship t'!Clwecn. 196
word origin. 18
P:dn behavior. assessment 100is
Bur~ verb:11 rating pain scalc. 61. 63
OswcSlry Low Back Pain Index. 65. 66
Rol;md Morris Sc:.tk 65, 67
Systemic Behavioral Obscrvation. 64~65
P:lin cyclc
clements in~'oJved in. 21
cXislclIccof,17-IS
illuslriltion. JR. 40J
P.lin di;lgram
desaiption.60
illusIT:ltion, 61
outcome .\.s,scssmellt. f,O
reliahilil)'.60-(11

Pain diary
illustmtion.64
purpose. 63
Pain Disit!>ilit)' Index. description. 65
I':lin queslionnaires
bias sources. 59
description. 5S
for localizing pain. 60-(11
lllcasllrcmelll SC:lIeS. 5&
for pOlill inlcnsity, 61. 62-63
for pain qualilY. 61-63 .
reliability. 59
lypes.58
validit)'.59-60
Pain r<:ferr:ll, (Sel' Referred pain)
P,llp,l\ion
description. 198
iliustf:l\ion, 198-199
lriggcr points. 205
Pa.ssive care. (Sl!l' alJtJ Conscrv:ltivc car..:)
J.clive care and, comparhon. 3S4
deconditioning syndrome and. 13
role in rehabilitation. 32-34. 33. 251
Pa.<;sive prepositioning. deflr:d. ~l))
Palhokinesiology. in kinetic chain. 358
POIlhologic asymmetry
Fukudtl-Urllcrbergcr Stepping Test. 331
neck rellel( measuremenlS. 331-332
POItient
chronic pain
education, 39
ways 10 confront, 38-39
dis."1bilily prone, profile. 36
environment and. 405--406, 406
pain behavior asscssmcnt tools
Oswcstry Low Back Pain Indc)\.. 65. 66
Pain Disability Index. 65
Rohll1d Moms Scale. 65, 67
Systcmic Beha\'iof:ll Observ:ltIOl1. 64-65
pain questionnaires
bia... sources, 59
description, 58
for IOCillizing pain. 60-61
measurement St"'I!cS. 58
for pJ.in iutensit). 61. 62-63
for pain quality. 61-63
reliability. 59
t}'p<:s. 58
\:llidily.59-60
Palient education
(uncliOll31 r..:slorollion, 167, J5S
lining tcchtliquc.~. 166-167
mOlivalion increases. 167-1(,3
rehabilitation. 165
rcinjur)' avoidance. 37
subjects for. 165
.....orkst<llion ergonomics. 167
P'lliell( history
effect 01\ tre:llment plan. 34~
forlllat. 397-398
for low hack pain cvalu:ltion. ;\-14. J57
pain drawing. 399
Palicnt-doclor rdalionship
obtaining patient confllJclIce..107
patiellt sclfrc~peci. 407-40S
principles of. 405-406
spirihl:llily issues. 409-410

......... ,........ '1""\,

PI)!. IS,',- !'ain Di:,,,l;Iilily Ind~..'(,)

1\'d,'r:\li" 11l0ljor
1",~ti~{lIllClric rcla:":llioll. 2i'J-2SU. :;.... 1
rl"i.:rrl.'d pain. 279
111=hIU:=S.<; evalu;l\iIIH, q:-:. IfS. 1111

I
~

I'C"II'r.lli" minor. p\lsli~"I11"'lri~' tc!as.;lli,'n,

2~1),:;;; I. 282
Pdt ;~, ":ll)\sed 'ymh.1lI1,\. lIlIl''':!..: illlh;I!
;1I1('~'.

1','I\'k!!!t

~IS

It.:-I

Ik,,npti(ll1. Xfl, 81)

illll~lr:lti(ll1c :fJ.'';,",WI. 382
P,lvi;,. i"lm,'lri,' 111allll:tl1r:K'lion, 2{)fJ
!\'r~"'l':i\llllllltl1r qU:llilie'. (If IIX'1)1I1\I10r rl<,:rfnr
m;ll1'~ .

hip. 2S4-2S5. 286, 372

lumh;,r spine CXIl,'ll.sinn. 28.'i-2H(,. 286
rih. 2:-6-21\7, 2SS
I1It1!'d..:s
;ttlduC'IIlTS. 2~9-:!61. 1M

106

rd\'k \.hliquilY
i!lu'lfalion. :!lo
ph~~iolo~i\." realtim".

f;lCililalilln lechnique:-. lower l\Carulac lix;lIors.

287 . US. 380
gr:wil)' and. 205-207. lOS
hip illlcrnal rolalors. 267. 2ftS
il\lli~;'lil\tls for. 257
j(lilll lIlohili/,;lliol1 fl~X'~'durl's

tri~fL'r POiIlL\. 27 1)

''-'I't '-'.

.lX---4\)

l'... rf'.rll1;lllc...\."onlilluulIl
ilhl'lr:l!ioll. 53
\\ IIldlll\" of Ilplimal a("!i\iIY in. 52
I'cri,"h:allisslIc. h;lrrier phCIlUIllCIl(lll. p:llp;ltiun
I'f. 21.11-202
!... riph.:r:ll cOlltrllJ. (Sa Fecdh:n;k mechanism)
I'cripher:tl nerve emr:l]llllen:. J-'l1

Peripheral nerve injltfY, lYpes: 342

Pcriphcrali/.ation respon;;e. 250
l'er;,cll1aliIY. ;ISre\'I~ (If. JOti
PFS, '.'ire Po\lf:l\."ilitaticltl ~uelChl
Ph:lftl1;ICOlhcr.tpy. dlf(,nk p:lin IrC:llmenl . .:IO::!
Pha,lC l1lu,t.:k~
e,\:l1nples of. 16
lil""r type. 27
Phy,ical ac:ivily redUClion. ISc,'c' Immohilization)
Phy,ical c.~all1il1alh1n
~'rih:ria filL 31.1
for low had pain.. 357. .197
PILE. I.)e~ I'rol=r.:ssi\c Isoinertial Lifling
E\":llualinn)
Pillow. pl'lI.:CJIlelll durinr !ilccp. , .... ,
IlJR. {S~t PostisolllClric relaxationl
Pirifunni..
flJllclinn;]1 an;\!\lJllY. 124
gcnt:ral cham,'lerislics, 12.:1
PI)qi\{Ullelrk rclas.alion, 208. 264-265,
265-26fJ
referred p;,in. 174. 2(>4
,horlened
body cnlllilur ~h:lIlf:c!-. 125. /27
lli~IUrhc(1 hlll.1y stalics. 125. 126
dfcel on hip Ucxion mo\'cment pancrns.
127. 12:3

ligh:ness c\"alu:\linn. 100, 103

trigger rnilll~. 26:;
Planl",r inpul
!C.) line (1(lslllr:11 syslem. 333
11l:lllipubliull of. :05
1'i'F. lSi'(' I'f(lpril\(cpli\"c ncurOlllu,~cul:tr facil
il,llion)
Pole v;mltin~. lumhar spine injuric!:. 351
P,)\ICOlllr-:lClioll inhibitioll. principles. 253
I'o\tf;lcilitati(\l\ str.:lch, 254
procedural steps. 257
f'(I~li<;ot1lelric r... I:l,'\(01lion, 201
('crvical spille . .Ii!)
eye II\Cl\'~llll.'n1S lUld. 2n4-205

ccrvh;al. 206, 271-27:!

lIi,gasuic:us. 20.Ii
cn:clor spinile. 268. 270. 270-271. .f73
gasIT("I(,:ncmius. 28..\, 28..1

gluteus maxirnus, 265

h;llllsiring. 258-259. 259, 373
iliI1p.was. 261-26~, 262-263. 372
infr:lspinalU$. lOS, 2.'\2. 283
Ic\"alor S4.-apulae. 2N. 275-276
!l1asticatory.207
multifidi. lumbar. 271. 272
mylohyoideus. ZOS
pectoralis Illajor. :!79-2S0. 281
pectoralis minor. 280-281, 2S2
piriformis, 208. 264-265.265-266
quadr:ltu.~ IUlllhorul1l, 207, 210, 267-268.
268-269
qU:ldric~ps. 265.167
rcclu~ f~nloris, 262, 263.372
r~srirator)' synkinesis and. 205, 206
:-c.l1cncs. 207. 218-279. 179
scmispin.:llis C.:lpilUS. 272. 272
scmispinalis ccrv;cu~, left, 272. 273
solcus. 284, 286
splenius capilus, left, 272, 273
stcmoclcidolll;lstoiJ, 276-278, 277-278,378
suboccipitalis. 276-277. 379
sub~aflul3ris.2m~. 282. 283-28"
supraspinalus.281-28)
tensor rasciae 1.1Iac. 263-264. 16-1-265
thoracic erector ~pin3e. 2;)6
uppcrtr.tpcl,ius, lOR, 210. 273. 27:\-275
.....risl extensof":', 204
origins of. 203
procedural sleps, 257
release IIlcch:mislll. 20J
lechniquc description. 2n..l
l'ostisomctric traClion. cervical spinc. 206
Postur.tl :malysis
hip movcments. altered
abduction. 363. 363-36-1
extcnsion, 363
il1ustmlioll. 29
neck lle:doll. 365
purpose. 29
respiration. altercd. 366
st::lpulohumeral rhyUun. altered. 365
lrunk l1exion. altered. 36-1
Po.<,turnl exercises. rounded shoulder:-:. 18f)
IlOS\llr.11 muscles
examples of. 26
liber t)PC. 27
lr,lining r~qllireme111s. '18
Postural syndrome. mechanical ilnd .~Ylllptnrnalic
respon:'>Cs, 10 loading. 242. 243-244
Poslurnl syslcm. line. (S('(' Fine (1(lstural syslem)

"1l..

~r

11'\11:;. ,.., l""M.IH.... 1IIIUl'lt:n;:, MJ-\I'lUJ-I.L

Postural Ionic aSYnlnletry

identifying. 331-332
p;l!hnlogic.331
physiologic. HI
PoslUra1 trnining p!;)tfonn. for POSlUr.\1 rehahilitalinll. 33S. J.N"

I
\

PO~ll1r~

drivinc:.lii-I7R
rurwarddr.lwll. 203. 203. 223. .MS
Ih':;lJ. .lXI
head rorw;Hd. 376
impropcr cxerci~c ronn .md. 361
lumhar disk prc;"sure and. 176. 176-177
lumhopclviC', 110
military correction, 177
neck,381
neck muscle activity and. 177
onhoslatie
;(synllilctric~ of. :\31-332
fine poslUral systcm. 329-:\30
fin~ncss of. :\30
roor. signs of. 177
rehabilitation
postur.JI tr.lining platform.
HR. 3.~8:
sitting
erect, 167
imJ1H1pcr. 167, 179
prolonged. low h.'lck pain and. 341
proper. 17R-179. 378
slumped. 177, 177
Posture disonkrs. psychologic aspc:ets. 33S
floslurolo,gists. hisl0l)' of. 319
POSIUl"\",:!;;:;;::
basis of
ccntrnl integral ion. 329-330
fine poslural system. 321)
limits of. 331
Power. ddined. 48
Praycr stretch. nO

or.

Pr~po.~itioning

active. 295
pas!\ive. 295
Pr~ssurc .,Igameter. soflli!i~llt: lendemess '1uan
lilic:ltiol1.74
Primary prevention. strall'gks, fr,lr low had
pain. 6
Prism tesls. I'm oculoll\OInr I\l\l.~des. 332-.1.1.".
333. J:\5-;\36
Progressi\'e hoincnial Liflln~ Exaluali(lll
Cylx:\ Uflask :md. I<lS
(lc.~cription. 149
Proprioccption. ddined. :lIt)
Proprio,:cpti~c lleur<Jmu:,cular fa("ilita
tion.25.1
exercises \(I illt.:rcasc. .1~~
inhihililry lcchnique.... 2:'1. ~5.J
Propritx'epwrs, 47, 329
Pro\'('C::lli\"c tc'liog. 92
Pro:c:il11al crtl!-"cd \ymlrtllll..... dl:tr.lC'leri.<;
lie!;. 97
I!:oas. {SC'l' Iliop,oa<;.l
Psychol,:ellic di:lgllu,is. lllW ll;ld pain.. 5-6
P... )'chos~>cial f'''lOr<;
chronic p;rin
alcxilhyllli'J. 393
nllllp.... lIsalion, 392
Ctlmpli:mcc. 3t)2:

....
,

429

INDEX

I',~..:h""\l\:ial faCltII'S-I"I1III;ml,"/}

lkpr..:."sinn ..")2
~ain. 39.'

liligalillll, 392
Illllliv:ltiol\. :\I)~
r':ClIgn iii Ilil. ,N:I- :"\1)':
"f tli ...;lhilily limn... Il;'licnl, 36
1l1~'lh{l\I" tl\ jlklllil'y. X-9, IS
1I\I~"<'li\llln;tin:s.

iJ

1'1I11d\'\\I~> illlpnllX'f

lilflll. /WJ
mcthlllis. '84
I'lhh lip. illhihih:tllllusd:, l:\';llualilll1,

I'ulljn~. Ill\..:alc

1O~. 105
Pu,hc,

illllslrali('11.325
pmprlocc[llivc intrc:Lscs, 323
I'u\hing. uns;,fe methods, n;-/

,i
J

PY~lIIJIi(ll\

cO"eel. de-fincLl. 59

QL {Sl'(' QU;ldr:lllls lumborullll

()u;ulralll., IUllllxlrulll
fum:liull. Ill:!
fUlKlinnal ;mal\lIllY. 128

l;.:n.:ral l;hanlch:ri.stics. 128

postisolllctric rcl:lxmioll. 207. 2/0. 267-2NI.
2Mi-16f)

rdcrr.:d pain. /73.2(17

sdf,wclching. 268. 2M
sh(lth:n..:d
body comour ch:mg..:s, 128, 130
disturbcd body stalics, 128, 1'29
effecl OJI rmwcmcnl paHcrns
hip extel\:-ioll. 12~, 130
lrunk !lcxion cXlensiun, 13L 131
ti!=II1IlCSS c\'alO:ltiull. UK), 103
trigger rx)ims. 265
Quadriceps
postisornclric rcl:IX>ltion, 265, 26i
sdf.stre1ching. 265. 167
.sl:lbilizalioJl exerciscs, 300-301. 301
str..:ngthening exercises. )47
QUOldrupcd tr:lck exerciscs
descrip1ion. 302-303

, )

-1
)

jllu.~lralion. 302,

..

I
,

),

'.

,)

,,):
I

<-)!

.~:1
\..

381

Qud)Cc Task Force

pUf]lQse. -l I 5-1 16
spinal disorder classifications, 361
whiplash classilic:ttions, 361
Questitlllll<lircs. (SC't' Dis<lhilit} questionnaires;
pain qUC!'iti<llluaires)
R:ldicubr pain. with low back pain
carc Sland:lrds. 34-35
olltcomc :lsscssmcnl, 165
Radiculop;llhy. indications for, 3-l-l
Rangc of ltl(ltiol1
funclion:11 c:lp:u:ity c\'alu:llion Icsls
cervical spinc, 78-79, 79 ....')0
hip mlaliun. };2, ,\j2-1U
lumbar spinc. 70. 77.411-41'2
thoracic spille. 78. 7,"j
lrunk TOlmil'Il, '7S. 7lJ
l<iss of. 2)1
lumhar spinc lesr.s
cxtensi(lll. 2.li
nc.\;,ion.237
side-gliding left, 23X
sidegliding right. 238
IUlllhop~h'ic. 298-299. 19c'1-.100

R:llio ~ale, of (l<,in mC;)"t:urcmcnt

desCription, 58
ex:nnplc.5B
Receptive fields. referred p:lin and. 24
RI,'Ciprocal inhibition. principles. 2;i:\
Rl'condilioning
ftlllctiOllal stabili7d,tion. 29:\
lrcatment stralcgies. 169
Recovery period
eomplicaling (:I\;um;. 356. H()-j57
factQ~ 111>11 prcdict, 166
timdillcs for. ul1colllplic:lIcd injur
ies. 38
Rectus ahdominus
gencr:ll charnclcristics. 131
wC:lkcl1cU
hody contour changes. 13:\. IJJ
disturbed body Slatics. 131. 1.12
dislurbed movcmcnt patterns. 133
ReclUS femoris
nc.'(ihility Ics!, 80--&1. 81
POSCiSOlllCtriC rcl:lll:alion. 262. 263. 3n
lightness evalualion. 98,100. 110
Red l1ags
dcfined.355.393-394
diSlllrbances of mood. :\94
cxamin:ltion of mood. 394
in history. 394
p!'iycho!'iocial i~t:ucs. 394
typc.t:. .156
Reference lines. body slatic assessment
b:lck view. 113-11-1. 114
fronl vicw. i i 3. i i 6
siue vicw. 114. IN. 116
vicw from abmc. 115. 1I 6
Refcrred pain
defined. 24
early discussions of. 22-23
crector spinac. 367. 36'7-368
facct syndromes. 367, )67-36.."
ncuropi:lslicil)' ano. 2-1
quantific:llion of. 74
sourccs
:lod.ucton;. 259
cl'rvical musclcs_ 271
cerviC:ll spine joints. /75. .lio
erector spinae, 26S
gastrocnemius. 284
t;luteus llliniUllls. 175
hamstring. 258
iliopsoas. 174. 261
infr<lspin:1lIls.253
joints, 22. 1'71
lev,lIor stapUlaL'. 172. 27;i
lumbar spine joints. 175
peclor:lli.s m:ljor. 1'7 1)
piriformis. 17oJ. :!(Il
qU;[dr;tlll.~ lurnborutn. /7.( :!67
scalencs. 172. 2'7s
soleus. 284
stcrnoclciliomaslOill. /7.1. 277
sulx>ccipilillis, 276
~lJhsc:lpularis. 21\.1
~upraspinatlls. 2S1
ICIIStlr faseine blac. 26:\
upper lrapczius. /7/. 27,1
symptoms.2 J

Regional disturballccs. as ahnormal illm:ss behavior sign. 7J

Rehabilitation. {St'" (d,w Atti\'e carel
accelcr'\lion-dccclcration syndrome. 3'78-379
hiomechanic:tl (actors, 15-17
dcconditioning. syndromc. 13
dl'fincd.195
funt'lion:\l lesting. 355
fUllctions. ~S6
lunge teSI. 196

PllllXlSC.356
types. 297
goals
355. 358, J 1-1-.t 15
hcadache. 370-371. 3'75-':;76
imlllobili7.ation
biochemical changes_ loJ
musculoskelelal. eO'cels of. 14. /7
ncgativccffccts.I3-15.15
mOlor system
3ctivc and pat:sivc Can!. J2-34. 33
,onsc['\':lli,'c treatment and. cOlllparison.
:;'1-31
fundall1cnloils, 355-358
patient selectiou. 355
primary goals. 32, 33. 39
nonspccilie back pain. 360
ou"omcs measures. attributcs of. 58
passi,'c physical thcrapy :l.nd. 3S5
patient cduc.:lIion. 165
pfll,(:ralll creation. 367
scialica. 360
Rdlatoilit:llion c)(crciscs. mu~,.'ular quality dch:rminaliQlls. -lS
Rcimt>un;cmcnt, ways IQ cn~uro:::. 37-38
Reinjury. ways to avoid. _~6
Rcl:tth'c n:st. defined. 37
Rcl3.'I::uion therapy. chrl,'lni.: rain treatment,

or.

401~O:!

Rclia!:lility
intl'r-c:<.:aOlincr.5Q
paill :md disability qlll'~ti"llnaircs, 59
pain inlensity sCll1cs. t> I
1l.'i'tr~lcsl, 59
Rcrm'toiliz:uion, Ircal1l\l'n! ~Ir:llr.:fics. 169
Rr.:p.:tition, effect on Illu:-..-k- fatigue, 16. 17
Rl'p..'litiyr,: ,qrain, dclin"d. :~
Rc~i:'lal1cr,: exercisc,", ell,'.:t ('n muscle. 49
Rcspir:llion
:tlt,'ro:::d. 366, 366
h... ;H.bdlcs and. 376
lillill~ tllora)( :11. J9;
R~'spir:\lion toordinali\l[) l,~t, d,scription. 8SS9,9(1
RL'~rira[(lry synkinesis

d,,in..-t.I.205
ll~" in pmlisomclri..- rd,l.,\,\li"'II. 206. '216
RF. ~S<l' Receptive lield~'
RhYlh1lliL' ,"labili~.ali{ll1. f,'r ~lh'\llder. 287, 289
Rl. \Sl'l' Reciprocal inhit>iti"lll
R\X'k\'r ",.ard
d,:'"Tiplion.320
ill\l._lr:llio!l. 320
Rol:llIJ \lorris SC:llc, \k~~rii'ti\'n.lt5. 6;
RO\1. IS..c R:lOge of 11I,'li,'I\'
Rllll\b<.'r~~

quotiClI1

lkh-ripliu!l. 33CJ
l\'w b:ll:"- pain i[)lPfl""~','nl" :md. :'137 . .!}i

nCnl"\Oll...1 11-\1 IUN VI'" I Ht:. ~P1NE:

R01:llOr cuff syndrome. (Sa Impingcmenl

syndromc)
ROlmors test
~rformanec of. 33<1, 33-1
purpose. 334
Running.. hnnbrlr spine injurict', 352
Sacr.ll ot.liqui(y, illustr.uioll. 220
Sacroiliac joint Syl1drolllC
allered hip atxluctiol1 ;ll1d. 363
description, 366-3(,7
di;lgnosis, )
palhology, ~45
$acroili,IC joints
adjustmcnll' of. effect on reflex responses, 47
mobili7"'ltion techniqucs, 210
Scalenes
'
posli50lUclric relaxalion, 207. 278-279. 279
rdel'Tcd rain, 171, 278
sclf-pol'lisoltletric rdaxation. 280
sdf-slretching, 279, 280
trigg.er points, 278
Scapula
conlr:.lcl-rdax techniques, 288, 291
facililation lcchniqucs, 287, 28R_289
stabilizers, stfCngthening exercise. 3S I
winging of, lOti, 109
Scapulohulllcral rhythm
altered
de.'icription, 365
gail analysis. 365
trealmcnt npproach, 365
glenohumer.ll mOl ion, 380
impingcmcnt syndrome and, 380
Scheunnann's disease. etiology, prolonged sitting.3<11
Scialie ncrye, referred pain, 176
Sciatica
case management. 3(10
enuses, 171,345
conservntivc care, 5. 360
etiology, 3
illU:'Ir:.ttion. 176

SCM.

(Sec Slcmoclcidl)mn.~IOid)

Scolimis, illustr:ltioll. 2]0

Sce-~,,\\' e~ercisc, 311. 313
$el.f-strclching
guidelincs for. 258
joint mobilization
lumbar "'pinc cxtem;ion. 286, 2Si
rib. 286-287, 288
thoracic spine extension. 286. 288
muscles
OldduClOrs. 261, 262
erector spinae. 270, 271. 3i3
g;\strocllelllius, 284. 285
gluteus maximus, 265. 26S
h'llnstring. 259. ]fIO. 373
iliopsoas, 26~, 263, 373
levator scapulae, 275, 276
piriformis. 265, 266-267
quadr:llUS lumborum, 26&. 269
quadriceps, 265, 267
rcclUS femoris. 264
t'ealcllcs, 279, 280
soleus. 284, 2S6
lensor fasci,le latae, 264
uppcr tmpezlUS, 274,275

Semicircular can"ls, law of, description, 333, 333

Semispil\3lis capitulO, POSliSOItlClrie relaxation.

272,272
Sem;spinali!' ccr"icus, poslisolllctrie rel;l;'<.at;on.
272,273
Sen!'jti1..:l.Iion, dorsal horn
associated neural cli:lIIgc!', 25
delincd.24
P:llhophpiology,25
Sensory motor slimublion
device... :md :lids
bal:lncc balls, 320
~Iancc shoes. 320. 321
Fillcr, 320, 321
minitfilmpoline. 320, 321
rocker board, 320, 320
Iwister.320
\\'obble board, 320, 320
indications for. 321. J2t
motor learning Slages. ~ 19-320
short fool
description, 322
eltercisc: program, 322
fonnation of. 32~
half step forward stance. 323
illustration. 322
passive modeling, 322
Shcrringlon's Law of Reciproc:l1Inhibition,
26,27
Shon foot
descriplion, 322
exercise program, 322
formation of, 323
h.M step forward l'tance, 323
iIlu~trntion, 322
passive modeling. 322
Short leg
pelvic obliquity (ronl. 220-221
sacral obliquity frolll, 22()"221
Shortened muscles. 118
Shoulder abduclion
components of. 102-103
coordination lcsl, description, 85. 88
inhibited nluscles evaluation. 102. 107
in paliellt with shortened upper uapc7.ius,
135. 135
Shoulder hl:ldc. ~tahilizalioll of. cV<lluation melhoOl', 102, 105
Shoulder girdle, sl:lbili1":ltioll of, e\'alunlioll melh
ods. 102. 107
Shoulder joinl
n:habilitation nl:lnagel1lcnl. 381
rhythmic slnbiliz:uioll. 2S7, 289
Shoulder Shn.lgging, 190
SI-JR. (Sa ScaplJ]ohunlcml rhythm)
51, (S('(' Sacroiliac joinl syndrome)
Sickncl's hnpaci Profile. 6J
description, 69
Side-liding, 228. 230. 249
Simulation, as ,lbnonl1;11 illness hch<l\'ior sign. 73
SIP, (Set' Sickness Impact Profile)
Silling
crect. 167
improper, 167,179
prolonged. low back pain :tnd. 341
pror'lcr, 178-179. 378
Sit-ups, improper technique. 190

A PRACTITIONER'S MANUAL

Skin dr'lg
causes, 200
hY()I=rnlgesic zone diag.nosis, 19:-;. 200
Skcping
felal posilion. ISO
ideal poslure. IRO
pillow pl;l\.clllelil. 1.~1
Slouching, 240
Slow,l\\'iICh lihers. dl.lr:ll.'lerislk~, ~7,:!S
Slumping, i76. In-liS
SOAP notes. ddincd. :;8-1
Soft ti.~suc
fmigue levels, 17
healing pha.'ic.~, 3-1
inlbmmatioll. 1:-. 37
remodeling. 14-15.38
repair, 14,37
lc~iol1.'i, p:llpation teqing'
connecti\'c 'issue, 200
skill,20{)
m:lIlu,,1 resislance h.'chniques. ~55-256
pain syndromes
b:uncr phenomenon. 203
managelllent guiddine~:. 36
lendemess
grading schefm'. iJ
qunnlificntillll, iJ
tension type~. 19
Soleus
poslisolTlctric rclaxalion. 284. 18fi
referred pain. 284
~c1f-strclehin,g. 28..1.

.;

2R6

cvnlualion. 10-1, IOi

trigger points. 28-1
Somatiz:lliun
defined, 391, 393
double mes.~;lges of, 395
Somali7.:nion dialhe<;i~
abandonment 396
abuse, 396
alcoholi.~m. 396
description, 393
surgical outcome. 396
Sorensollicst. for lumbar spine, 41-1.
Spa:;m
misdi<lgnosis of. 28
poslisomclric relax <Ilion. descripli(11l. 203-204
lishtncs:; ;md. differential diagnosis. 97
Spccl.'h, muscle dysfunction. 197
Sphinx c:o;crcisc, ISf)
Spina bifid:t. illCidcn('c in J;)'llInal'l:'. 350
Spinal column, (S{'(' Spinel
Spinal cord. J;.r.I), matter. "irritable ()('llS." 2J
Spinal cre~'wrs.lighlnc'~ cv;,llIali\m, 100. /(U
Spirwl IO;ldillg. deli ned. 227
SpiMI l1cr\'c roots. di~~: :md, rdnlitmt'hip hetwcen. 170
Spinal pain, (.:i('t~ 1.0\\ back pain)
Spinal st:lhili'l.alinll.ISu Functional sl:lhilizalion)
Spine
an:ltonlY of. 341-3..12
hndy slillics, 113. 217
cer\,;c;ll. (Sa Ccrvical spine)
columns (If. ~41
descriptiun. 170
illustralitl!1. 169
lumhar. (SI'e' Lumb~r 'ipinc)
tighlnes.~

"

.-~

:7

431
Spi 11\,'--':'(1/" ;11/11,/1
pll.~tllr;)1 disorders. :n I
poswral tonk ;lsyllilll"try. 331-:'U2
st:,hilit:>.361-362
)

I'l{lr.ll'i~, (SI'e 'Jlltlr;,ck spine)

Splenius ':ll,iIIlS. p!.lstisollJ"tric rcl;lltalioll.
~n.27.l

SI"ll1dyloli"lhcsis
dl;lr.ll'I,'ri\lics, .142
nlllllllnll sit....s fl.r. J42
htllmi,', .Ie
lu\\' h;Kk p:.in tlCCUITCl":C .3
Ire.llmenl plan. 3-'2

Splllldylulysis
ch:lraCh:ristics. 3~2
CllllllllQll sites for. 341
inciucllI:c of
ill gylllllasts, 3S0
ill weight lifters. 35 J
Sporb. (St',' dho Athkll:s)
lumhar spine injuries
h311cl. 350-351

h:ls..:I:I:.II. 353
foolll;11!. 351-352

golfers. 352-353
t;.Ymnastics. 350
ja\'c1in throwers. 352

pole \".:luhing. 351

running, 352
lennis. 353

W'ller sports, 351

weight lifting. 351
Spurts medicine. 411
principles. 415
Spray and Stretch. indic:llion~ for. ::!56
Squat strength tcst. descriplion. 84-85. 87
Squats
<IS stabiliz.ation exercise. 305, 306
using gymnaslic ball. 313. 3/3-314.314
Squatting, ::IS lifting. It..-dmiquc, 1M
Swbilization
dyn:unit. 295
(ullclional, (Sel' FUllclional slabiliz;llioll)

Ire:lImcn( str;Ltegics. 1r,C;

Swhili7-'llioll progralll, foal,. 293-::!9-1
St:lbilornclry, line postural ~y~tCl1l Illl:a
smemcllls
description. J:n
Romberg's quoliclll. 33;, 337
SlilllCC phal'e. of ~ait. IIJ7
Siand to kneel tel'l
descriplion. 83-S4
illustr:ltion, .%
Slatic nll.'(;hanicl'. locomutor syslelll. cllmpo
nenls. 45
Stemoclcidoma...loid. {51'(' al\(} Nel:k l11u:"'l:k,)

functional analOllly, 136

gener:ll charaCleristic.... 135
poslil'omelrie rda;(;Ition. 207, 2/0. "!76-278.
177-278. J7R
rderro:d pain. 173. 27i. 377
shorlened
body c.:on!our change'. 137,137
disturbed bod)' stali", 136. f.l6
s!renglh leSI. description, 87-88. 90
tightness C\'illuatiorl, n. YV. 110
!rigger poi nil'. 177

Slimulusrcspon$C rd:uionship. receptor il1\'Ol\"clIlcnt in, 47

Straight leg misl: lest, 81. 8/
Simin
pOlin :ind. rdOlliollship between. 1%
n::pclilin:

defined. 3S
pOlin :lnd. 293
Slrcngth (ontilluum, as cxampk

(If

l1I11s(ul;lr

t;~.d:!k::.1S

Sirength mea.~urclllents. nomlal funClion aud, 75

Stl\..-Ss!SIt:lil1 cur\'c
dcfincd. 16
hysleresis illustr'.ltioll. /7
for ligamenls. 16
Stretching
cOlll1ecli\'c lissuc...., 258
c!cctrornyographie dala or. 27
manu:11 rcsht.mee techniques and, 256
safety rulcs, 257
self. (See Selfstretching)
Subacule pha...e. of injury. 34
funclionaltcsling.74
Subjecll\'e factor!', of polin, methods to me:l
sure, 74
Subluxalion. dclincd. 22
Suboccipit::llis
paslisomelric relaxation. 276-277. 379
refcrred pain. 276
Iriggel' points, 276. 376
Subsc<lpul::lris
POl'liS(lmClric rcl:U:l\ioll. 108. 282, 283-284
r.:fcrrcd flain. 28:\
triggcr points. 283
Substan<.:c abuse. chronic pain patients anti.

395-396
Supcrliciallcndcmess. as abnonnal illncs!' beha\,
ior sign. n
"Supcnn:m" e;(crci..c
description. 311t)
ill(l.~tr:ttioll. 309, 312. 374
Supmh)'llid mu~de. lightncss c\'aluatinn. 110
Supr:t'ipill:!tu,
pnsli!'\\IllClric.: rclaxati(lII. 281-2SJ
n:fcrrcd p.. in. 281
trigger point~. 282
Surgery
n1Jlscr\,;lti\"c C:llC .md. cumparison. 5
disk cxtru_~i(ln. :'
frcqucncy uf. 16t)
fllr !lIW back P:lill. IWO:1'\lSC. 5
Suslaincd fX)~iti()nillg. 2:!.l:i
Swing phaw. of gail. 197
S)'ltlr<lthetic ~)'llIpWlllS
dclin..:d.2-1
di:lgntlstic le't, 2'
Sy.\l~lllic

hcha\illral

~1.~.scSSl1\elJt,

I)h~cr\'ati(m.

pain h<:lla\'ior

6-1,-()

lennis. lumbar \pinc injurics. JSJ

Tellsih: stres~()r~. 343
TCIISil>l1

111t1sdc. da\\ifit:atiull of. 255

palp~ltioll. 1~!K
Tensor faSCiilC hlt~lC
ftllKtiunal ~11:ltlIIl1Y. 122, 124
general ch:l(;lcteristics. 112
pusliso1l1ctric rd.u;~uiull. 2(13-26-1. 2(J-I-265

rcfcl'Tcd p-,in, 26:.

sclfstrelchillg. 26..~
shoncllcd
lxx.Iy conlour CIl;IOCS, 12:' /:!4
disturbed body statics, /13. 11..hip r.cxion mO\"ClUcnl impail111\'lu". 11-1. 1::5
ligh!ncsl' c\"llualion. 9~. 100, 110
lrigger point:-. 26\
Tcs\retcsi rdi;lbilily
~;:f;;;::d. 59
of McGill P,lin Quc:'liol1n~lirc. 61-6~
TR... (Sec Tcnsor fasciae I:II:1c)
Thigh adductors
inhibitcd, evaluation of. lOS
poslisottlctric relaxalion, 259-261. Z6/
tightness cvaluation, 98-99. /00, /02
Third rally pa)'or. rcimburscmcllI from
<]u:\ntification of symptomatic ,and funclional
progress. 38
ways 10 ensure. 37-3S
Thixolroph;c bcha::ior. 254
Thoracic crector spinac muscle. postisomctric rc
la:talion. 206
Thoroldc outlet syndromc. postural effcct.~.
376-377
Thoracic.: spine
mobiliz:ltion proccdurcs
poslisomctric relaxalion. ::!S6. 287
sclfSlrctching, 286. 288
strelching exercises, 383
r.lngc of motion tests. 78. 78
Thor.\columb;n junction. forward-dr.lwn posture
and. 222. 213
Throat. c\"alualion of. suprahyoid muscle tight.
ness. 110
lllru~t manipulation
lumbar ::pinc. 2/7
proper technique. 213-215
Thumb, hypcrcxlcn~ion \CSls. (N hypcrmobilily
eV;llu:ltions. /10, II'
Thumbs test
dcscriplillll. 336
illuslr:ltillil. 336
Tighlnes.... muscle. ,S('(' Mu:"ck. tightnc!<-:)
Tighlness \\.. "knc..:.. defined. 9i
Ti..suc
illllllObiJj~.c<1. injury risks. 17
:o.of1. (Sa Suflli.. ~uc,
Toc louche:.. improper tcchniquc. /S9
Tor(IUC Illlasurcmcnt\. lumb..r :--pine. -112
Torsimla' Slfcs:-ors, ) .( 1
1'05. (St'/' Thoracic Ollliet syndrolllc)
Tmcli<lll
iSOlllctrk Ill.mua!. (If pch-is. ~O(j
rhyllullil' prune
dcscriptioll. 2 j()
illustratilllJ, 2/7
Tr'lilling
cndur:mce. eff..-ct on IIlllsc!.::'. J<)
flln.:e . ..:tleet on rnu~ck~. 4".1
IOC(ll11l'lI}r system rcacli\".ttil\ll. 5.1
pmg,ra1ll crealion. criteria. 5~
rcsistillll.:.... clrcct on lJlusck~ ..11)
Traiuill!! I\};ld. eOlllwl lllctlwd:-delillitilill Ilf furce. ~x
gravity In~lnip\1]i\ti\Ill~. 4S
traillil1~

lhrc:-hold. .::~

"

Tr:lining range
dl::;;lcd. 295
funclional s.t.abilizmion. 29-1-295
lumbopclvic. 298-299. 298-300
methods. 10 identify. 295
movcment sensitivities and. 29~
Training tllTc~hold. defined. 48
Tr.lpcl.iu~

lo\\'er
faeilil:uion techniques. )80
hume exercises. j,li2
miLh.lk.
contr;lctrdax tcchnique. 288. 290, 290
facilitalion techniques, 288, 290, 380
home exerciscs, 382
upper
referred pain. /71
tightne$$ e\'alu:nil:lI\, 98, 9.~, 109-110
Tre:ltmcllt ;lpproachcs. dtronic pain
acupuncture. 401
b<::havioral thcr.lpy. 401
biofcwback, 40\ -402
cognitive {hcmpy. 401
family thempy. ~02
goals, 38. 400
hypnosis. 401-402
m:mipulmi\'c thcf:lpy. (S('(' M:mipul:'lIi\'c
thef:lpy)
phamI3colher::apy.402
rdaxation thc~lrY. 401-102
Triceps sur;te. tighmcss c\'aluation. lUI. /0-1
Trigger poilll~ 1()'\
facet p<lin, 367
hip Il1(Welllents. <lllered
;loouction, 3~
extension, 363
manual resistance tedllliqu.::s. 255
po~tisometric relaxation :Illd. 204
musclcs
;Idductors. 259
cervical. 265
erector spinae. 265. 367
gastrocnemius, 2tN
h"lIl~tring. 258
jliopso;\~. 26:!
infr.l~pinatus. 2S~

Icvator ~l;:'lpula..:. :!75

p..:cloralis major. 279
piriformis, 165
<Iu:ldratus lumOOrulll. J:65
scalenes. 278
~okus. 28-1
~t.::rnocleid(Jmasltlid, 277.37/
suboccipitali~, 276. 376
sub~eapulilrj~. 28)

.... , , ........ ' .... ' , ..... , ' V U

VI

supraspin;ltus. 282
lensor fasciae 1;lI:.Il'. 2{H
uPI'll.:r tr.tpc1.ius. 27.'
lI1yofascial. joiut dysfun.:tioll :lIld.lIilTerenliJI
t.liagnu.~is. 366
ned; l1c.xioll, 36.'\
flalp;ltion or. 205
rl:~rir;lli(}ll. Olilercu, .'66
sl'apulohumeral rhylhm. alt..:reJ. 3h5
s~~fl !issu~' "~"I!d~. ~!e.'" :!Il,~
!rullk flexion. altered. 36-1
!rullk Il1wcring frum push.up. .l6(i
we;lkm:ss, ddillcd. ~9
Tri>. (5.,, Trigger pl.\int~)
Trunk
body st;ltic dislllrb'\Hces. 217
dead bug exercises, 346-3~7
..:xtensor enduranc..:, 37/
fh:~i()11

allcr..:d mO\'ClllClll. .'6-1, JfJ.J

ill P;lliclll with shorlcncd qua<lr:llus lum
borum. 131. 13/
lowerins froll~ push.up. treallllcut ;Jrproach.365
r.lngc of motion te.~l.~. rotation. 7S. 7V
Mabilization rtlutinc:-. 196
:-Ircngth tcsts
,,:xlcnsion. 92. 91
Ik~ion. 87. 90. lJ2
side raising. 90-91. 9/
:-ucngthclling pmt;r.:.nlS..'';6-:U7. 3JS
dl:adhug. 346-3H. 3.J7
:-lr..:lching excrcisc~. 3-1S
Trunk curl up
illustrmion, 20-1
for muscle tighlllCS:- cqlu:ltiolls.
Training I(lad. control methods
102. 105
Twistcr
dc:-criptlon. 320. 326
purpose. 32(1
Upper crossed syndrome
pastur.1I signs. JM
scapulohumcrJI rhythm, 365.365
Upptr c:(tremity
body static lllcasurcrnCnl~ uf. 113-114
prehcnsion. 197
:-Irengthcning. of. 3J 7
UPi'll.:r trapezius
pustisolllctric rd;lx"linn. 208.2/0. 27J.

273-275
refcrrcd pain. /71, 273
~clfstrclching, 27./, ::!i5
:-hortcncd
body C~H\!llur chan!;c~, /J.I, 1.15
diswrbed body st;.IIic,. 133, 13.J

"

, ...

O)r

,,~t:,

,... rnt\\..<

,;;,';,II:X,:

I I

11I"'<':111\:'"

lVI~r::,n

I""i"".,

,::)

IVlt\I'llUt\L

:,~:;

Iri~f..:r I'llilll'i.

"273
V"lidity. u{ pain ami di:-;loility llu",tioll'
naires, (1(1
VAS. (Sf'<' \'[,u:lI ;llIalo~ SC;tll')
V...rhal \k,,ripliv... sC;lk~. Bm~. p.lin illt":lI~it~
l11C,I~llr"'lll~'lIl, (.1. (,.I
V":I:-idillllx1. ;.cwbi, hcnl'!its ..,-1')
V":11\.'hrall'\,lulIlli. \S,, Spill")
VCrlchr..1j'lilll'. /7l1
Ve:-tihular :lpp:lr;lltb. fUlleti"n..~2'1
Ve~tihul..r dl"luJas..\~3-3:\J
Veslihlll:lr neuritis
postural ~\\ <lying. 330, 33/
st:ltllkille~igral\l ar":;lS, 33/
Visioll. intcgration dismd..:rs . .:129.-,'1,1 I
Visllal analog ~eak
pai,1I i,llellsilY 1I1easurCIllCllt. (.1, 62,7.\-71
paill llH.:;I:-urClllClll. :'is
vi,w:,i IIlSPC":llllll. pllrj1usC', II.'
W:ller Spllrb. Iumoar spine illj\lrie~. 351
\VCE. (Sa Work e:Ij1:1city e"';llu:ulml)
\VUR ncurons, (Sn' Wide d)'lIanllc r:mge
nCUWl\s)

"Weak link:' :-trenfthC'lling, 37

.''\

')
,

\Ve"klle.~:-, lIlu~l;lc

anhrogenlr.:. 29
slrC'lell, :!S-21J
tighlllCS:-.28
tri~~cr point. 29
Weiht lifting. lumh;ar spine injuric:-. J51
WEST st;md:lrd cvahl'llioll. dc.~(:ripti\m.
IJl'i-I-l'J
wESTEPIC urI Capacily Test
dcscripti~ln, 149
illllstration.149
Whipl:ISh. Quebec Task Force studies. 361
Wide dynamic r:mgc lIcuruns. lleurop:.nhk pain
amI. 25
Willd{lW o{ optimal ;It:li\'ily. ill pcrrorman.....: ,'t.IlItillmllll. 52. 53
WindlIp.256-257
Wohhle OOard. dcscriplion. nil
Work eap:Icity evaluatioll
fUllction:d capacity ;lIlU, cOrTl..'lalil'lIs betwc..:n.
purpo:-c. is
\Vmkstalinll ert:0ll(lllli{'!i
dt;lir :-euing:-. 167. /79
C(llllpuicr. /if)
lte:lIlachc rdil':f, :\75-:n(1
Wri.~t. C:c.ICIl'orS, postismlletric n:la.'('llioll. ::01
Writill,t: wcuge. 178
wSI:. (Sa WEST standanl cv,llll:ltioll)

."
:i

is.

.,
)

.,
.J

.~