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

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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

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

CRAIG UEBENSON and JEFF OSLANCE

6: Evaluation of Muscular Imbalance

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97

VLADIMIR JANDA

7. Diagnosis of Muscular Dysfunction by Inspection

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

LUDMILA F VASILYEVAand KAREL LEWIT

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

8. Evaluation of Lifting

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LEONARD N. MATHESON

Sec/ion 111. Patient Education

9. Back School

153

PAUL D. HOOPER

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10, Patient Education '

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

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CRAIG UEBENSON and JEFF OSLANCE

169

Section IV. Functional ReslOrarioll
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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

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. . .21.)3

JERRY HYMAN and CRAIG L1EBENSON

Appendi.

14.1 Ex.ercise Checklist

. ..•.....•.•......316

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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.......

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391

GEORGE E. BECKER

20. PatientIDoctor Interaction

A05

WILLIAM H. KIRKALDY·WILLIS

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

Index

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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 Berquist·Ullman 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 long·term 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

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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

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-'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

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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
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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

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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

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

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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

3

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###BOT_TEXT###quot;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###BOT_TEXT###quot;t: structural
pathologic conditions that call be clearly determined as the

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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

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FOR COST·EFFECTlVE 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)

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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

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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

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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

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