Chiropractic a Biopsychosocial Care Model

August 2009 Dr. Keith Walburn 1

2009 FWCI Educational Conference – Chiropractic Breakout

CHIROPRACTIC

A BioPsychoSocial Care Model



Dealing

with

Clinicians



Dealing With People

• Thoughts

• Feeling

• Rationalizing

• Search for significance

• Misunderstanding

• Advertising

• Outside influences

• Work and social pressure

• Fear

• Anxiety



Immediate Care

• Reduce the focus on symptoms

• Control anxiety by reducing the what if’s

• Reduce deconditioning -limit rest & disability

• Treat pain and dysfunction

• Reduce pathologic focus

• Problems found in people not imaging studies

• Biologic crises makes up less than 5%

– i.e. Radiculopathy, cancer, organic disease



Condition Appropriate Activities

• Hurt vs Harm• Reduce deconditioning• SAW/RTW• Doing the right thing the right way• Reduce pathologic movement patterns• Not all bad pain is a bad problem



General Health Issues

• POSTURE: – A reflection of physical function not just how we stand or sit

• DIET: – Fuel to run the body on

• SMOKING: – All the known risks

• EXERCISE: – Physical conditioning vs physical destruction

• SAW / RTW: – Low likelihood of increased physical harm



Hypothetical Rx Medication

• Detrimental to mental health

• Associated w/ increased

– Rate of substance abuse

– Risk of disabling LBP

• Scientifically established positive for

– cancer risk, heart disease, child & spouse abuse, divorce, and early death



The Deadliest Occupation

• “Unemployment” beat out – Steeple jacking – As the riskiest profession

• “Being Unemployed has the same pathologic equivalent as smoking 10 pks of cigarettes per day”

• Ross,JF Risk: where is the real danger? Smithsonian: Nov 1995 p42-53



Over Medicalizing Makes People Sick

“For each ailment that doctors treat they produce 10 others in healthy individuals by inoculating them with a pathogenic agent 1000 X more virulent then all microbes – The idea they are ill”

-- Proust 1880



Identifying The Real Issues

• FLAG: Biologic issues

• FLAG: Psychological issues

• FLAG: Social issues

• FLAG: Litigation

RED

YELLOW

BLUE

BLACK



FLAG: Biological Issues

• Confirmed Radiculopathy

• Nerve Disease

• Muscle Disease

• Fracture

• Obesity

• Burns

• Pathogenic Movement Pattern

REDWerdnig-Hoffman disease (a type of spinal muscular atrophy). Small muscle fibers within separate muscle fascicles.



FLAG: Psychological Issues

• Depression

• Bipolar Disorder

• Conversion Disorder

• Somatization

• Compliance

YELLOW



FLAG: Social Issues

• Single Parent

• Care Giver

• Support Network

• Substance Abuse

BLUE



FLAG: LitigationBLACK



CHIROPRACTIC EFFICACY

Spinal

Manipulation Treatment



Measured Outcomes

• Objective VS subjective

• Measured not felt

• Quantitative VS Qualitative

• Specificity VS Reliability



Measured Outcome Requires Measured Intake

• Complete History

• Information collected on intake forms

• Educational levels

Use forms

already validated• Roland-Morris• Oswestry• Waddel• Pain Diagram• Pain Scale

To know how far you’ve come, you need to know

where you started



• WWW.Functional RatingIndex.Com



• WWW.Functional RatingIndex.Com



Chiropractic

• Physical Functional Medicine

• Accurate Pathologic and Functional Diagnosis

• Evaluation and Treatment



Tool Box

• PROVOKE vs EVOKE

– Manipulation

– Medical bag

• REACT vs RESPOND

– Everything else

– Semi truck



Why do patients often continue to complain when the orthopedic tests

are negative?

Because their kinetic dysfunction and

deconditioning have not yet been addressed



? Why are we not excited about doing Re-Examinations ?

• Orthopedic or pain provocative tests are usually negative

– After 4-6 weeks of time, when nociception normalizes

• Thus, little useful information is obtained

– That directly affects our treatment approach

• Because our primary mode of treatment is manual,

– Various approaches of palpation help us decide

– The location, force, and variety of manipulation,

– Which are performed on every treatment visit

• Tests used must impact our treatment decisions

– In order to affect our treatment plan



How can deconditioning and dysfunction be properly assessed?

• Through the use of physical performance tests or, the FCE

– These are tests that measure loss of function including strength, balance or proprioception, range of motion, and muscle length

• By including a FCE as a 4th to 6th week “re-examination”

– Deconditioning and functional impairment can be identified and remeasured at a later date to determine the benefits of the new treatment plan consisting of rehabilitation (active care) concepts

• Weaning patients from passive to active care is obtained in this process



Which exercises ?

• Specific exercises are designed after each FCE test– Found in exercise CD’s and manuals!

• Thus, a new treatment plan – Emphasizing rehab concepts – Can be easily & immediately implemented – Following the FCE examination

• Hence, a renewed value in the exam process is appreciated– By performing the FCE



Reflex Response vs. Willful Action

Involve Muscles & Tendons which cross joints and produce movement or maintain stability and are affected by muscle tone



Tools Versus Toys

• Provoke ideal reflex response

• Resolve hurt and harm

• Do not teach the reflex system

• Patient does not get better

– Measurable physical functional improvement



Higher Truth

These affect all outcomes

Practice: What we do every day

Habit: A reflex response

Character: A 3rd party observer

Destiny: The outcome



Does The Character?

Protect and Preserve?OR

Compound Physical Harm?



Two Part Problem

• IN

– Sensory

– Ideal

• OUT

– Motor

– Adaptation



Evaluation by Observation

• Simple

• Basic

• Simple

• Essential

• Simple

• Everyday• Characteristic



Character

• Sitting

• Standing

• Sitting

• Standing

• Breathing

• Standing

• Seeing



(Your Name) Rule

The body knows it can’t fall off the FLOOR



TrainingA variety of disciplines sharpen proprioceptive senses

• Standing on a wobble board or balance board

– is often used to retrain or increase proprioception abilities, particularly as physical therapy for ankle or knee injuries

• Yoga or Wing Chun involve

– Standing on 1 leg (stork standing)

– & other body-position challenges



Training

Tai Chi’s slow, focused movements of practice provide an environment, whereby the Proprioceptive information being fed back to the brain stimulates an intense, dynamic "listening environment" to further enhance mind/body integration



Training

• Several studies have shown

that the efficacy of these types

of training is challenged by

closing the eyes – because the eyes give

invaluable feedback to establishing the moment-to-moment information of balance



Training

• There are even specific

devices designed for

proprioception training: – such as the Proprioceptor system,

– which consists of shoes with specially designed balls on the soles to make athletes work harder to balance



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Doctor, Do No Harm !!



Hurt Versus Harm

“ I am still waiting

for the first study

that demonstrates

that we can help someone

by taking them out of work”

Stan Bigos MD chair AHCPR



Impairment

• Proprioceptive illusions can also be induced, such as the Pinocchio illusion

• The proprioceptive sense is often unnoticed because humans will adapt to a continuously-present stimulus;

• This is called habituation,

desensitization, or adaptation



PNF (proprioceptive neuromuscular facilitation) Stretching

• Good range of motion makes – Better biomechanics – Reduces fatigue and – Helps prevent overuse injuries

• PNF is practiced by – Chiropractic physicians, – Physical therapists, – Massage therapists, – Athletic trainers and – Others[1]



POSTUREThe Physical Character

Assumed 98% of the Time



Sitting / Standing

• Static

• End Range

• Ideal

• Dynamic

• Physical Advantage

• Adapted



Hard at Work

Not how we stand or sit,

but the position we are going to start our

next movementfrom



Posture Is The Result of Action

AND

NOT THE REAL PROBLEM



Physical LawsCannot Be Broken



A Body at Rest

You fill It In



For Every Action There is an

Equal and Opposite Reaction

Sherrington:

Law of Reciprocal Innervations



Dynamic Function

• Long

• Tight

• Loose

• Short

• Loose

• Tight



Old Habits

• Are your patients trying to do the right things with the wrong tools?

• Are they really doing the wrong things and making the problems worse even though they get relief?



Look Good?



Toe Touch

Loading

Versus

Lengthening



A/P Pelvic Neutral

• Lifting the front• R/A reflex tone • Pelvic perturbation

• Pulling down the back• Static load• Locked knees



Two Types Of MusclesPostural And Phasic

• Muscles facilitate joint movement in the body and help maintain posture

• Muscle strength changes for reasons, including:– Sitting or standing

– Repetitive motion

– Injury

– Lack of exercise

– De-conditioning

• Changes cause a muscle imbalance in the body




• According to Vladimir Janda(1), muscle imbalances develop between muscles that

– Have a tendency to develop tightness and

– Other muscles which are prone to inhibition

• Janda classified muscles into two groups

– Postural

– Phasic



Postural Muscles

Have a tendency to become:

• Overactive

• Hypertonic

• Weak

• Shortened in length

• The psoas muscle, a hip flexor, is an example of a postural muscle



Psoas musclestabilizes

lower back and pelvis.



Phasic Muscles

Have a tendency to become

• Weak

• Inhibited

• The gluteus maximus muscle, a hip extensor, is an example of a phasic muscle




• The tendency for – a specific muscle to become overactive and – another muscle to become inhibited – occurs over time – creating a muscle imbalance and – an altered movement pattern

• The physician must be able to recognize – the muscular imbalance and – the altered movement pattern – in order to prescribe – appropriate relaxation and strengthening exercises – to restore the normal movement pattern in the

body



Postural Muscles / Phasic Muscles• Biceps Femoris

– Gluteus maximus

• Hip Adductors – Gluteus medius

• Piriformis• Rectus Femoris• Psoas • Erector Spinae• Quadratus Lumborum• TFL



Recognizing Patterns and Imbalances

• There is a specific pattern to the

sequence of muscle activation involved

during joint movement

• Two specific patterns to be discussed are

Hip Extension and Hip Abduction




Hip extension and hip abduction movement patterns involve specific muscles:

• Gluteus maximus

• Gluteus medius

• Psoas

• Quadratus lumborum

• Erector spinae

• Piriformis• TFL• Biceps femoris• Adductors• Rectus femoris




• These muscles are categorized either as the

(1)primary mover/agonist

(2)antagonist or

(3)synergist according to their function




• The primary mover/agonist

– Initiates & performs the main function for that specific joint movement

• The synergist

– Assists the agonist during the movement

• The antagonist

– Acts in opposition to the agonist and

– Moves the joint into the opposite direction of the action of the agonist



Hip Muscles

• Affect balance and agility• Refine movements• Are very prone to fatigue

Posterior 1

Anterior

Posterior 2



X-Ray of Arthritic & Normal Hip

Overuse and fatigue of postural stabilizers

increases static load,

contributing to osteoarthritic degeneration



Knee Above Beltline

Findings from single leg stability test:

• Can’t do without holding on

– see foot function

• Can’t do

• Contracts ES and/or QL

• Knees Locked Back

• Tight “Soas”



Ligaments and Muscles of the Knee



Foot Function

• Hand

• Canoe

• Dys-affrentation: pertabate

• Not vestibular; deconditioned response

• Vestibular; close eyes

• “FUN”ctional stability



Range: End vs Mid

• Vertical Gaze

• “Soas”/Hamstring

• Load increase

• Reduced ROM

• 10 Toes

• Rectus/erector

• Load reduction

• Ideal ROM



Muscle Strength Curve

““Bell-shaped” curve: The muscle is weakest at end range Bell-shaped” curve: The muscle is weakest at end range and strongest in mid-rangeand strongest in mid-range

weakestEnd Range Start Range



Anterior Head Translation

• Weight of melon

• All head stabilizers are below

• C5/6 STD

• Breathing

• Load multipliers

• Substituted for Abdominal Function



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Cervical Osteoarthritis



Osteoarthritis vs “the other” STD

• Serial Traumatic Degeneration: A common non-inflammatory progressive degenerative disorder of primarily weight bearing movable joints

• Misnamed as it is a non-inflammatory condition

• 1983 A/F primer of rheumatic disease



Shoulder Joint

http://upload.wikimedia.org/wikipedia/commons/9/90/Shoulderjoint.PNG



Do You Know Squat?

• Stand 3 inches form the wall

• Do the hips stay under the head

• Sit/stand



You Can’t Do It For Them

Don’t lead them to believe, you can break physical laws



Teach by Example

• Tell them

• Inspire

• Show them

• Impress



Repeat Only perfect practice

makes perfect

'Swim faster with half the effort by improving your swimming technique'



Breathe

• Diaphragm

• Low rate

• Bell jar

• Stand/supine



Pelvic Tilt

• Supine

• Knees up

• Increase afferentation

• Breath



Chin Tuck

• “?” Rule

• Increase affrentation

• Ocular synkinesis

• String on balloon

• “AND”

• RHOM…..



Tools of the Trade

• Portable

• Dynamic

• Multi task

• Physical example: K. I. S. S.

• Ideal………………….. not normal



The 3 B’s

• Balls

• Bands

• Boards



These Devices Proprioceptive Input, Speed of Contraction, Motor Output

• Arokski et al. 1999• Balogun 1992 • Beard et al. 1994 • Blackburn et al. 2002• Bullock-Saxton et al. 1993• Clark et al. 2005• Eils et al. 2001• Heitkamp et al. 2001• Ihara & Nakayama 1996• Lanza et al. 2003• Linford et al. 2006• Myers et al 2003• Osborne et al. 2001• Rodd et al. 2001• Vera Garcia et al. 2000• Wise et al. 2001

Rocker and Wobble Board



Sitting on Unstable SurfacesO’Sullivan et al. 2006

• Compared EMG and spinal motion while sitting on stable & unstable surfaces

• Found increased spinal motion on unstable surface, but no increase in EMG

• Noted deeper postural muscles may be involved in making postural adjustments



Sensorimotor Training (SMT) Dr. Vladimir Janda (1928-2002)

• SMT is a progression of specific balance exercises that stimulate the sensorimotor system

• He noted that balance & reflexive stabilization is more important than strength in functional activities



Sensorimotor Training Progression

1. Static

• Maintain balance on progressively unstable surfaces (Stability Trainers & Balance Boards)

• Progress by shifting weight, perturbations, closing eyes, adding head movements

• Progress to unilateral stance



SMT Outcomes in Older Adults

SMT improves balance & gait

in older adults– Rogers et al. 2001, 2002, 2003

Kronhead 2001;

Shimada et al. 2003;

Shores et al. 2002;

Waddington et al. 2003



Exercise Ball EMG Studies

• In general, an unstable surface elicits more trunk EMG compared to a stable surface

Co-contractions of trunk as pelvis support decreases



Exercise Ball Clinical Outcomes

• Increased muscular strength, speed & endurance– Brown et al. 2000, Carter et al. 2006,

Cosio-Lima et al. 2003, Cusi et al. 2001, Ligget et al. 1997, 1999, Salvaterra et al. 2001, Stanforth et al. 1998

• Improved firing patterns– Cosio-Lima et al. 2003, Beard et al. 1994

• Improved postural stability– Baker 2006, Cosio-Lima et al. 2003,

Kronhed et al. 2001, Rogers et al. 2001, Shores et al. 2002, Stanton et al. 2004



School Figures

• + x o O ⃞ - reverse direction• Feet / foot / “look ma!!”• Open / close and lateral gaze• Fast / moderate hard / less full• Head still

•AND



Exercise Ball Training

• Advantages– Variety of postures and exercises– Increases muscular activation – Activates muscles reflexively

• Disadvantages– Falls– Bursting (not with SDS) – Fatigue & Compensations



For Best Outcomes

• Re-test with regularity

• Observe posture and have demonstration of skill development as part of re-exam

• Your expectations will be reflected in the patient’s actions



Documents

Chiropractic a Biopsychosocial Care Model