Chiropractic A Biopsychosocial Care Model

2009 FWCI Educational Conference – Chiropractic Breakout
CHIROPRACTIC
A BioPsychoSocial
Care Model
August 2009 Dr. Keith Walburn 1
Dealing
with
Clinicians

Dealing With People

• Thoughts • Advertising
• Feeling • Outside influences
• Rationalizing • Work and social

pressure
• Search for
significance • Fear
• Misunderstanding • 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

• RED FLAG: Biologic issues
• YELLOW FLAG: Psychological issues
• BLUE FLAG: Social issues
• BLACK FLAG: Litigation

RED FLAG: Biological Issues

Werdnig-Hoffman
• Confirmed Radiculopathy disease (a type of
spinal muscular
• Nerve Disease atrophy). Small
muscle fibers
• Muscle Disease within separate
muscle fascicles.
• Fracture
• Obesity
• Burns
• Pathogenic Movement Pattern

YELLOW FLAG: Psychological Issues
• Depression
• Bipolar Disorder
• Conversion Disorder
• Somatization
• Compliance

BLUE FLAG: Social Issues

• Single Parent
• Care Giver
• Support Network
• Substance Abuse

BLACK FLAG: Litigation

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 Use forms
• Information collected on already validated
intake forms • Roland-Morris
• Educational levels • Oswestry
• Waddel
• Pain Diagram
• Pain Scale
To know how far you’ve

come, you need to know
August 2009
where you started
Dr. Keith Walburn 17
• 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 • REACT vs
RESPOND
– Medical bag
– 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 ?
• Because our primary mode of

treatment is manual,
– Various approaches of palpation
• help us decide
Orthopedic or pain provocative
– The location, force, and variety of
tests are usually negative
manipulation,
– After 4-6 weeks of time, when
– Which are performed on every
nociception normalizes
treatment visit
• Thus, little useful information is
• Tests used must impact our
obtained
treatment decisions
– That directly affects our treatment
– In order to affect our treatment
approach
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 • OUT
– Sensory – Motor
– Ideal – 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

Training
A 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

Doctor, Do No Harm !!
August 2009 Dr. Keith Walburn 38 38

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]
POSTURE
The Physical Character
Assumed 98% of the Time

Sitting / Standing
• Static • Dynamic
• End • Physical
Range Advantage
• Ideal • Adapted

Hard at Work
Not how we
stand or sit,
but the position
we are going to start our
next movement
from
Posture
Is The Result of Action
AND
NOT THE REAL PROBLEM

Physical Laws
Cannot 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 • Short
• Tight • Loose
• 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 • Pulling down the back
• R/A reflex tone • Static load
• Pelvic perturbation • Locked knees

Two Types Of Muscles

Postural 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

Postural And Phasic
• 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 muscle
stabilizes
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


Postural And Phasic
• 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

Recognizing
Hip extension and hip abduction movement
patterns involve specific muscles:
• Gluteus maximus • Piriformis
• Gluteus medius • TFL
• Psoas • Biceps femoris
• Quadratus lumborum • Adductors
• Erector spinae • Rectus femoris

Recognizing
• These muscles are categorized either

as the
(1)primary mover/agonist
(2)antagonist or
(3)synergist according to their function

Recognizing
• 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
Anterior
Hip Muscles
• Affect balance and agility
• Refine movements
• Are very prone to fatigue
Posterior 1
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 • 10 Toes
• “Soas”/Hamstring • Rectus/erector
• Load increase • Load reduction
• Reduced ROM • Ideal ROM

Muscle Strength Curve

End Range Start Range weakest
“Bell-shaped” curve: The muscle is weakest at end range

and strongest in mid-range

Anterior Head Translation

• Weight of melon • Breathing
• All head stabilizers • Load multipliers

are below
• C5/6 STD • Substituted for

Abdominal Function


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 • Show them
• Inspire • 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
Rocker and Wobble • Clark et al. 2005
Board • 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

Sitting on Unstable Surfaces

O’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

Chiropractic A Biopsychosocial Care Model

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2009 FWCI Educational Conference – Chiropractic Breakout

August 2009 Dr. Keith Walburn 2

Dealing With People

• Feeling • Outside influences

• Rationalizing • Work and social

August 2009 Dr. Keith Walburn 3

• Reduce the focus on symptoms

August 2009 Dr. Keith Walburn 4

Condition Appropriate Activities

August 2009 Dr. Keith Walburn 5

General Health Issues

August 2009 Dr. Keith Walburn 6

• Scientifically established positive for

August 2009 Dr. Keith Walburn 7

The Deadliest Occupation

• “Being Unemployed has the same pathologic

August 2009 Dr. Keith Walburn 8

Over Medicalizing Makes People Sick

August 2009 Dr. Keith Walburn 9

Identifying The Real Issues

• YELLOW FLAG: Psychological issues

• BLUE FLAG: Social issues

• BLACK FLAG: Litigation

August 2009 Dr. Keith Walburn 10

RED FLAG: Biological Issues

August 2009 Dr. Keith Walburn 11

YELLOW FLAG: Psychological Issues

August 2009 Dr. Keith Walburn 12

BLUE FLAG: Social Issues

August 2009 Dr. Keith Walburn 13

BLACK FLAG: Litigation

August 2009 Dr. Keith Walburn 14

August 2009 Dr. Keith Walburn 15

August 2009 Dr. Keith Walburn 16

Measured Outcome Requires

To know how far you’ve

August 2009 Dr. Keith Walburn 18

August 2009 Dr. Keith Walburn 19

• Accurate Pathologic and Functional Diagnosis

• Evaluation and Treatment

August 2009 Dr. Keith Walburn 20

August 2009 Dr. Keith Walburn 21

Why do patients often continue to

Because their kinetic dysfunction and

August 2009 Dr. Keith Walburn 22

? Why are we not excited

• Because our primary mode of

August 2009 Dr. Keith Walburn 23

How can deconditioning and dysfunction

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

• Weaning patients from passive to active care is obtained

Reflex Response vs. Willful Action

August 2009 Dr. Keith Walburn 26

Tools Versus Toys

August 2009 Dr. Keith Walburn 27

Habit: A reflex response

Character: A 3rd party observer

Destiny: The outcome

August 2009 Dr. Keith Walburn 28

Does The Character?

Protect and Preserve?

August 2009 Dr. Keith Walburn 29

Two Part Problem