From: webinfo@ChiroViewPresents.com 8/22/00 By way of background, Kim is co-director of SportsMedicine & Rehab Clinics of Washington, a multidisciplinary company. As many know, he is a popular speaker at numerous conventions and participates as a team physician and consultant to high school and university athletic programs, as well as being a chiropractic faculty member. He is currently a postgraduate faculty member of numerous chiropractic colleges and is the current president of the ACA Rehab Council. He has participated in college sports, and has served as a trainer, coach and team doctor. Dr. Christensen is the author of numerous publications and texts encompassing musculoskeletal rehabilitation and nutrition. If you have questions or comments, please send them to me and I can pass them along to Kim. His email address is kimchristensen@netzero.net #1 Here's what Kim had to say... Rehab and the Sacroiliac Joint Kim D. Christensen, DC, DACRB, CCSP A dysfunctional sacroiliac (SI) joint is often ignored or dismissed as an insignificant feature of musculoskeletal health. 1,2 However, SI subluxation is a legitimate syndrome, separate from the type of low back pain associated with disc conditions, lumbago, or sciatica. 1-6 In fact, SI joint dysfunction has been implicated as a common cause of back pain in more than 30% of children. 3 Additionally, a study involving the correction of SI joint dysfunction in patients presenting to a chiropractic center over one day found an incidence of 57% for SI joint dysfunction. 7 Clinically, the SI joint can give rise to buttock and leg pain, which is often difficult to differentiate from other causes of low back pain. 8 Furthermore, dysfunction of the SI joint may be a contributing factor in failed back surgery syndrome. 9 What the SI Joints D0: The role of the SI joints is to functionally participate in converting the pelvis into a „resilient, dynamic, accommodating base that dissipates weight, absorbs shock, and provides a singular proficiency unique to bipedal locomotion.¾ 10 In four-legged animals, body weight is distributed horizontally over the spine. Taken from an engineering point of view, this weight-distribution method is superior to the upright human musculoskeletal system, which has a single cantilevered support at the hips. The human spinal column is configured so that the total weight of the upper body rests on the two small SI joints at the juncture of the sacrum and ilia. The stress placed on this area in the upright position makes the lower back susceptible to injury. SI Dysfunction: Primary SI dysfunction arises from trauma such as blows, falls on the buttock, or from attempts to save oneself from falling. Knocking the SI joints out of place can affect the structural integrity of the entire spine. The SI joints themselves are held in place by small ligaments, which can be stretched out of position if there is a traumatic dislocation. The whole pelvic girdle can be tilted to one side in the aftermath of a traumatic injury. Tissues in the area become inflamed and muscles spasm, pulling on the hip bones and rotating them out of place. A secondary dysfunction comes on slowly, producing a chronic misalignment. Muscle atrophy on one side and overdevelopment on the other may be associated with a scoliosis with pelvic tilt or an actual shortening of one leg. 5 Over time the entire spine can be affected, and one shoulder blade or one side of the ribcage may appear more pronounced than the other. Eventually, uneven pressure on the spine may grind away at the protective discs between the vertebrae. Treatment Approaches:The goal of treating SI subluxation is to restore a normal relationship between the sacrum and ilium and to maintain it with suitable support. 2 Many authors concur in principle but differ in exact methods of restoration and supportive care. 1,5,9,11 After the SI joint is examined and evaluated, the direction of displacement is determined. Joint correction is made by inducing a „rotary movement of the ilium in the direction exactly contrary to the one in which the displacement has occurred.¾ 5 Achieving suitable support to maintain joint integrity requires consideration of predisposing factors. Here is where special attention should be paid to the kinetic chain. Beginning at the foundation of the chain, the feet may exhibit excessive pronation or supination that can contribute to SI syndrome. Effects may manifest as muscular imbalance and skeletal distortion that transmit directly to the pelvic ring. Functional leg length inequality can also result from foot disorders or structural anomalies. Custom-made orthotics and lifts should be pursued in treating the corresponding symptoms. 1,11,12 The effects of heel-strike shock on the pelvic structure should also be noted. Shock forces of 5-7 g¼s (5-7 times body weight) are transmitted and dissipated through the body and reduced to 0.5 g at the jaw. 13 Hip and back pain are natural consequences when such force is present, particularly in cases where SI dysfunction exists. A shock-absorbing material built into a custom-made orthotic can have a significant effect in reducing initial heel impact. Corrective exercise done at home can be recommended as an adjunct to clinical treatment. 1,5,14 Activity should focus on developing strength in the abdominals and supporting pelvic muscles. This can also enhance the shock-absorbing properties of the tissues. Patients exhibiting marked SI instability may require use of a corset, belt, or strapping. 1,2,11 Additional lumbar support can also be provided by a postural back rest when seated, or by a pillow designed to provide adjustable support for either the lumbar or cervical areas. Proper cervical support during sleep is an often overlooked area of consideration in SI cases. Because the body is essentially a kinetic chain, elongation of supporting soft tissues in the cervical spine may ultimately lead to spinal misalignments that can aggravate the SI syndrome. Cervical support pillows help to promote patient comfort, and also help adjustments to hold. SI Rehab: Do¼s and Don¼t¼s Here is some additional advice for your patients with SI dysfunction/pain: Do walk briskly 2-3 miles a day to strengthen stretched-out sacroiliac ligaments and reduce them to their proper size and position. Don¼t rely on bed rest -- ligaments will further slacken from disuse. Don¼t bring your knees to your chest, perform sit-ups, or bend over from the waist with your knees straight. All of these motions will displace the SI joints. Don¼t use heat treatments after a back injury. Heat expands the ligaments, contributing to further instability. Do ice the area. Ice reduces inflammation and relaxes muscles. References 1. DonTigney RL. A review. Physical Therapy 1985; 65(1):35-44. 2. Cox HH. Sacro-iliac subluxation as a cause of backache. Surg, Gynec & Obstet 1927; 45:637-648. 3. Mierau DR et al. Sacroiliac joint dysfunction and low back pain in school aged children. JMPT 1984; 7(2):81-84. 4. Jessen AR. The sacroiliac subluxation. ACA J of Chiro 1973; 7(s):65-72. 5. Cyriax E. Minor displacements of the sacro-iliac joints. Br J Phys Med 1934; 9:191-193. 6. Freiberg AH, Vinke TH. Sciatica and the sacro-iliac joint. J Bone & Foot Surg 1934; 16:126-136. 7. Gemmell HA, Heng BJ. Low force method of spinal correction and fixation of the sacroiliac joint. The Amer Chiro 1987; Nov:28-32. 8. Gemmell HA. The sacroiliac joint. Success Express 1988; 12(1):56-59. 9. McGregor M, Cassidy DC. Post-surgical sacroiliac joint syndrome. JMPT 1983; 6(1):1-12. 10. Janse J. Clinical biomechanics of the sacroiliac mechanism. ACA J of Chiro 1987; 12(s):1-8. 11. Grieve GP. The sacroiliac joint. Physiotherapy 1976; 62(12):384- 400. 12. Schafer RC. Clinical Biomechanics. Baltimore: Williams & Wilkins, 1983. 13. Voloshin AS, Burger CP. Interaction of Orthotic Devices and Heel Generated Force Waves. Ninth Intl. Congress on Applied Mechanics. Canada, 1983. 14. Thompson A. How to Cure Your Aching Back. New York: Doubleday, 1971. #2 ChiroView Presents welcomes Dennis Shavelson, DPM, C.ped - Department Head - Orthotics & Biomechanics. . . I would like to welcome Dr. Shavelson to the ChiroView Presents broadcast. Over many years, given high levels of interest displayed by chiropractors relative to foot orthotics and biomechanics, I thought we would be better served by setting up a separate department. Dennis is a podiatrist and certified pedorthist practicing at The Weill-Cornell Medical Center in New York City. As president of Chirothotic Orthotic Lab, he also serves as medical director of Genovation, Inc., the developers of The ProFootScan System. For more information, you might want to visit http://www.chirothotic.com or http://www.profootscan.com. As the introduction to this department, here is what Dennis has to say. . . Functional Lower Extremity Biomechanics, Foot Orthotics and Chiropractic Dennis Shavelson, DPM, C.ped My name is Dr. Dennis Shavelson and I have been practicing lower extremity biomechanics and dispensing foot orthotics for over thirty years. I am honored to have been selected to be the Biomechanics and Orthotic Department Head for ChiroView Presents. I am convinced that every chiropractor has the ability to improve patient care while generating new income when they dispense foot orthotics in practice. In this, my first broadcast, I am going to define Lower Extremity Biomechanics and foot orthotics to the audience and site some historical references. Then, I will try to present an overview of the current trends in biomechanics and foot orthotics. Finally, I will discuss the therapeutic and economic benefits of working with foot orthotics in chiropractic practice. I hope that I can stimulate enough interest in biomechanics and orthotics to get you to give them a try. Simultaneously, I hope that I can provide enough mentoring to allow chiropractors who currently dispense foot orthotics to find reasons to make lower extremity biomechanics an even greater part of their practice. Lower extremity biomechanics is the science that studies normal and abnormal mechanical relationships in the human body from the low back down when in closed chain kinetics. This means that the subject is either standing (stance) or active (gait) and weighted upon the ground. A foot orthotic is any support or strut, applied at the feet, that offers the feet and posture improved quality of life, improved balance and reduction of pain and other symptoms. The first foot orthotic was probably a piece of rolled up cloth placed in a shoe that gave the arch of the foot support and comfort. In the early 1900¼s, craftsmen made custom arch supports from a cast of the feet in various materials from stainless steel (rigid) to leathers, corks and crepes (semi-rigid, flexible). They added heel cushions and metatarsal pads to the support that offered varying degrees of postural comfort to their users. In the 1970¼s, a podiatrist named Merton Root, D.P.M., discovered that control of the subtalar joint, in addition to arch support, alone produced significant postural comfort. He used wedges of material to restrict subtalar joint motion (pronation and supination) at the heel and front of a thermoplastic shell that was heat pressed to a positive cast of the foot. He developed a diagnostic and treatment regimen based on his findings that included a doctor¼s prescription reflecting his/her diagnosis and examination. The prescription foot o! rthotic was born. In the last thirty years there have been advances in diagnostic instrumentation, orthotic materials and fabrication that allow biomechanists to prescribe foot orthotics that last longer, are more accurate, and have improved outcomes. There are two basic schools of thought in biomechanics: The first is accommodative biomechanics or the cushion-support concept. Soft, cushion materials (leathers, laminates and crepes) are formed into an arch cushioned shell and then padding is added as heel lifts, heel cushions or metatarsal pads. Accommodative orthotics are safe, comfortable and supportive. They provide considerable relief for foot problems, work well for balancing unequal limbs and provide varied levels of postural comfort. They are good shock absorbers and are especially useful for geriatric patients and subjects with advanced deformities. The second is functional biomechanics or the strut concept. Semi- rigid or rigid materials (thermoplastics, fiberglass and graphite) are heat-molded to a positive cast to form a shell with arch support and a cupped heel to hold the foot in place. Wedged posts are added to the heel area that control subtalar joint motion and strut the posture. A foot orthotic fabricated in this manner can prevent the posture from collapsing reducing the need for compensation to occur within the posture itself. The supported posture becomes stronger and more efficient. A doctor¼s evaluation and prescription as well as guidance for break-in and care are important to insure the best outcomes. Functional orthotics provide excellent relief for foot and postural problems, as well as for balancing unequal limbs. They are excellent shock absorbers and can actually control and correct for biomechanical pathology. Casts for orthotics are taken with either foam or plaster and are off weightbearing, semi weightbearing or weight bearing. All three techniques are easy to learn and quick to perform after a short learning curve. Accommodative orthotics need a semi weightbearing or weightbearing cast that comes close to reproducing the surface of the foot. Functional orthotics need a non weightbearing or semi weightbearing cast with the subject held in neutral or healthy position so that the orthotic shell will prevent the foot from deforming while holding the foot in healthy position. I have always believed that the fee for a foot orthotic should reflect the doctors¼ diagnostic, prescribing and dispensing „skill and time¾ since all orthotics probably involve about $20 of materials. Also, a prefabricated orthotic should cost less than one generated from a laboratory. These are the relative fees for the various foot orthotics that reflect doctor and fabrication time. 1. Over The Counter $20-50 2. Prefabricated $50-70 3. Customized Prefabricated $75-125 4. Flexible Custom $125-175 5. Prescription Scanned $175-225 6. Semi Flexible or Rigid Custom $225-450 When it comes to fees, the more sophisticated the diagnosis, prescription and orthotic, the more likely to have insurance reimbursement. However, it is my experience that when I deliver a proper presentation, along with an option of credit cards and payment plans, most of my patients have prescription orthotics made. I offer an unconditional money back guarantee that has resulted in my refunding patients 15 times in 30 years because orthotics work if they are well selected, well casted and well fabricated. Orthotics elevate the level of care you offer in your practice. They are a source of new patients and additional income. Chiropractors dispensing four orthotics weekly, plus office visits, casting fees, and check-ups can generate up to $50,000 in additional practice revenue. In the beginning, biomechanics and foot orthotics seem more complicated than they really are. For that reason I welcome any and all questions. If you have questions or ideas for future broadcasts relating to „biomechanics and orthotics¾, then please contact me directly @ drsha@profootscan.com. If you would like to contribute a broadcast to this department or have additional comments, please contact Sig @ webinfo@ChiroViewPresents.com. I hope you find this information helpful and welcome aboard. Dennis Shavelson, DPM, C.ped ChiroView Presents Department Head Biomechanics and Foot Orthotics