Aims and sources

This chapter covers topics that are as varied as the problems our patients bring to us to solve or assist with, falling as they do under the broad classifications discussed in earlier chapters: biochemical, biomechanical and psychosocial.

Some of the biomechanical self-help approaches in this chapter are derived from a series of copyright-free articles by Craig Liebenson DC (2001) that were written for the Journal of Bodywork and Movement Therapies, entitled ‘Self-help for the clinician’ and ‘Self-help for the patient’. The authors gratefully acknowledge Dr Liebenson’s far-sighted contribution to the field of rehabilitation, with earnest appreciation. Other strategies, designed for patient use, that have been included in this chapter are summarized from the text Multidisciplinary Approaches to Breathing Pattern Disorders (Chaitow et al 2002) of which one of the authors of this text (LC) is a co-author. Grateful thanks are due to the other authors, Dinah Bradley Morrison PT (1998) and Chris Gilbert PhD (2002).

Additional strategies presented derive from diverse sources, some of which will be acknowledged (if the source is known), while others are based on the personal clinical experience of the authors.

Coherence, compliance and concordance

Patients seldom automatically do as they are advised. Unless the required activity is understood and its relevance to the individual’s health status made clear, the chance of regular application of anything, whether it involves exercise, dietary reform, breathing modification or lifestyle change, is small.

Gilbert (2002) provides insights into what is a very real problem for anyone trying to encourage a patient to modify habitual patterns of use, whether this relates to posture, breathing or other activities. Gilbert’s focus is on breathing, which, as he points out, has its own unique dynamics.

When the topic is ‘learning to breathe better’, the teaching/learning situation as usually set up presents a quandary. The patient is informed of an erroneous breathing pattern and is offered help in learning to correct it. This exchange takes place during rational verbal interaction. But the breathing problem emerges from a system that is far from the rational verbal realm. Changing one’s breathing is not the same as improving one’s tennis serve or ski technique; breathing is a continuous process and fully automatic in the sense that it does not require conscious supervision. Also, since breathing is so essential to life, there are multiple controls and safeguards to ensure its operation. Teaching someone to interfere in this process is presumptuous. We can commandeer the breathing mechanism temporarily with full attention, but as soon as the mind wanders elsewhere, automatic mechanisms return. Yet progress is quite possible. The interaction between voluntary and involuntary can be addressed with respect for the deep, protective systems which are trying to ensure adequate air exchange in spite of conflicting messages from various areas of the brain. The problems which create the need for breathing retraining may derive from emotional sources or from injuries, poor posture or habits acquired through compensation for some other factor. Assuming there is no current structural or medical impediment to restoring normal breathing, the challenge is to allow the body to breathe on its own, in line with the metabolic needs of the moment. To change a chronic breathing pattern it is necessary to make the conscious intervention less conscious, more habitual.

This, then, is the challenge we all face: helping someone to understand a/ why change is needed, b/ offering a means whereby the change can be achieved and then, c/encouraging the process of turning a strange new experience into a habit.

In Volume 1, second edition, Chapter 8 (pages 173 and 174 in particular – see also Fig. 8.3 in that chapter) rehabilitation and compliance issues are discussed. An abbreviated summary of some of the key elements of that discussion is included in Box 7.1 of this text.

The patient exercises in this chapter are presented in appropriately headed boxes. Information for the patients to encourage better compliance or to offer background data from which they may derive encouragement to comply with whatever is suggested for self-application is also given. In some instances combinations of these presentations are used.

Background information for the clinician will mainly be found in Chapter 6, although in some instances there are brief introductory notes for the clinician in this chapter as well.

What we can learn from research into compliance

In the 2nd edition of Rehabilitation of the Spine, Liebenson (2007) embraces a remarkable shift to a new patient-centered model of management of spine disorders. ‘Rather than focusing merely on pathology and symptoms, the emphasis is on recovery, reactivation, and self-management. Passive care approaches utilizing medication, modalities, and manipulation are being replaced with an active self-care paradigm.’ He provides overwhelming evidence in support of these concepts along with the ‘reasons why a traditional biomedical way of thinking is far from ideal for a multifactorial problem such as spine pain.’

A number of studies have looked at the basic question: ‘Why do some people not comply with home-exercise or other self-help strategies that are known to be able to help their condition?’

Åsenlöf et al (2009) examined the long-term effects of a Tailored Behavioural Treatment (TBT) protocol, compared with an Exercise Based Physical Therapy (EBPT) protocol. Compliance and outcomes were far better in the TBT group. One interesting outcome, apart from the compliance issue, was that fear of movement/(re)injury increased in the EBPT-group, but not the TBT group.

The key elements of TBT are summarized as follows:

Obviously a great deal of effort and collaboration is required in such planning – but it makes sense that outcomes are likely to be better (and they are) than by simple ‘homework’ prescription.

Howard & Gosling (2008) found that patients who have a positive attitude, more education and more previous positive experiences in relation to health, sport and exercise are more likely to be compliant to practitioner prescribed exercise rehabilitation programs. They also found that personal characteristics – such as attitude, education and past experience relating to health, sport and exercise – need to be assessed prior to exercise prescription. Gaining an early insight into whether a patient is likely to be ‘compliant’ or ‘non-compliant’ can provide practitioners a basis upon which to design their rehabilitation processes.

Biomechanical self-help methods

Positional release self-help methods (for tight, painful muscles and trigger points) (Chaitow 2006)

When a person feels pain, the area that is troubled will usually have some degree of local muscle tension, even spasm, and there is probably a degree of local circulatory deficiency, with not enough oxygen getting to the troubled area and not enough of the normal waste products being removed. Massage and stretching methods can often help these situations, even if only temporarily, but massage is not always available or may be impractical if the region is out of reach and you are on your own.

If the pain problem is severe, stretching may help but at times this may be too uncomfortable. There is another way of easing tense, tight muscles and improving local circulation, called ‘positional release technique’ (PRT). In order to understand this method a brief explanation is needed.

It has been found in osteopathic medicine that almost all painful conditions relate in some way to areas which have been in some manner strained or stressed, either quickly in a sudden incident or gradually over time because of habits of use, poor breathing habits, posture and other influences. When these ‘strains’ – whether acute or chronic – develop, some tissues (including muscles, fascia, ligaments, tendons, nerve fibers) may be stretched while others are in a contracted or shortened state. It is not surprising that discomfort emerges out of such patterns or that these tissues will be more likely to become painful when asked to do something out of the ordinary, such as lifting or stretching. The shortened as well as the overstretched structures may have lost their normal elasticity, at least partially. It is therefore common for strains to occur in tissues that are already chronically stressed in some way.

What has been found in PRT is that if the tissues that are short are gently eased to a position in which they are temporarily made even shorter, a degree of comfort or ‘ease’ is achieved, which can remove pain from the area. They may also then begin to function more normally and allow movement or use without (or with less) pain.

But how are we to know in which direction to move tissues that are very painful and tense? There are some very simple rules and we can use these on ourselves in an easy-to-apply ‘experiment’. Now, perform the steps in Box 7.2.

Box 7.2 Patient self-help. PRT exercise (Chaitow 2007)

• Sit in a chair and, using a finger, search around in the muscles of the side of your neck, just behind your jaw, directly below your ear lobe about an inch. Most of us have painful muscles here. Find a place that is sensitive to pressure.

• Press just hard enough to hurt a little and grade this pain for yourself as a ‘10’ (where 0 = no pain at all). However, do not make it highly painful; the 10 is simply a score you assign.

• While still pressing the point bend your neck forward, very slowly, so that your chin moves toward your chest.

• Keep deciding what the ‘score’ is in the painful point.

• As soon as you feel it ease a little start turning your head a little toward the side of the pain, until the pain drops some more.

• By ‘fine tuning’ your head position, with a little turning, sidebending or bending forward some more, you should be able to get the score close to ‘0’ or at least to a ‘3’.

• When you find that position you have taken the pain point to its ‘position of ease’ and if you were to stay in that position (you don’t have to keep pressing the point) for up to a minute and a half, when you slowly return to sitting up straight the painful area should be less sensitive and the area will have been flushed with fresh oxygenated blood.

• If this were truly a painful area and not an ‘experimental’ one, the pain would ease over the next day or so and the local tissues would become more relaxed.

• You can do this to any pain point anywhere on the body, including a trigger point, which is a local area that is painful on pressure and that also refers a pain to an area some distance away or that radiates pain while being pressed. It may not cure the problem (sometimes it will) but it usually offers ease.

The rules for self-application of PRT are as follows.

• Locate a painful point and press just hard enough to score ‘10’.

• If the point is on the front of the body, bend forward to ease it and the further it is from the mid-line of your body, the more you should ease yourself toward that side (by slowly sidebending or rotating).

• If the point is on the back of the body ease slightly backward until the ‘score’ drops a little and then turn away from the side of the pain, and then ‘fine tune’ to achieve ease.

• Hold the ‘position of ease’ for not less than 30 seconds (up to 90 seconds) and very slowly return to the neutral starting position.

• Make sure that no pain is being produced elsewhere when you are fine tuning to find the position of ease.

• Do not treat more than five pain points on any one day as your body will need to adapt to these self-treatments.

• Expect improvement in function (ease of movement) fairly soon (minutes) after such self-treatment but reduction in pain may take a day or so and you may actually feel a little stiff or achy in the previously painful area the next day. This will soon pass.

• If intercostal muscle (between the ribs) tender points are being self-treated, in order to ease feelings of tightness or discomfort in the chest, breathing should be felt to be easier and less constricted after PRT self-treatment. Tender points to help release ribs are often found either very close to the sternum (breast bone) or between the ribs, either in line with the nipple (for the upper ribs) or in line with the front of the axilla (armpit) (for ribs lower than the 4th) (Fig. 7.1).

• If you follow these instructions carefully, creating no new pain when finding your positions of ease and not pressing too hard, you cannot harm yourself and might release tense, tight and painful muscles.

Figure 7.1 Positional release self-treatment for an upper rib tender point

(reproduced from Chaitow 2000).

Muscle energy self-help methods (for tight, painful muscles and trigger points)

When a muscle is contracted isometrically (which means contraction without any movement being allowed) for around 10 seconds, that muscle as well as the muscle(s) that performs the opposite action to it (called the antagonist) will be far more relaxed and can much more easily be stretched than before the contraction. This is known as ‘muscle energy technique’ (MET).

You can use MET to prepare a muscle for stretching if it feels tighter than it ought to, before gently stretching it. It is also useful for self-treating muscles in which there are trigger points.

In this sort of exercise light contractions only are used, involving no more than a quarter of your available strength. Now, practice the steps in Box 7.3.

Box 7.3 Patient self-help. MET neck relaxation exercise (Chaitow 2004)

Phase 1

• Sit close to a table with your elbows on the table and rest your hands on each side of your face.

• Turn your head as far as you can comfortably turn it in one direction, say to the right, letting your hands move with your face, until you reach your pain-free limit of rotation in that direction.

• Now use your left hand to resist as you try to turn your head back toward the left, using no more than a quarter of your strength and not allowing the head to actually move. Start the turn slowly, building up force which is matched by your resisting left hand, still using 25% or less of your strength.

• Hold this push, with no movement at all taking place, for about 7–10 seconds and then slowly stop trying to turn your head left.

• Now turn your head round to the right as far as is comfortable.

• You should find that you can turn a good deal further than the first time you tried, before the isometric contraction. You have been using MET to achieve what is called postisometric relaxation in tight muscles that were restricting you.

Phase 2

• Your head should be turned as far as is comfortable to the right and both your hands should still be on the sides of your face.

• Now use your right hand to resist your attempt to turn (using only 25% of strength again) even further to the right starting slowly, and maintaining the turn and the resistance for a full 7–10 seconds.

• If you feel any pain you may be using too much strength and should reduce the contraction effort to a level where no pain at all is experienced.

• When your effort slowly stops see if you can now go even further to the right than after your first two efforts. You have been using MET to achieve a different sort of release called reciprocal inhibition.

You have now used MET in two ways, using the muscles that need releasing and then using their antagonists. This improvement in the range of rotation of your neck should be achieved even if there was no obvious stiffness in your neck muscles before the start of the exercise. It should be even greater if there was obvious stiffness.

Both methods work to release tightness for about 20 seconds, which then allows you the chance to stretch tight muscles after the isometric contraction.

MET contractions are working with normal nerve pathways to achieve a release of undesirable excessive tightness in muscles. You can use MET by contracting whatever part of your body is tight or needs stretching and especially any muscle that houses a trigger point. Always contract lightly using either the tight muscle itself or its antagonist, hold for 10 seconds, then stretch painlessly.

Exercises for spinal flexibility

As we age and especially as we adapt to the multiple mechanical stresses and injuries of life, the muscles which support and move the spine, as well as other soft tissues such as the tendons and supporting fascia, and the joints themselves, can lose their ability to efficiently perform all these movements. When it is healthy and supple, the spine can flex (bend forward), extend (bend backward), sidebend to each side, as well as rotate (twist).

The four exercises described below (one flexion – Box 7.4, one extension – Box 7.5 and two rotation – Box 7.6) as well as those in Box 7.7, will help maintain flexibility or help to restore it if the spine is stiff. They should not be done if they cause any pain. Do these in sequence every day to maintain suppleness. The exercises described are designed to safely restore and maintain this flexibility

• If it hurts to perform any of the described exercises or you are in pain after their use, stop doing them. Either they are unsuitable for your particular condition or you are performing them incorrectly, too energetically or excessively.

• Remember that these exercises are prevention exercises, meant to be performed in a sequence so that all the natural movements of the spine can benefit, and are not designed for treatment of existing back problems.

Box 7.4 Patient self-help. Prevention: flexion exercise (Chaitow 2004)

Perform daily but not after a meal.

• Sit on the floor with both legs straight out in front of you, toes pointing toward the ceiling. Bend forward as far as is comfortable and grasp one leg with each hand.

• Hold this position for about 30 seconds – approximately four slow deep breathing cycles. You should be aware of a stretch on the back of the legs and the back. Be sure to let your head hang down and relax into the stretch. You should feel no actual pain and there should be no feeling of strain.

• As you release the fourth breath ease yourself a little further down the legs and grasp again. Stay here for a further half minute or so before slowly returning to an upright position, which may need to be assisted by a light supporting push upward by the hands.

• Bend one leg and place the sole of that foot against the inside of the other knee, with the bent knee lying as close to the floor as possible.

• Stretch forward down the straight leg and grasp it with both hands. Hold for 30 seconds as before (while breathing in a similar manner) and then, on an exhalation, stretch further down the leg and hold for a further 30 seconds (while continuing to breathe).

• Slowly return to an upright position and alter the legs so that the straight one is now bent, and the bent one straight. Perform the same sequence as described above.

• Perform the same sequence with which you started, with both legs out straight.

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