The Challenge of Teaching Rehabilitation to Chiropractors

By Craig Liebenson, DC

What follows is an evolving goals and objectives statement from the key faculty of the LACC rehabilitation diplomate program for their first 100-hour course.¹ The faculty involved are John Hannon; Robert Lardner; Curtis Rigney; Susan Green; Pamela Tunnell; Donald Murphy; Scott Chapman; Carol DeFranca; Maria Perri; Ron Lefebvre; Clayton Skaggs; and Natalie Gluck.

Goals

Introduce the model of functional pathology of the motor system to health care providers interested in musculoskeletal dysfunction.

Objectives

1. teach basic core skills with minimum competency;
2. introduce additional skills;
3. teach the concept of the functional approach to the locomotor system. This would include biomechanics, functional anatomy, and holistic analysis of the locomotor system;
4. model how to use the skills in practice (how, when and why; time management; billing documentation; etc.).

Realistic expectations should be fostered in course participants. True expertise comes only from an apprenticeship learning environment, not a hotel course. A small set of core skills will be taught at each class with "Monday morning" applicability. Problem-solving reviews will occur with each session of previously taught material. This will include a review of core psychomotor skills previously taught.

Between 3-5 core skills will be taught at each session. These will be drawn from the following areas:

Analysis

1. posture
2. gait
3. movement patterns
4. muscle-length tests
5. palpation of soft tissue & bony landmarks
6. palpation of joint movement (i.e., "passive modeling")
7. quantifiable functional tests

Treatment

1. postural advice
2. PIR
3. sensory-motor training
4. spinal stabilization treatment
5. soft-tissue techniques (i.e., myofascial release)

The First 100-Hour Skills Objectives

Analysis

Posture

1. Postural analysis

• pelvis (unleveling, tilt, distortion)
• scapulae (winging, elevated)
• head/neck (reclination of C0/1)
• forward-drawn posture (pelvic -- compare to sitting)
• hypermobility (standing to sitting)

Gait

2. Gait analysis

• pelvic unleveling (with or without circumduction)
• pelvic unleveling with pad overhead
• poor hip extension with compensatory hyperextension of L-spine
• poor hip extension with backward walking
• pronation
• knee hyperextension
• trunk rotation (symmetrical/asymmetrical)

Movement Patterns

3. hip extension
4. hip abduction
5. trunk flexion
6. shoulder abduction
7. neck flexion
8. push-up

Muscle-Length Tests

See PIR section

Palpation of Soft-Tissue and Bony Landmarks

9. fascial shift
10. hyperalgesic skin zones

Palpation of Joint Movement (i.e., "passive modeling")

11. SI springing

Quantifiable Functional Tests

12. squat endurance test
13. Soresen static trunk extensor endurance test
14. single leg stance test

Treatment

Postural Advice

15. Brugger relief position

PIR

16. subscapularis
17. hamstrings
18. adductors
19. iliopsoas
20. piriformis
21. upper trapezius
22. levator scapulae
23. scalenes
24. lumbar spine -- extension
25. hip joint -- posterior glide
26. cervical manual traction

Sensory-motor Training

27. small foot
28. rocker/wobble board
29. balance shoes
30. perturbations

Spinal Stabilization Treatment

31. pelvic tilts and abdominal bracing
32. dead bug
33. bridge
34. curl-up
35. quadruped
36. horizontal side support
37. superman
38. squat
39. lunge
40. wall ball
41. wall angels
42. PNF lower trapezius

Soft-Tissue Techniques (i.e., myofascial release)

43. splenius capitus fascial shift
44. gluteal fascial shift
45. erector spinae fascial shift

For each of the core skills that are taught, the following learning approach will be utilized:

1. establish minimum competencies;
2. encourage study groups;
3. engage in active learning review of previous skills
   • problem solving (if technique is unsuccessful)
   • time management
   • documentation
4. administer a skills examination;
5. model not only how, but also when and why skills are performed.

Participants will be exposed to the practical skills, even though competency may take several months of practice. The aim is to slowly gain skills acquisition and perfection. Professor Lewit introduces techniques allowing us to make our mistakes and be "heavy-handed", but knowing that over time, with proper reinforcement and practice, these skills will become honed and perfected. This is also our aim here in North America. Therefore, you will be given every encouragement and opportunity to become adept and be tested as such at appropriate times.

To optimize the educational process, LACC utilizes a core faculty who regularly keep in contact with each other and who teach at limited sites where the model can be taught under strict conditions to the highest reasonable standard in an integrated fashion. This core group is in the process of establishing minimum competency guidelines, testing criteria, and ongoing educational opportunities as a "team", both for themselves and course participants.

Reference

1. LACC postgraduate division.

Craig Liebenson, DC
Los Angeles, California
cldc-flash.net

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