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July 2004 Table of Contents
- Ergonomics: The Often Overlooked Component of
Postural Correction
- By Scott J. Heun, D.C.
Dr.
Heun practiced chiropractic very successfully for over twenty years. As a second
generation chiropractor he has a unique perspective on the profession. At
various times he has owned and operated single and multi-doctor offices, managed
multiple office locations, as well as a physical therapy and rehabilitation
center. Dr. Heun successfully implemented an intern program in the last 8 years
of practice and was a preceptor for Palmer College of Chiropractic-West. Dr.
Heun is a Certified Chiropractic Sports Physician (CCSP), taught the CBP® II
elective at Life-West and is a CBP® Certified Fellow and CBP® Instructor. Dr.
Heun retired from practice in 2004 and is now a full time practice consultant
with Total Practice Management International, LLC.
The chiropractor who chooses to offer the patient the option of improvement or,
if possible, correction of his/her abnormal posture, must address all of the
components which contribute to the patient’s structural problem. In addition to
manipulation, stretching, drop table or instrument adjusting and the various
forms of traction presently available, the doctor must address the patient’s
lifestyle and body positions. Furthermore, to insure the patient is compliant
and that all known variables contributory to the patient’s structural problem
are adequately addressed, the patient must be under the direct supervision of
the doctor as often as is practical.
There is no substitute for in office traction,
Mirror Image® exercise, and practical and functional chiropractic education
provided by the doctor. Patient communication should be done directly, both in
day to day interaction and in spinal care classes. Furthermore, the doctor must
also explore and, when indicated, interdict appropriately in the areas of
lifestyle habits, hobbies, recreation, work and household chores. This input is
most effectively delivered on an individual basis directly by the doctor rather
than by pamphlets, posters or web based information dissemination.
Therefore, postural chiropractic adjustments,
active exercises and stretches, resting spinal blocking procedures, extension
traction and ergonomic education are deemed necessary for maximal spinal
rehabilitation.
Structural Rehabilitation of the Spine
and Posture: Rationale for Treatment Beyond the Resolution
of Symptoms
JMPT Volume 21 Number 1 January 1998
The critical areas to assess are:
1. Sleep position and sleep surface
composition.
2. Sitting position at work and at home,
including computer orientation.
3. Telephone usage (at work and on portable or
cellular phones).
4. Driving position (especially in instances
wherein patients are commuting for extended time periods).
5. Video or Television viewing positions.
6. Hobbies, recreational or athletic pursuits.
The inclusion of simple questions on your
initial history form which request the patient to provide information pertinent
to these (potentially) contributory activities, allow the doctor to ascertain
which areas to address in subsequent visits. For example:
1. Do you sleep primarily on your side, your
back or on your belly? 2. Do you sleep on a conventional box spring
and mattress, a waterbed or an airbed?
3. How many pillows do you place under your
head while sleeping?
4.How many hours per day do you sit?
5. Do you use a telephone at work? If so, do
you use a headset?
6. Do you participate in any specific exercise
program? If yes, what exactly do you do?
7. Do you play any sport? Explain.
8. How long is your drive to work each day? Do
you drive as part of your work day? If yes, how many hours per day?
Questions such as these allow you to streamline
the history process while still obtaining useful information to assist the
patient in the resolution of his/her problem. I suggest you orient these
questions in a “yes and no” and short answer format to expedite this process.
After the patient has been presented with
his/her “Five Minute Report of Findings™,” and has decided upon a course of care
with you, you may begin to incorporate the information gleaned from your initial
history into the day to day care of the patient in the form of MicroReport©.
(What you discuss with the patient during your delivery of the adjustment and
occasionally during traction.)
Sleeping position can be addressed very
effectively while the patient is on the adjusting table. This topic is also
important for others to hear and is easily accomplished when you are utilizing
“open adjusting.” Place the patient on his/her side, adjust the headpiece to a
neutral position and let him/her experience the position he/she must embrace in
order to maximize his/her opportunity to improve his/her structure. This same
technique is employed in the supine position. When needed, you may introduce a
patient to a cervical pillow or “nocturnal cervical support” in this same
fashion.
Furthermore, by requesting that the patient’s
spouse accompany the patient to his/her office visit, the doctor may teach both
the patient and the spouse about proper sleep positions. Involving the patient
and his/her spouse in the rehabilitation process magnifies the effectiveness of
your recommendations and creates the opportunity for you to stress the
importance of good postural habits to a prospective patient.
Offices in which the Total Practice Management
International (TPMI) scheduling protocol has been implemented will face no
challenge with the implementation of my next suggestion: the driving position
assessment. This specialty procedure should be performed at the end of a cluster
of adjusting just like any other specialty procedure. As always, specialty
procedures are pre-scheduled, and situated between adjusting clusters.
The doctor (or a well trained intern or
assistant) accompanies the patient to his/her automobile, after first having
arranged that the patient park his/her vehicle close to the office entrance or,
when possible, in a pre-selected spot for just this purpose. The patient is
instructed to sit in the drivers’ seat in order to demontrate his/her current
driving position. Once this position is critiqued, the doctor initiates changes
to the patient’s position in this order:
1. First, place the rear view mirror in an
extreme position from where it is currently positioned; alter the side mirrors
in a similar fashion. (Accurate repositioning will occur later in this process.)
2. Determine if the patient’s model of
automobile has memory seating. If so, plan to make changes to the seating
position and then register them with the system to prevent changes you make from
being easily altered by the patient.
3. Alter the seat to address the patient’s
specific posture. Be sure to also extend the headrest to a point above the
center of mass of the head. If possible, it is best if the patient can be taught
to keep his/her head in contact with the headrest at all times while driving.
For some, this may pose an initial challenge. However, if the patient is
consistent and committed, this new postural position acts as a Mirror Image®
exercise. There is an added benefit to the patient when “exercising” in this
fashion. Performing a complex activity such as driving while modifying an
established postural position adds to the total positive proprioceptive input
and provides greater impact to the patient’s nervous system in the new,
corrected posture.
4. Your last step is to reposition the
previously distorted mirrors to accommodate the patient’s new driving position.
Often the mirror position becomes the reminder to the patient to maintain
his/her new postural position.
With the ready availability of digital cameras,
obtaining images of patients sitting at their work stations has become much
easier. You may need to obtain permission from the patient’s employer prior to
initiating this process. However, this in itself may create the opportunity for
you to educate the employer about what you do as a biomechanics expert and why
this may be important to his/her particular business and overall productivity.
You may find yourself examining the ergonomics of the entire company if you are
deft in presenting your case.
In instances where a digital camera is not
available, a disposable unit will suffice. Have the patient employ a colleague
to expose the necessary images or photos. Be sure to instruct the patient to
remain candid to insure you obtain accurate information. Once you have the
required images, you may print them and draw on the images to illustrate how the
patient’s position needs to be modified to improve his/her working posture. A
copy is kept in the patient’s file and a copy is provided to the patient for
reference. A follow up set of images to determine patient compliance is advised.
These images should be obtained 4-6 weeks following the initial photos; always
prior to the Re-X-ray and Re-Report of Findings.
Common patient habits which may negatively
impact your care:
1. Reading or watching television in bed.
2. Recliners of all types, especially when
coupled with television viewing.
3. Ill positioned computer monitors.
4. Bifocal or trifocal eyeglasses which demand
cervical flexion to be utilized effectively.
5. Improper use of the StairMaster™ exerciser
or treadmill. (Many patients will read necessitating they look down while using
these devices. The reverse application of Dr. Don Meyer’s very effective
traction protocol!)
6. Weight training emphasizing the chest and
biceps, avoiding the back and legs and resulting in disproportionate strength in
the internal rotators of the shoulder, and poor development of the postural
muscles in the spine, gluteals and thighs.
The chiropractor who is sincere in his/her
desire to “Fix, or get to as near normal (Spinal Model) as possible” his/her
patient’s spine and posture must diligently apply the appropriate Mirror Image®
Adjusting, exercise and traction, and insure that the roughly 23 hours and 15
minutes wherein the patient is out of the doctor’s direct control are supportive
as opposed to detrimental to the clinical protocol recommended.
When the patient’s ergonomics are effectively
addressed, you are ensuring that the input of your clinical protocols have
maximum effectiveness. To ignore the patient’s ergonomics, and thereby ignore
one key element responsible for the patient’s current postural manifestation,
not only reduces the probable benefit of your care, but encroaches upon the
patient’s potential for improvement or correction of his/her problem. Examine
your current procedures in the area of patient ergonomics and implement this
critical component of patient care into your clinical procedures.
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