Be compelling for compliance
By Dirk Keenan
Chiropractic and prescribed “maneuvers” a synergistic effect – and that’s no stretch
By Dirk Keenan
Most patients are incompliant when it comes to following prescription exercises unless you can provide compelling reasons to do so. As an example of incompliance, while most of us recognize that flossing will counteract and prevent gingivitis, those who are more concerned about the more immediate and potentially pressing issue of halitosis may floss more regularly.
It’s a more pressing and urgent concern compared to the threat of receding gums in the future.
Improving patient compliance in prescribed exercise: the importance of language
The challenge my patients have with prescribed exercises is the tendency to stop once they feel they are asymptomatic. The lack of sensation during a workout may send a subliminal message that the activity is no longer required. Ultimately, when the patient stops their exercises and adjustments, the net effect will increase the chance of a re-occurrence. Almost all of my returning patients had forgotten or stopped doing the exercises that we recommended they do for life. Those patients that returned decades later, with new complaints, frequently reported performing the daily activities helped them eliminate back pain.
To encourage better compliance and outcome, I have taken to recommending “maneuvers.” A medical doctor I was a friend with while studying chiropractic reminded me of this term. To my amusement, her awareness of the chiropractic lexicon was minimal,
and she called spinal adjustments, maneuvers.
At some point, I decided to reframe my daily exercise prescription for my patients to patient maneuvers for joint mobility and function. I explained that it was joint mobility that could we could maintain by performing these maneuvers every day. There’s immediate “buy” into the idea that doing self- maneuvers can assist patients in managing their mobility longer. Further, when they chose to do the exercises regularly from the beginning of care, they would be actively aiding in their treatment and thus reduce their symptoms. By comparing the similarities of the maneuvers to similarities of some adjustments, they were more inclined to do them. Patients like to be empowered to participate in a meaningful way in their recovery and the maintenance of that recovery.
This departure from the prescription of exercises to prescribing maneuvers was generally accepted much more readily. Exercise sounds like work and “stretching” sounds dull. Patients can appreciate the idea of mobilizing the spine daily as being necessary. I noticed that the increased compliance for these maneuvers had improved patient outcomes.
I have observed less compliance with more extensive recommendations, and for that reason, I keep it basic and quick to obtain the most significant long-term impact.
“Maneuvers in bed”
To my patients, I explain that all animals mobilize their spine immediately upon waking up because it is ingrained within their brain to do so. For this automatic behaviour to exist across all mammalian species, timing must be important. Even human babies mobilize and extend their spines immediately upon awakening.
In my experience, patients get the best results when they mobilize while we are still in the bed, supine, and before gravity takes effect. Our spines decompress, and muscles typically relax during sleep, making us more likely to benefit from mobilization from that state. The mobilizations I recommend are simply alternating knee to chest, and bilateral knee to chest and spinal twist, each with a five- to ten-second hold, repeated twice in the morning and twice in the evening before sleep. Complete these in bed with mild intensity. These mobilizations are similar to what’s typically recommended elsewhere, but the distinction is they are being performed before weight-bearing (at least in the case of the morning exercises). I find it essential to stress the importance of doing them before arising in the morning if they are to be as effective.
Patients with sacroiliac joint disorders may find significant help including a “standing” alternating hip flexion maneuvers up to 100 times a day in small doses of five repetitions after a maximum of 20 -30 minutes sitting. I refer to this maneuver, which loads and unloads the sacroiliac spine and thus helps the adjustment and prevents pelvic subluxations as standing alternating hip flexion exercise (SAHFE).
Cervical spine patients are asked to forward flex – extend and laterally flex their c-spines four times daily along with similar analogous maneuvers for their shoulders. Each position held for two to 10 seconds. I may suggest pairing the timing of these maneuvers with meals and before bedtime so that the association serves as a reminder.
Are you tired after adjusting? Can you spare me 30 minutes once a week?
Strength training is another area where patients can be reluctant to engage, particularly given the onerous perceived time investment required. About eight years ago, I became interested in the book “Body by Science,” written by Dr. Doug McGuff. His book also had the subtitle: “A research-based program for strength training, bodybuilding, and complete fitness in 12 minutes a week.” I had worked out in the past and was convinced of the value of strength training for a host of conditions. The possibility of increasing strength in such a short period of training was highly motivating for my patients and me.
In Ottawa at the time, there were no fitness clinicians specially trained in this area with one exception who happened to practice at my gym. I waited three months to get an appointment, and I had to pay for 12 visits in advance before I was accepted into his waiting list. I can tell you that it was worth the wait, and after a short period of two years, I was much stronger than ever before. Given my personal story and the science behind this method, I started recommending strength training to all my patients to help them maintain their adjustments, and benefits to their bone density, cardiovascular function, blood sugar regulation, body composition, and mental health.
The sessions were short and physically and mentally demanding. Within a short time, they became invigorating with recovery taking place almost immediately.
The essence of this super-slow training method was to have individual muscle groups under tension for up to two minutes, and that the point of each exercise was to induce muscular failure. One to two minutes of “time under tension,” sufficient enough to cause the muscle to fail, will stimulate the adaptive response of muscle growth. Five to seven resistance exercises would be planned per weekly session with a clipboard and stop-watch to ensure that the appropriate weights and time was being recorded. Meetings were a week apart to allow full recovery. Muscle strengthening and hypertrophy appears to take place relatively quickly, and results are noticeable in less than a month with only weekly sessions. Sessions are very intense but fortunately brief. Experiencing muscular failure is unpleasant at first, and for this and other reasons, experts recommend the use of trusted and well-made equipment for compound exercises. The likelihood of injury during a properly supervised high-intensity session of strength training using equipment is insignificant when compared to other training methods.
I believe patients can and do appreciate chiropractic to be central to healthy living and chiropractors need to set the example with their health. Almost everyone can afford 20 minutes each week to do high intensity “super-slow” resistance training at the gym. As the average Canadian adult consumes 14 hours of television a week, 20 minutes of spare time seems manageable. This type of resistance training is relatively easy, extremely safe and appropriate for all ages. An appropriately trained fitness consultant with access to high-tech and safe machines are recommended for best results. At age 61, after seven years of training, I have never felt better. I believe that I can attribute that outcome to the combination of regular monthly chiropractic care combined with weekly high-intensity strength and resistance training.
Conclusions and opportunities
Given that the scientific literature now recommends chiropractic care to be combined with exercise, I believe that the re-branding of exercise to include the term “maneuver” will resonate with patients and may help improve clinical outcomes. Whether they are acute, sub-acute or maintenance patients, they will benefit from daily maneuvers if they are maintained throughout their lives.
Commencing high-intensity strength training should be a goal for patients transitioning from acute care and who are seeking further vitality while preventing chronic lifestyle-related disease. It is safe, incredibly useful and very helpful in supporting the adjustment.
To my knowledge at this time, there is no regulated health profession that is routinely advocating for patients the documented health benefits of high-intensity super-slow resistance training. I challenge chiropractors to actively resist the presumed natural decline in health and vitality that accompanies ageing and utilize super-slow strength training to improve patient outcomes as well as their health. Chiropractors who demonstrate knowledge, proficiency in health maintenance, and can set a personal example in the area of prevention and fitness and will be able to practice as long as they wish.
Should chiropractors and their educational institutions begin to include the well-researched prescription of high-intensity resistance training as an advanced part of the chiropractic intervention and the chiropractic lifestyle, chiropractic could legitimately claim a stronger role as leaders in health promotion and chronic disease prevention. As a CCA Government Relations representative, I have learned that government is very receptive to strategies to create savings in the cost of treatment and in the prevention of chronic lifestyle disease, which currently represents the highest burden to our health care budget. Chiropractors should play an expanded role in health promotion and chronic disease prevention to make a significant impact in reducing this burden.
Isn’t that worth 20-30 minutes a week?
- Margot Shields and Mark S. Tremblay, Screen time among Canadian Adults
- Body by Science; A research-based program for strength training, bodybuilding, and complete fitness in 12 minutes a week: Doug McGuff MD and John Little McGaw Hill 2009
- Associations of Resistance with cardiovascular disease morbidity and mortality; Medicine & Science in Sports & Exercise, March 2019-vol 51 p 499-50
- Resistance Training for Glycemic Control, Muscular Strength and Lean Body Mass in Old Type 2 Diabetic Patients; Diabetes Therapy 2017, June 8(3); 459-473
- High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women with Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial; Journal of Bone and Mineral Research; October 2017
- Chronic Disease Prevention Guideline 2018, Population and Public Health Division, Ministry of Health and Long Term Care
- Mental Health Benefits of Strength Training in Adults, Patrick J.O’Connor May 7, 2010; American Journal of Lifestyle Medicine
- J Gerontol A Biol Sci Med Sci. 2000 Jul;55(7):B336-46.
- Effects of high-intensity resistance training on untrained older men. I. Strength, cardiovascular, and metabolic responses
Dirk Keenan is a second- generation chiropractor practicing in Ottawa’s oldest clinic for the past 34 years. Dr. Keenan pursues an active interest in multi-disciplinary clinics, Interprofessional education, and chiropractic practices abroad. He is currently in the midst of establishing an international locum service. Interested parties in international locums, multi-disciplinary practices, or interprofessional education can contact him at firstname.lastname@example.org.