Rehab vs prehab: What does this mean in chiropractic practice?

Many people seek out chiropractors for the treatment of various musculoskeletal complaints, most notably lower back pain and neck pain.

As chiropractors, we know that approximately 80 per cent of Canadians will experience an episode of back pain at some point in their life, and many people will suffer ongoing bouts of lower back pain related to poor posture, work positions, pregnancy, sports, etc. (Ruas and Vieira, 2017). It is imperative that chiropractors be well versed at treating and hopefully preventing these issues in their patients. This is where the role of rehabilitation (rehab) and prehabilitation (prehab) come into chiropractic practice.

Rehab and prehab are common buzzwords within the manual medicine community, often with vague descriptors attached to them. The Oxford Dictionary of Sports Science and Medicine defines rehabilitation as the “restoration of an injured person to the level of physical fitness he or she had before the injury.” Both rehabilitation and prehabilitation programs are designed to build strength and increase functional capacity, but the timing of their delivery is different. Prehabilitation has traditionally been associated with preparation for surgery; with patients being given physical and/or lifestyle modifications to help improve recovery time and decrease their post-surgery pain levels following surgery. Rehabilitation programs begin after the injury, often in conjunction with treatment, while prehab programs occur prior to treatment being given, often in the form of surgery.

Research has found that those patients who receive a targeted pre-surgical exercise program prior to knee or hip replacement surgery can decrease the odds of needing inpatient rehabilitation by up to 73 per cent, with significant improvements in functional status and muscle strength (Rooks, 2006). An article by Jack, West, and Grocott (2011) discussed the usage of prehab for elderly subjects. The authors found that although there was a “paucity of high-quality clinical trials,” prehabilitation can improve specific fitness measures prior to surgery including levels of physical activity, fatigue, and health related quality of life in cancer patients as well as improved general fitness. More recently, a systematic review by Cabilan, Hines, and Munday (2015) found that “…prehabilitation has no significant post-operative benefits in function, quality of life and pain in patients who have had knee or hip arthroplasty for osteoarthritis; however, there is evidence that prehabilitation may reduce admission to rehabilitation in this population.” Despite the mixed results in the literature, the bulk of the research appears to be favourable for the use of prehabilitation programs.

Considering the needs of the patient
While some patients may be coming in for care in advance of an upcoming surgery, others are looking for traditional treatment and strategies to prevent future occurrences of their pain. Many research studies have shown that traditional treatments offered by chiropractors often perform better when combined with exercise (Leininger et al, 2016; Maiers M et al, 2014; Petersen et al, 2015; Southerst et al, 2015; Walston and Yake, 2016). A study by the National Chiropractic Board of Examiners found that 98 per cent of surveyed chiropractors reported using “corrective and/or therapeutic exercise” as part of their treatment plan. This is where the use of individualized exercise programs directed at either injury rehabilitation or injury prevention can be beneficial. Although pragmatically, it’s important to stress that prehabilitation exercises are best directed at preventing chronic injuries, as traumatic injuries can occur without warning when a load or force too great for the tissues to withstand is applied, causing tissue failure and ultimately injury.

In order to customize a prehabilitation exercise program for a patient, there are three main points that must be addressed:

• Injury history of the patient: this should include the success and failure of previous treatments.
• Movement competency: knowing how well your patient can squat, hip hinge, etc., is important so we can determine where along the exercise continuum to start with their programming.
• Type and level of participation: the type of sport as well as the level of competition will impact the intensity of exercise prescription.

The injury history of your patient is an important starting point for designing and implementing a prehabilitation exercise program. Patients with a history of ACL injury, chronic lower back pain, repetitive strain injuries or tendinopathies must all be treated differently and have exercise selections customized. Along with their injury history, the success and failure of previous treatments is important to include. For example, Jill Cook’s research on tendinopathies has demonstrated favourable responses to appropriate loading, including eccentric exercise, and more recently heavy, slow resistance training. Knowing if your patient has performed the appropriate rehabilitation for their prior injuries will help inform their training.

Research by Lauersen (2014) has shown that strength training programs can reduce sport related injuries by nearly two-thirds and overuse injuries by nearly half. However, many factors can contribute to overuse injuries. Giffin and Stanish (1993) found that muscle imbalances, excessive training load, and poor technique could all contribute to the development of chronic overuse injuries. Fortunately these factors are all modifiable once they are identified. The use of a movement assessment tool can be beneficial for identifying muscle imbalances and movement deficiencies to recognize major areas of limitation.

There are several movement assessment tools utilized by manual therapists, with the Functional Movement Screen (FMS) and Selective Functional Movement Assessment (SFMA) among the most commonly used. The FMS was long touted as a screening tool to identify those deemed to be more vulnerable and susceptible to injury (Butler et al, 2013; Cook et al, 2014; Kiesel et al, 2007). Busch et al (2017) have linked the poor scores in the shoulder screens of the FMS and SFMA with increased likelihood of overuse injuries during a baseball season. A recent systematic review by Bonazza et al (2017) in the AJSM found that the FMS had excellent inter-rater and intra-rater reliability. They also found that those with a composite score of <14 had a higher likelihood of sustaining an injury, compared to those with higher scores. Similarly, a critical appraisal of the SFMA from the November 2018 issue of Journal of Sports Rehabilitation found that although some of the studies surrounding the FMS/SFMA were low-quality, the SFMA could correctly identify dysfunctions and limitations, which assisted the clinicians in the creation of an individualized exercise program. Furthermore, research by Baser et al in the Journal of Sports Rehabilitation(2018) found that administering personalized intervention programs based on individual FMS scores was beneficial. This research helps support the usage of a movement assessment tool, such as the FMS or SFMA, to help screen our patients for major deficiencies and asymmetries with movement which can then be used to provide individualized exercise advice.

Preventing MSK injury with exercise
Another excellent example of directed exercise to help prevent musculoskeletal injury is the FIFA 11+ program. This is a program developed to help reduce injuries in youth soccer teams using a standardized warm-up, which was designed by “an international group of experts based on their practical experience with different injury prevention programmes for amateur players aged 14 or older” and should replace the usual warm-up prior to training. A study from the British Medical Journal in 2008 found that when teams performed these exercises at least twice a week, there were 37 per cent fewer training injuries, 29 per cent fewer match injuries, and almost 50 per cent fewer severe injuries. One of the exercises included in the FIFA 11+ is the Nordic hamstring exercise. A 2017 systematic review and meta-analysis by Attar et al found that injury prevention programs that include the use of the Nordic hamstring exercise decrease the risk of hamstring injuries among soccer players. Further research is needed to link specific injuries with exercises; for example, Attar et al mention a possible connection between the reverse Nordic hamstring exercise and quadriceps strain. Similarly, it has been theorized that the Bunkie test might be a tool to identify weaknesses and imbalances in the kinetic chain of athletes. Although whether these restrictions and limitations result in an increased injury occurrence has not yet been shown (DeGennaro and Swogger, 2015; Van Pletzen, 2010).

Similar to the Bunkie protocol, Dr. Stuart McGill has found a correlation between core endurance testing and lower back pain. In his research, McGill has found core endurance tests to be decreased in those who suffer from nonspecific lower back pain compared to healthy controls. Previous research has shown that workers who reported lower back pain had decreased trunk extensor endurance, and Biering-Sorenson (1984) found that a lack of endurance appears to be a predictor of future occurrences of LBP. Research from Abdelraouf and Abdel-Aziem (2016), suggests the use of these exercises to help prevent lower back pain in collegiate athletes. Many chiropractors are familiar with McGill’s “Big Three” exercises: the bird dog, the modified curl-up, and the plank. These tend to be the hallmark exercises of many lower back and core rehabilitation exercises, although they may also be appropriate for prehabilitation programs in those concerned about future bouts of nonspecific LBP.

As with any exercise program, it is important for prehabilitation exercise programs to be progressive. An article in the Journal of Strength and Conditioning Research in 2015 found that individuals suffering from mechanical lower back pain who had acceptable levels of lower back endurance could benefit from performing a more complicated exercise, such as the deadlift. Similarly, Welch et al (2015) found that free-weight based resistance training including deadlifts and squats improved strength, motor control, and other physiological aspects such as increased cross sectional area in individuals with chronic LBP. Berglund (2016) found that deadlifts may be beneficial for subjects with mechanical low back pain, as they provide clinically relevant points of education including hip hinge patterning, and motor control strategies.

These research studies highlight the need for patients to be coached and cued to perform exercises correctly, particularly as the difficulty increases. Although time consuming, being present to instruct your patients in the performance of their exercises can be very helpful. Otherwise, building a referral network with knowledgeable personal trainers, strength coaches, and other rehabilitation professionals including kinesiologists and athletic therapists can be helpful for both your practice and your patients.

From a practical perspective, we can build upon the work established above to develop a solid exercise regimen for our patients. Knowing your patient’s injury history, their personal goals, and previous levels of activity can all be beneficial for prescribing an adequately challenging program. Moreover, a movement evaluation such as the FMS or SFMA is a good starting point to try and identify areas of improvement. Marrying these findings with the research surrounding overuse injuries common to an individual’s sports and other daily activities, as well as their relevant injury history can help to offer a truly individualized prehabilitation exercise program. Although we may not be able to prevent all musculoskeletal injuries, offering our patients a thorough and individualized exercise regime may help them build capacity for their activities.  

Overall, there are numerous positive effects associated with exercise including: improving muscular strength and endurance, increased blood flow to affected tissues, maintaining adequate range of motion, neuromuscular retraining, improved aerobic capacity, patient empowerment including increased self-reliance and decreased fear avoidance, exercise-induced analgesia, and much more. While the research may be lacking in terms of definitive answers to preventing musculoskeletal injuries, there is no denying the benefits of exercise.

Many patients entering a chiropractic office can benefit from the gradual and guided introduction to exercise, particularly when it is individualized to their specific concerns. At the end of the day, exercise is medicine. 

Dr. Brett P. Guist graduated from CMCC in 2015 and is a chiropractor practicing in Burlington, Ont., with a focus on rehabilitation. In addition to his role as a chiropractor, he also teaches and conducts research and has been published in several peer-reviewed journals.

REFERENCES

Abdelraouf OR and Abdel-Aziem AA. The relationship between core endurance and back dysfunction in collegiate male athletes with and without nonspecific low back pain. Int J Sports Phys Ther. 2016 Jun; 11(3): 337-344.

Ainsworth K and Hagino CC. A survey of Ontario chiropractors: their views on maximizing patient compliance to prescribed home exercise. J Can Chiropr Assoc. 2006 Jun; 50(2): 140-155.

Alaranta H, Hurri H, Heliovaara M, Soukka A, Harju R. Non‐dynamometric trunk performance tests: reliability and normative data. Scand. J. Rehabil. Med. 1994;26(4):211‐215.

Alaranta H, Luoto S, Heliovaara M, Hurri H. Static back endurance and the risk of low‐back pain. Clin Biomech. 1995;10(6):323‐324.

Attar WSA, Soomro N, Sinclair PJ, Pappas E, Sanders RH. (2017). Effect of injury prevention programs that include the Nordic hamstring exercise on hamstring injury rates in soccier playres: a systematic review and meta-analysis. Sports Medicine (2017) 47: 907-916.

Balthazard P, de Goumoens P, Rivier G, Demeulenaere P, Ballabeni P, Deriaz O. Manual therapy followed by specific active exercises versus a placebo followed by specific active exercises on the improvement of functional disability in patients with chronic non specific low back pain: a randomized controlled trial. BMC Musculoskelet Disord. 2012 Aug 28;13:162

Bergland L (2016). Deadlift training for patients with mechanical low back pain (unpublished medical dissertation). Umea University, Sweden.

Biering‐Sorensen F. Physical measurements as risk indicators for low‐back trouble over a one‐year period. Spine. 1984;9(2):106‐119.

Bonazza NA, Smiun D, Onks CA. Reliability, validity, and injury predictive value of the functional movement screen: a systematic review and meta-analysis. American Journal of Sports Medicine.2017 March, 45(3): 725-732.

Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopath2010;18:3

Busch AM, Clifton DR, Onate JA, Ramsey VK, Cromartie F. (2017). Relationship of preseason movement screens with overuse symptoms in collegiate baseball players. Int J. Sports Phys Ther. 2017 Nov; 12(6): 960-966.

Butler RJ, Contrears M, Burton LC, Plisky PJ, Goode A, Kiesel K. (2013). Modifiable risk factors predict injuries in firefighters during training academies. Work.2013 Jan 1;46(1):11-7.

Cabilian CJ, Hines S, Munday J. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review. JBI Database System Rev Implement Rep.2015 Jan; 13(1): 146-87.

Christensen MG, ed. Job Analysis of Chiropractic. Greeley, CO: National Board of Chiropractic Examiners; 2000.

Cook G, Burton L, Hoogenboom BJ, Voight M. (2014). Functional movemtn screening: the use of fundamental movements as an assessment of function – part 1. Int J Sports Phys Ther.2014 May;9(3): 396-409.

Cook G, Burton L, Hoogenboom BJ, Voight M. (2014). Functional movemtn screening: the use of fundamental movements as an assessment of function – part 2. Int J Sports Phys Ther.2014 Aug;9(4): 549-63.

Cook JL, Rio E, Purdam CR, et al. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med 2016;50:1187-1191.

Da Silva Santos R and Galdino G. Endogenous systems involved in exercise-induced analgesia. J Physiol Pharmacol. 2018 Feb; 69(1):3-13.

DeGennaro A and Swogger B. Examining relationships between Bunkie protocol and athletic injury. Carnegie Mellon University. <http://www.jcstrengthandconditioning.com/uploads/5/1/2/9/51292221/degennarobunkie.pdf>

Federation Internationale de Football Association (FIFA). (2007) “The 11+: A complete warm-up programme to prevent injuries manual.” FIFA Medical Assessment and Research Centre (F-Marc).

Feldenkrais, M. (1981). The Elusive Obvious. Cupertino, CA: Meta Publications.

Gordon R and Bloxham S. (2016). A systematic review of the effects of exercise ad physical activity on non-specific chronic low back pain.Healthcare. 2016 June; 4(2): 22.

Kent M (2006). Oxford Dictionary of Sports Sciecne and Medicine. Oxford University Press.

Kiesel K, Plisky PJ, Voight ML. (2007). Can serious injury in professional football be predicted by a preseason functional movement screen? N Am I Sports Phys Ther. 2007 Aug; 2(3): 147-158

Holmberg D, Crantz H, Michaelson P. (2012). Treating persistent low back pain with deadlift training – a single subject experimental design with a 15-month follow-up. Advances in Physiotherapy, 14(2): 61-70.

Lauersen JB, Bertelsen DM, Andersen LB. (2014). The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. Br J Sports Med 2014;48:871-877.

Lehtola V, Luomajoke H, Leinonen V, Gibbons S, Airaksinen O. Sub-classification based specific movement control exercises are superior to general exercise in sub-acute low back pain when both are combined with manual therapy: a randomized controlled trial. BMC Musculoskelet Disorde. 2016 mar 22;17:135.

Leininger B, McDonough C, Evans R, Tosteson T, Tosteson AN, Bronfort G. Cost-effectivenss of spinal manipulative therapy, supervised exercise, and home exercise for older adults with chronic neck pain.Spine J. 2016 Nov; 16(11):1292-1304.

Li C, Carli F, Lee L, et al. (April 2013). “Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study”. Surgical Endoscopy. 27 (4): 1072–82.

Maiers M, Bronfort G, Evans R, Hartvigsen J, Svendsen K, Bracha Y, Schulz C, Schulz K, Grimm R. Spinal manipulative therapy and exercise for seniors with chronic neck pain. Spine J. 2014 Sept 1:14(9):1879-89.

McGill S, Grenier S, Bluhm M, Preuss R, Brown S, Russell C. Previous history of LBP with work loss is related to lingering deficits in biomechanical, physiological, personal, psychosocial and motor control characteristics. Ergonomics. 2003;46(7):731‐746.

Liebenson C. Rehabiliation of the Spine (2ndEd).

Petersen SB, Cook C, Donaldson M, Hassen A, Ellis A, Learman K. The effect of manul therapy with augmentative exercises for neck pain: a randomised clinical trial. JMan Manip Ther. 2015 Dec;23(5):264-75.

Randhawa K, Sutton D, Yu H, Gross DP, Jacobs C, Goldgrub R, Stupar M, Mior S, Carroll LJ, Taylor-Vaisey A. The effectiveness of noninvasive interventions for musculoskeletal thoracic spine and chest wall pain: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. J Manipulative Physiol Ther. 2015 Sept; 38(7): 521031.

Rizzo, Terri Heinrich. Arthritis Foundation.”Pre-hab for sugery: getting in shape prior to surery can make recovery easier.” < https://www.arthritis.org/living-with-arthritis/treatments/joint-surgery/preparing/prehab-surgery.php>

Rooks et al (2006). Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty. Arthritis and Rheumatism. 2006 Oct 15;55(5):700-8.

Ruas CV and Vieira A. Do muscle strength imbalance and low flexibility issues lead to low back pain? A brief review. J. Funct. Morphol. Kinesiol. 2017, 2, 29; doi: 10.3390/jfmk2030029.

Soligard T, Myklebust g, steffen K, holme i, silvers h, Bizzini M, junge A, dvorak j, Bahr r, Andersen Te (2008) A comprehensive warm- up programme to prevent injuries in female youth football: a cluster randomised controlled trial. BMJDec 9; 337:a2469. doi: 10.1136/ bmj.a2469

Soligard T, nilstad A, steffen K, Myklebust g, holme i, dvorak j, et al. compliance with a comprehensive warm-up programme to prevent injuries in youth football. Br j sports Med2010;44(11):787-793.

Van Pletzen D. (2010). The relationship between the Bunkie-test and selected biomotor abilities in elite-level rugby players (Unpublished master’s thesis).

Vina J, Sanchis-Gomar F, Martinez-Bello V, Gomez-Cabrear MC. Exercise acts as a a drug; the pharmacological benefits of exercise. Br J Pharmacol. 2012 Sep; 167(1):1-12.

Walston Z and Yake D. Lumbar thrust manipulation and exercise for the treatment of mechanical low back pain in adolescents: a case series. J Orthop Sports Phys Ther. 2016 May;46(5):391-8

Warburton DER, Bredin SSD. Health benefits of physical activity: a systematic review of current systematic reviews. Curr Opin Cardiol. 2017 Sep; 32(5): 541-556.

Welch N, Moran K, Antony J, Richter C, Marshall B, Coyle J, Falvey E, Franklyn-Miller A. The effects of a free-weight-based resistance training intervention of pain, squat biomechanics, and MRI-defined lumbar fat infiltration and functional cross-sectional area in those with chronic low back. BMJ Open Sport Exerc Med.2015 Nov 9;9(1):e000050.

Williamson J, Pahor M. Evidence regarding the benefits of physical exercise. Arch Intern Med. 2010 Jan 25; 170(2): 124-125.