14 I Winter 2018 www.anjc.info www.njchiropractors.com I 15 Legislative Update Legal Ease Chiro Assist TECHNIQUE Council REHABILITATION Council Legal Q&A S C H O L ARSHIP WI N N E R S Thoughtful chiropractic physical rehabilitation begins with an accu- rate assessment of the entire kinetic chain. As active care and resistance activities are introduced, it is imperative that your patients are progressed according to established principles for maximal results with the goal being return to function/ sport. The rehab continuum is based on the SAID Principle (Specific Adap- tations to Imposed Demands) as its foundation. All exercise programs are based on the SAID Principle and in reality, it applies to all body systems. •  Specificity relates to the goal (stability, endurance, power, hyper- trophy, flexibility, etc.), the target tissue (muscle, tendon, myotendinous junction, joint, ligament, etc.), as well as the anticipated restoration of function or activity expected. •  Adaptation is the change that occurs on the target tissues in a progressive, controlled manner to reach the desired functional goal. •  Imposed Demands are the proce- dures and exercises chosen regard- less of whether they incorporate bands, weights, balls, machines or functional movement patterns on unstable surfaces. The net result is a logical progression of chosen activities in a relevant manner. Additional aspects of the exercise continuum that actually fall under specificity include tempo, load, volume, frequency, duration and rest interval during training. Let’s review each individually. Exercise tempo is not simply the speed at which the exercise is performed. It applies to the relative speed of the three contractile com- ponents of the given exercise. The eccentric component is considered essential for deceleration of move- ment and for maximal myotendinous tensile load: the concentric compo- nent is for power and strength: the isometric component is the point where the concentric motion ends and the eccentric motion begins. All three of these variables can be manipulated to achieve different results. For example, applying the SAID principle to tempo would be to emphasize the eccentric motion in treating tendinopathy. Another example would be to add a longer isometric hold at the mid-point to enhance joint stability. Load (intensity) is related to the training goal of the specific exercise. Common resistance activity goals are to improve stability, endurance, hypertrophy, speed or power. Load is matched with the specific goal and is quantified as sub-maximal or maximal. Sub-maximal activities can be done several times a day if not daily and the patient will feel “like I can do more” or “these exercises do not feel like they are doing much at all.” Maximal exertion activities are done to the point of fatigue or near fatigue and require one to three days of rest in between workouts. Quantifying and documenting load is most commonly described by the repetition maximum, RM, formula. Essentially RM is the greatest amount of load that can be performed in a full, controlled ROM at a given number of times before fatigue. For example, 3RM means at a given load only three repetitions can be performed before fatigue sets in and 1RM would be only one rep- etition can be performed at a given load. The average deconditioned patient will generally start at 70-75 percent RM on exercise which would be equivalent to approximately eight to 10 repetitions. Conversely, 85 percent RM is a load equivalent to 85 percent of the 1RM load. This formula can be applied with bands, free weights or machines. Another effective and equally acceptable determination of load is the Borg scale of perceived relative exertion, PRE. The scale is either 6-20 or 1-10 and can be performed in any treatment room with elastic resistance. The exercise intensity is determined by placing the patient’s perceived level of exertion within the appropriate range, again using the SAID principle. Using the 0-10 scale, PRE is for 0-2 for acute conditions, 3-5 is for subacute and to develop stability and 7-10 would be for strength and power. See Figure 1. Volume is the total number of sets (the number of sessions an exercise is performed) and repetitions (the number of times each exercise is done within each set) of an exercise within a workout and is inversely related to load. The higher the sets and repetitions the lower the load and the higher the load the lower the sets and repetitions. All training is cumulative, and it is important that the appropriate volume is achieved to attain the desired goal. By Dr. Donald DeFabio ANJC Council on Physical Rehabilitation and Performance Chairman EXERCISE PROGRESSION: The Rehab Continuum 0 Nothing .5 Very, Very Weak (just noticeable) 1 Very Weak 2 Weak 3 Moderate 4 Somewhat Strong 5 Strong (heavy) 6 7 Very Strong 8 9 10 Very, Very Strong (almost maximum) Maximum BORG SCALE Rating of Perceived Exertion RPE Clinical scenario: Mary’s low back is in the sub-acute stage and needs to maintain a sub-maximal load. She has been doing her core stability exercises – three sets, 15 reps, two times a day for two weeks – but mentions her back gets tired and sore when she stands for over 30 minutes. A movement assessment reveals core stability is her weakest link. Therefore, her volume needs to be increased by adding sets or reps or a combination of both. The details of the modification are based on the SAID principle. Frequency can be related to the number of times an exercise is per- formed (daily, weekly, monthly) or even within a training cycle: squats three times a week, core three times a week, arms one time every two weeks. Of course, frequency is also related to the load, training goal and overall volume of the program. Duration also relates back to the SAID Principle. If the same exercise, fre- quency, load and volume is repeated continually the effects will plateau. The Imposed Demand is no longer there. Most corrective exercises need to be re assessed every four to eight weeks to determine if the patient has plateaued. Rest interval is the time allowed between sets within an exercise session and is directly related to the metabolic re-fueling for the muscle. For example, in 30 seconds approximately 50 percent of the ATP and creatine phosphate stores are restored. Therefore, repeated short rest intervals leads to faster accumu- lation of lactic acid and reduced neu- romuscular control. It takes 60-90 seconds for the creatine phosphate to recycle, therefore, rest times for patients in the sub-acute, stabilization or endurance phases of care would be in this range so the build-up of lactic acid is avoided. Athletes training for maximal strength and power need rest intervals of 3–5 minutes to fully recover based on their volume (high load, lower reps). For today, start your sub-acute patients on a sub-maximal resistance program – remember, sub-maximal implies the patient’s pain does not increase with the exercises. Start with three sets of 10-15 reps, two exer- cises per body part at 50 percent RM or 3-5 on the Borg scale, twice a day. Tempo is four seconds eccentric: two seconds isometric: two seconds con- centric with a 60-second rest interval. Reassess the volume, frequency, load weekly and after four to six weeks, reassess the functional deficits and modify the exercises as needed. Finally, as Doctors of Chiropractic it is imperative that we have our patients exercise in proper posture and joint alignment, regardless of the body part. Patients understand posture and it reinforces better mechanics. More importantly it reinforces to our patients the DC Difference when it comes to rehab as we treat the entire person, not just the injury. The next article in this series will apply the SAID principle to the endurance and strengthening phases of the exercise continuum. References: Clark M, Russell A, NASM Essentials of Performance Enhancement, 2007, Calabas CA Kisner C, ColbyLA, Therapeutic Exercise: Foundations and Tech- niques, 6th edition, F.A. Davis, Philadelphia, PA Donald DeFabio, DC, DACBSP, FAC, is in private practice in Berkeley Heights, NJ, and is the team chiropractic doctor for a local university. His exercise protocols can be found on his YouTube Channel which has over 4.1M views. He conducts Relevant Rehab, Running Boot Camp and small group seminars to teach the keys of successful integration of active care into the chiropractic office. He can be reached at DeFabioChiropractic@ gmail.com or www.DeFabioDiffer- ence.com for questions, to register for his workshops and copies of his patient handouts. (Ketogenic Diet Continued from page 11) The long-perceived notion that high-fat diets are unhealthy partly stems from the fact that guide- lines from the American Diabetic Association are predicated on the assumption that diabetics are on their medications, which would necessitate carbohydrates in the diet to prevent hypoglycemia. This is why the American Diabetic Association currently recom- mends eating 40 grams of carbs per meal. This recommendation along with other guidelines were created under the assumption that diabetes is irreversible and is a disease that needs to be man- aged for the rest of patients’ lives. There can be a learning curve for patients transitioning to a keto- genic diet. This is why education and coaching is critical. Commu- nication between clinicians and their patients is encouraged to keep the patients on track. Devi- ations from the diet may occur at times and every effort should be made by the clinician and the patient to get back on track. The ketogenic diet can be a life-sav- ing tool for diabetics or anyone wishing to improve their health. Tom Bilella, DC, MS, CCN, CNS, DACBN, CISSN, is chairman of the ANJC Nutrition Council. He maintains a successful practice in Red Bank, NJ, where he special- izes in metabolic syndrome, peak performance, weight loss, and chronic conditions. His goal is to educate patients in the com- munity to lead a healthier, more productive life without the use of unnecessary drugs or surgery. He also coaches natural clinicians on how to be more successful in practice through his Legends Club program. He can be reached at drtombilella.com.