By Dr. Jeffrey Tucker
My personal in-office experience of patients that present with pain after a motor vehicle injury is consistent with a 2010 study by Hincapié CA, et al. I find most patients report pain in multiple body areas and that isolated neck pain is extremely rare. Hincapié CA, et al report 86 percent of 6481 Saskatchewan residents that responded reported posterior neck pain, 72 percent indicated head pain, and 60 percent noted lumbar back pain. Ninety-five percent of claimants reported some pain within the posterior trunk region, comprising the posterior neck, shoulder, midback, lumbar, and buttock areas.
Regarding cervical rehab for these patients, in the past I’ve used everything from bodyweight isometrics and elastic Thera-Bands to strengthen the neck; dumbbells and kettlebells to strengthen the upper body; low load exercises for strength and motor control concepts performing 10 repetitions of deep neck flexor activation against an inflatable blood pressure cuff and a whole lot more.
All of these are effective at reducing acute and chronic neck pain. Oh, I can’t forget teaching patients all the foam rolling, stretching, warm-ups and cool downs I can get them to do. I can probably do an entire seminar on rehab compliance at this point.
My treatment choice has always depended on the individual patient, whether they are young or old, active or inactive, conditioned or deconditioned. Truthfully I don’t see a significant difference between the different treatment modalities. Most patients obtain clinically important improvements at 6 weeks after the beginning of treatment and exercise programs. I think that is in line with what most practitioners were taught to expect. However, I still see that 10% (plus or minus) or so of clients take a lot longer than 6 weeks to resolve and have on-going residual complaints and problems. On the other hand, I love treating chronic pain patients that come into my office that were not originally treated by me – those who had previous chiropractic care, acupuncture, medical care or physical therapy without active rehab (they just received passive modalities). With some new tweeks on rehab, I expect good results with these individuals. My hands-on treatment over the past few years seems to include more cervical mobilization (stair-stepping technique), lower cervical manipulation (rather than upper cervical manipulation), thoracic manipulation, and I continue to do a lot of specialized deep soft tissue therapy for pain reduction. The deep tissue work is especially valuable to the upper cervical region. Over the last few years, I’ve added warm laser, but it is so unpredictable who will benefit and change and who doesn’t, I’m losing interest in the whole “laser” thing for the cervical region.
One of the most helpful things I’ve learned in the last five to six years is Dr. Kim Christensen’s Neuromobilization technique. If you have a patient with radiculitis, this technique can produce some clinically important reduction of pain immediately posttreatment. The biggest changes in my cervical treatment come in my rehab. Helpful strategies in the past several years include using the NASM protocol for the ‘overhead squat’ as a diagnostic tool and treatment guide, and using the Functional Movement Screen (FMS) as a predictor of risk for injury.
My latest rehab management strategies for MVA & cervical spine patients:
Manual therapy: lot of personal thought and patient time figuring out manual maneuvers and stretches to influence the fascia – that thin fibrous layer consisting of longitudinal and transverse connective tissue fibers. Restrictions seem to show up everywhere. Along the sacrotuberous ligament, the thoracolumbar fascia, the latissimus dorsi muscle, the spinous processes of all of the thoracic vertebrae, the angles of ribs, the serratus muscle, the splenius capitis muscles and the deep fascia of the neck.
Balancing (sensorimotor training) exercises as early as possible. I start patients standing with a narrow stance, progressing to tandem stance and single leg stance. The progression includes the use of foam under each foot to augment postural instability. Manipulate visual inputs (focusing on a point 2 meters away on the wall at eye level and under, with eyes open (EO) plus eyes closed (EC) conditions). I use 30 second bouts.
Stretching exercises is still part of many cervical rehab programs but dynamic stretching and mobility of the thoracic spine to influence the cervical spine is enhancing rehab routines. Mobility needs to be taught before stability. We have to reduce neck/shoulder stiffness and enhance neck range of motion. The static stretches for the levator scapulae, suboccipitals, SCM, pectoralis minor, and scalenes continue to be at the top of the list. I am enjoying using the stretch strap from Theraband.
Strengthening exercises after the deep neck flexors (DNF): Sometimes I begin with the head positioned against gravity to enhance isometric strength of the neck extensor muscles. I still do typical strengthening exercises for the paraspinal muscles and shoulder girdle muscles (upper and middle trapezius, rhombo-serratus). These exercises help increase the sustained isometric effort tolerance of the neck muscles. Progression includes unstable surface
and escalating resistance and movement pattern improvement. I begin my corrective exercise strategy with bodyweight, progress to Therabands resistance, then progress to free weights and kettlebells.
Oculomotor and head/eye exercises
: In the upright, sitting and supine positions I teach patients eye tracking while moving the head. This involves coordination exercises and re-establishing proper movement patterns.
The progression includes increasing neck rotation amplitude, instability on a stability ball and augmenting neck muscle activity with the head in a weight-dependent position. For the past few years I’ve been using the overhead squat for cervical evaluation. Dr. Christensen and I wrote a chapter on the cervical spine in Mike Clark’s new book. In the past we used the overhead squat as a movement pattern to evaluate the ankles, knees, and lumbopelvic-hip complex. Now we use it to evaluate the cervical spine as well. Just think of it as closely rel ated to the supine cervical flexion movement pattern. Have the patient perform the overhead squat. Observe them from the front and side. The normal pattern would be for them to lead with the posterosuperiour aspect of head. If the SCM’s and subocciptals are dominating, they will lead with their chin. This is a faulty pattern. Remember these muscle actions:
Antomical action of longus capitus and colli (cranio-cervical flexion) nods the chin.
SCM extends the cranio-cervical region and flexes the neck.
Scalenes are neck flexors.
During the overhead squat I seem to find a lot of overactive SCM, anterior scalene, and suboccipital muscles.
Here are a couple of corrective exercises:
Scalenes and hyoids can be short, limiting cervical extension. Hyoid stretch: teeth touching – extend the neck – open mouth and your head extends further. The stretch is close the mouth = fascial stretch of hyoids. To find out if it‘s articular, perform the chin tuck and extend the cervical spine over the upper thoracic region.
4 Point Kneeling: The head and neck are passively positioned in neutral alignment, then the patient actively moves (turning side to side, looking up and down) and attempts to return to neutral position. Perform this procedure twice. Notice if they can come back to the neutral position. Score: Good = the patient accurately and confidently returns to the neutral position both times without making adjustments. Average = the patient returns to neutral position with reasonable accuracy but lacks confidence – may need to make several adjusting movements or is “not quite sure.” Poor
= the patient cannot return to the neutral position and is often very unsure of the correct position as evidenced by the vacant facial expression that frequently is associated with performing this test.
I’m sure there are dozens of specific treatments, exercises, and natural remedies out there for our patients. I’d be interested to know about them, but if you’re following the rehab model in all its facets – manipulation/mobilization, modalities, diet, activity, exercise, leisure, sleep, stress prevention – I think you’ll find we do so much good!
I have new material to share with you.
Dr. Jeffrey Tucker can be contacted at:
11600 Wilshire Blvd. #412, Los Angeles,
CA 90025, phone 310.473.2911
and on the web at www.DrJeffrey-
1. J Occup Environ Med. 2010 Mar 30. Whiplash
Injury is More Than Neck Pain: A Population-
Based Study of Pain Localization After
Traffic Injury. Hincapié CA, Cassidy JD, Côté P,
Carroll LJ, Guzmán J.
2. Comerford lecture notes 2009.
Dr. Tucker completed Chiropractic training at Los Angeles College of Chiropractic.
He has a post graduate Diplomate degree in Rehabilitation and is certified in
chiropractic spinal trauma. He is a past-president of the Santa Monica Chiropractic
Society. Dr. Tucker served on the Chiropractic Rehabilitation board. He is a
member of the California Chiropractic Association and the American Chiropractic
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I’ve been upset about cholesterol lowering drugs for years. I want what’s best for you. My practice and the techniques I use are based on enhancing the nervous system through more natural alternative therapies. Cholesterol is integral to your cell membranes and is critical for nerve function. Every nerve in the body is covered in fat (cholesterol). Sixty percent of the brain is composed of fat (cholesterol). And cholesterol is vital for the production of sex hormones. Lowering cholesterol levels too much can have a very dangerous effect on brain and nerve function. From everything I read I believe that a healthy cholesterol level is less than 200 mg/dl and greater than 110 mg/dl. Some studies even suggest a cholesterol of 230 mg/dl is healthy. Strive for LDL less than 100 mg/dl; HDL for males – greater than 50 mg/dl, HDL for females greater than 60 mg/dl. I am now actually seeing patients on cholesterol lowering drugs with levels too low. Cholesterol is so important that your body does not rely on food sources alone.
How can you lower cholesterol without the use of statin drugs? These are the most consistent recommendations I have made that get results:
Most people are familiar with garlic as a cholesterol lowering substance. Allicin, the main biologically active ingredient in garlic, along with its associated chemical constituents, have been shown to lower total cholesterol. If you use a supplement, take 600 to 1200 mg a day divided into 2 or 3 doses.
UltraMeal Plus contains phytosterols – plant extracts that are sterols. These are types of compounds that bind to the bad fat when we eat, and take it out of body. They greatly reduce the production and absorption of bad cholesterol. UltraMeal Plus can be ordered from Metagenics.
Another one of my favorites is niacin, also known as vitamin B3. It has a tremendous efficacy. Niacin can raise HDL – the “good” cholesterol – by 15 to 35 percent, making it the most effective drug available for raising HDL cholesterol. In larger doses, niacin can reverse atherosclerosis by also lowering LDL and triglyceride levels.
Another substance that lowers cholesterol is red yeast rice. But it is not one of my favorites because it is really no different than taking Mevacor (a statin drug), and like other statins, it will interfere with CoEnzymeQ10. So, if you are taking a statin drug, I believe it’s absolutely mandatory that you supplement with CoQ10. This compound supports cardiac function and statin drugs block its production. Take 100-200 mg a day.
After several years of educating patients on the paleo diet and seeing the results on lab tests and body composition tests – I still highly recommend the paleo diet – low carb, minimizing fruits to a max of two per day, mostly sticking to only berries in small amounts, multiple servings of non starchy veggies, especially dark leafy greens, eating lots of protein from fish, meat, eggs, and chicken. I especially recommend wild salmon 2-3 times per week, grass fed meat only, a variety of nuts & seeds especially macadamia nuts, walnuts & almonds for snacks. I even want you to eat healthy fats: avocado, coconut butter, use coconut oil for sauteeing, or extra virgin olive oil. I would avoid dairy as much as possible.
In addition I recommend omega 3 fish oils (EPA-DHA 720) daily, liquid CoQ10 (NanoCell Q10), and UltraMeal Plus medical food shakes (www.DrJeffreyTucker.meta-ehealth.com)
Be sure your diet is high in fiber. Eating eight to 10 grams of soluble fiber a day lowers LDL cholesterol by about 5%. Oatmeal is a good source of soluble fiber. Also, soluble fiber supplements are available now (Metagenics has a good brand). Soluble fiber can also be taken as a weight loss aid. People who take a serving of soluble fiber in 8 oz of a calorie-free liquid 30 minutes or so before every meal tend to eat less. They lose weight without changing anything else.2-3
Of course exercise has so many benefits — maintaining function, controlling weight, lowering blood pressure, fighting depression, etc. — if exercise were a drug, it would be a blockbuster. Most people look for a pill instead of making healthy choices and taking action. Don’t be like them. Exercise is the best way to raise your HDL (the “good” cholesterol).
I have patients that are decreasing there overall cholesterol by double digit points in one month by including UltraMeal Plus medical food shakes. UltraMeal Plus contains plant sterols which have benefits in lowering cholesterol. I recommend using UltraMeal Plus as an adjunct to Therapeutic Lifestyle Changes (TLC). If TLC is not enough, then resort to formulas such as Cholarest SC and Lipotain. Insinase alleviates the underlying inflammation that interrupts the signal from the insulin receptor to the glucose transport vesicles to allow glucose into cells.
It’s important to understand that the rationale for abdominal training goes far beyond “looks.” The increased strength and recruitment of the abdominal muscles will carry over into better posture and more body control, both in daily life and in sporting movements. Working the muscles you can’t see — the ones deep inside your core areas — can be a difficult process, but target those areas and your whole body benefits. Not only will you look better, but you’ll also have more strength and suffer fewer injuries.
Here’s a great beginner routine for anyone who doesn’t focus on their abs regularly or who hasn’t exercised this area (or any area) of the body in awhile. Perform this routine at the end of your regular workout or as a stand-alone workout, 3-4 days a week. Start with six repetitions per exercise and build up to 15 reps each (except the plank – you can perform one set and increase your holding time, up to one minute). Complete the routine as a circuit, doing one set of each movement in succession and without resting. If that feels easy, try to perform the circuit a second time after a 90-second rest.
||Single-Leg Abdominal Press: Lying on your back on a floor mat or a padded bench, touch your right palm to the right knee. Raise your right leg off the floor so your knee and hip are bent at 90-degree angles. Rest the right hand on top of your right knee. Push your hand forward while using your abdominal muscles to pull your knee toward your hand. Hold for three deep breaths and return to the start position.
||Repeat this exercise using your left hand and left knee. Keep your arm straight and avoid bending more than 90 degrees at your hip.
||Opposite Hand on Opposite Knee: Push your right hand against your left knee while pulling your knee toward your hand. You’ll be pushing and pulling across the center of your body. Repeat this exercise using your other hand and leg. Hold for three deep breaths and return to the start position.
||Hand on Outside of Knee: Raise your left leg off the floor so your knee and hip are bent at 90-degree angles. Place your left hand along the outside of your left knee. Use your hand to push your leg inward. At the same time, create resistance by pushing your knee away from the center. Keep the back flat. Repeat using your other hand and leg.
||Opposite Hands on Opposite Knees: Place each hand on the opposite knee, toward the inside of each knee. Your arms will cross over each other. Push your hands against your knees and create resistance by pulling your knees in toward your hands. Hold and repeat.
||Hands on Outside of Knees (right hand/right knee): Use your hands to push your legs in toward the center of your body. At the same time, create resistance by pushing your knees out. Hold and repeat.
||Plank: Lie on your stomach. Raise yourself up so you’re resting on your forearms and your knees. Keep your head and back in line and imagine your back as a tabletop. Align your shoulders directly above your elbows. Squeeze your core muscles. Create resistance by pressing your elbows and your knees toward one another. Neither should move from their positions on the floor. Hold for three deep breaths, then return to the start position and repeat.
Talk to your doctor before beginning any exercise program if you have an existing health condition that limits movement, or if you haven’t really exercised before (or if it’s been a long time). You want to make sure you’re doing these exercises correctly, so ask your doctor to explain the precise movement if you’re not absolutely sure. Then get started on your perfect abs one repetition at a time!