The awesome transformational power of the chiropractic adjustment has been well documented throughout our history in chiropractic. The reordering of neural patterns has long been a key model for explaining the systemic benefits from a spinal adjustment. Yet, the most misunderstood adjunct to the adjustment has been the world of neuro-muscular reeducation. Properly done. NMR exercises are designed to powerfully reorganize the neuro-mechanical interface and allow the body to completely reset the motion programs embedded in the neural network. The adjustment sets in motion the possibility for change. The NMR exercises complete the loop and. in so doing, dramatically increase the holding power of the adjustments. NMR exercises are not primarily done to improve posture, strength or flexibility. They are done to re-train the neural response patterns that coordinate and control body position and movement. A side benefit is improved posture and ease of movement. Too many chiropractors have fallen into the trap of only providing passive care in a program of care that may last for months. This not only creates a "red flag" for the third party payers, making them more likely to deny the necessity of your care; it also sets in motion the "Law of Diminishing Utility" A progressive program of exercise counteracts the "Law of Diminishing Utility". We refer to this law as the "Cheeseburger Law". For example, if you really love cheeseburgers, and you order 4 cheeseburgers at one time, the first one would be awesome, the second, pretty good, the third. OK: but, by the time you got to the fourth, you wouldn't want any more cheeseburgers! If each office visit to your practice is identical, just like with the cheeseburgers, the utility or usefulness of your care, in the eyes of your patients, diminishes over time. By following a protocol of exercises that challenge your patients to their level of competence without frustrating them, you will sustain a consistent level of perceived value in the eyes of your patients. Your patients can also feel and monitor their own success. Patients love being able to reach their goals as they progress through the 6- step NMR protocol. Celebrating their accomplishment also encourages them to continue care beyond pain-relief. The net effect is a patient who receives a superior outcome from your care and has more stability and a much-improved chance of never experienc- : a relapse. One of the key elements of the NMR exercise program is the "Swiss" or "Gymnic" Ball exercises. Other equipment, such as wobble boards, and rocker boards or sandals, provide additional options available to clinicians that utilize this area of functional rehab. NMR exercises can be administered by a trained staff member or by a physical therapist. Typically these exercises work best following the adjustment. It is recommended that the patient be past the passive, acute care phase and ready for an active rehabilitation program. Utilize postural exercises in combination with stretching in accordance with the specific injured area. Because we view the entire spine as a "closed chain", these exercises, although seemingly organized to rehabilitate a lumbar injury, are just as appropriate for a cervical injury. Remember, taking your patients through this process is a method for neural re-mapping. A patient may begin any exercise at any level (A. B. C). But. he may not advance to the next stage until all exercises within a sta°e are, at a minimum. Level B for one week or three visits (including the instruction visit). If you are rehabilitating an athlete, he may be proficient at the Level C on a first attempt. He may advance to the next stage on the next visit, when he can perform a Level C proficiently. This means that some patients may not advance as quickly as others. Slow progress may indicate the necessity to alter the treatment plan, and should be brought to the doctor's attention. Now. for the exercises... Exercise 1: Neurodevelopmental Exercise (Posterior Pelvic Tilt): Note: This exercise is the foundation for all other NMR's, which must be performed with a proper pelvic tilt. Instructions: The patient must be able to master an NMR exercise to a level B for 1 week or 3 visits, whichever comes first (this includes the instruction visit). Level A = Assisted (Exercise with Assistance) Level B = Basic (Exercise without Assistance) Level C = Challenged (Basic with the addition of extremities for difficulty) Instructions: Level A: Lie flat on your back with your hands flat on the floor. Therapist puts hand, palm up, under low back to accentuate position. Bend your knees and keep your feet flat on the floor. Press your lower back onto the floor, while pulling up and in with the muscles of the lower abdomen. Hold the contracted position for 10 seconds; relax and rest 3 seconds. Perform 10 repetitions. • Level B: Pelvic Tilt: Instructions: Patient is supine and performs exercise unassisted: Perform supine. Hold for 10 second intervals; repeat 10 times. • Level C: Pelvic Tilt: Instructions: Patient is supine and performs unassisted: Perform supine: Lift one leg at a time, alternating, holding for 10 second intervals; repeat 10 times. Exercise 2: Unilateral Lower Extremity: Instructions: Standing Posterior Pelvic Tilt. Patient stands on each leg 10 times for 10 seconds or to the point of fatigue. Level A: The patient is able to use a chair or wall to balance him- or herself during exercise. Level B: The patient can perform the exercise without assistance. Level C: The patient is instructed to trace out the letters of the alphabet (A-E) with the toe of the raised leg. Exercise 3: Seated Swiss Ball: Instructions: The patient sits on the ball, feet at shoulder length apart. The patient assumes a position of a pelvic tilt with erect spinal posture. • Level A: Basic Bounce Starting Position: Sit correctly on the ball in optimal posture. Movement/Exercise: Begin bouncing by pushing feet into the floor and tightening thigh and hip muscles to slightly lift trunk: relax. Continue bouncing by alternately tightening and relaxing these muscles as vigorously as balance, coordination and comfort allow in optimal posture. Level B: The patient raises one heel at time until he or she can perform a small march by lifting one foot at a time completely off the ground. Level C: The patient straightens out one leg at a time so that it is parallel with the ground. Continued on Page 48 \ ...from Pa^e 46 Exercise 4: Bridge: Instructions: The patient forms a bridge between his or her body and a Swiss ball. Level A: The patient places his or her shoulders on the ball and feet on the floor. Level B: The patient lifts up to bridge position and then raises his or her heels from the ground, one at a time, and performs a small march with his or her feet. Level C: The patient bridges up and straightens out one leg at a time, so that it is parallel with the ground. Exercise 5: Abdominal Curl Up: Instructions: The patient sits on the ball and then slides the buttocks forward, until the shoulders are on the ball and the body forms a bridge with the floor. Level A: The patient slowly curls up by raising his or her shoulders up from the ball, while reaching, with arms extended, for the knees. Level B: The patient curls up, with arms folded across the chest. • Level C: The patient curls up, with the hand placed lightly by the side of his or her head at the ears. To avoid straining the neck, it is important not to interlock the fingers behind the neck while performing this NMR. Exercise 6: Superman Position on Swiss ball: Instructions: The patient sits with the ball in front of himself, in a "prayer position". With the heels against a wall, the patient extends his or her body forward. It is essential that proper posture be maintained during this NMR. Level A: The patient performs the Superman position with arms at his or her sides. Level B: The patient performs the Superman position, and then extends both arms out in front of himself, as though fly ing like Superman. Level C: The patient performs the flying position and then performs a freestyle-stroke swimming motion with his or her arms. Approximately 80% of your patients should be able to perform NMR to the final stage of Swiss ball exercises within a 3-month period. II a patient's progress is delayed, or they plateau at a particular stage of NMR exercises, without being able to advance to a level B, it may be necessary to re-examine your treatment protocol. Briefly, this is a tool that is not only simple and effective, it motivates patients to refer, and stay beyond pain relief while, at the same time, getting you the best reimburse- nient. Does this sound like a chiropractor's dream? It is. These six simple and powerful exercises can transform your patients and your practice. Today, take this step into the practice of your dreams! Dr. John Markham is a chiropractor in practice in Marietta, Georgia. He is a sought-after kevnote speaker on the topics of personal and practice development. A Palmer graduate in 1978, Dr. Markham has been a professor at Life University and a team instructor for Activator Methods. Dr. Dianne M. Bavnes is a chiro- praetor in practice in Pensacola, Florida. She is also a Registered Nurse, and practiced for 10 years in nursing, before opening her chiropractic practice. Dr. Baynes is a 1986 Graduate of Life University, Marietta, Georgia, where she graduated Summa cum Laude, as Class Salutatorian. Dr. Baynes and Dr. Markham are both Senior Coaches for Breakthrough Coaching, and can be contacted at www.mybreakthroiiiih.coin. or bv telephone at 1-800-723-8423. o
