The Clinical Rehabilitation Specialist
By Craig Liebenson B.Sc.(Syd.Uni).M.Chiro.(Macq.Uni.) Chiropractor

Introduction
The clinical rehabilitation specialist (CRS) is a health-care provider who can diagnose disease and treat patients with clinical conditions, identify functional deficits in the musculoskeletal system and use specific patient-centered exercise to correct them. This is in contrast to other fitness experts such as personal fitness trainers, Pilates or Yoga instructors, etc.. The CRS is a qualified clinician and part of the health care team responsible for the management of musculoskeletal disorders. According to the World Health Organization’s revised guidelines on disability, the goal of health care is to enable patients to return to participation and independent functioning in their chosen activities^12,15. This goal is patient-centered rather than doctor-centered in that the goal is restoration of activity tolerance rather than removal of impairments⁴. The CRS is the ideal person to facilitate a return to participation in activities of daily living (ADLs) for the patient.

The CRS must be skilled in administering the diagnostic triage necessary to rule out red flags of serious disease. He is uniquely qualified to offer patient-centered care within a biopsychosocial (BPS) and best-evidence context via reassurance and reactivation advice^2,14.

Patients want to know the cause of their pain, the prognosis, treatment options, self-care, and any precautions they should take^1,11. It is important to not only describe the benefits of various evidence-based treatment options (e.g. manipulation, over the counter medication, heat or ice, etc.), but also the risks of being overly careful. Specifically, they should be advised that believing hurt equals harm promotes the dangerous process of deconditioning¹³. This should be substituted with pro-active training in spine sparing strategies (e.g. ergonomics, lifting strategies, micro-breaks, etc.) and spine stabilization exercises (e.g. motor control training)^4,7,8.

Functional Assessment
To practice this model of musuloskeletal pain management requires 3 basic things. One, a functional assessment; two, therapeutic exercise; and three, a clinical audit process (CAP). The traditional medical, orthopedic and neurologic evaluations are necessary but not sufficient to facilitate resumption of activities or participation. Rehabilitative management must include a specialized functional assessment screen^4,5. This evaluation of impairments is essential to identify the patient’s “weak link”. Testing an individuals performance capacity involves screening for less than 20 functional impairment tests^4,16,17.

Therapeutic Exercise
Once a functional assessment has identified if deconditioning of a “weak link” related to the person’s activity intolerances is present then TE is required to stabilize the patient in their ADLs, job demands, or sports and recreational activities. Therapeutic exercise training involves a staged progression beginning with simple movement exploration and progressing to activity specific functional training (table 1). Such TE should always occur with an emphasis on coordinated movement in a relatively pain-free range of motion (ROM). This “painless and appropriate range for the task at hand” is defined as the patient’s “functional range”^4,10.

Table 1

Stages of Therapeutic Exercise
1. Movement Exploration
2. Isolated stability training
3. Functional integrated training (FIT)

Therapeutic exercise progresses from simple, uncomplicated movement exploration (cat-camel, bracing, etc.) to low-load neuromuscular training which isolates key stabilizers (e.g. transverse abdominus, multifidus, quadratus lumborum, gluteus maximus, etc.) or movement stereotypes (e.g. hip hinge, dying bug, bird-dog, cervico-cranial flexion, etc.). These exercises should emphasize coordination and endurance training. By coordination what is meant is agonist-antagonist muscle co-activation, “neutral” joint control, and avoidance of abnormal substitution movement patterns.

Therapeutic exercise progressions are complete when progress to functional activities as exercise has occurred. For instance, squats, lunges, pushing, and pulling. This final stage (stage 3) of functional integrated training (FIT) is achieved when the patient has demonstrated appropriate load sharing via mobilization (stage 1) and neuromuscular isolation of key stabilizers or movement patterns (stage 2).

Fortunately, therapeutic exercise requires knowledge of only about 20 families of related exercises (e.g. dead-bugs, bird-dogs, side bridges, squats, lunges, functional reaches, etc.)⁴. A CRS should master the craft of training patients in all of these exercises and their variations.

Clinical Audit Process
In order to streamline the process of functional assessment and training the CAP is needed to customize the patient’s self-care exercise prescription. Without this step the CRS is merely a technician training each “weak link” that is found. In fact, the CAP is the art which allows the CRS to utilize the craft of functional assessment and training efficiently and appropriately for each individual patient. The cornerstones of the CAP are the identification of the patient’s unique mechanical sensitivity (MS) and abnormal motor control (AMC) patterns. These unique components individualize the care and make it truly patient-centered.

Evaluating the patient’s MS is the main tool for the CRS in identifying the patients starting point for therapeutic exercise. The MS are the movements and positions which reproduce the patient’s characteristic symptoms⁹. For instance, orthopedic tests or ROM tests can identify the patient’s MS or the limits of their functional range. In the CAP the appropriate office or self-care prescription is identified when through empirical trial a treatment is found which reduces the patient’s MS. Such “within-session” improvement in ROM testing has been shown to result in a 3.5 greater likelihood of “between-session” improvement for the patient³. In fact, exercise prescribed according to one’s directional preference has been shown to be superior to evidence-based care. Since a “holy grail” in management of musculoskeletal pain management is to be able to accurately identify patients likely to have a speedy recovery vs. those who are prone to chronicity then using the patient’s MS as part of the CAP is a revolutionary approach in patient care⁶.

Evaluating the patient’s AMC is the main tool for the CRS in identifying how to progress the patients therapeutic exercise program. The patient’s AMC is defined as incoordinated movement patterns (e.g. Janda’s hip extension or abduction patterns)⁴. Once a patient’s MS is declining exercises can be progressed to those which address the patients AMC. This is why the patients functional range is defined by Morgan as “the pain-less and appropriate range for the task at hand”¹⁰.

Conclusion
A key to managing musculoskeletal pain is to reassess, reassess, and reassess. The CRS should learn the craft of a discreet set of reliable and valid functional tests therapeutic exercises. However, the real expertise involves the astute use of the CAP to identify the beginning point for self-care and the necessary progressions of the patient’s therapeutic exercise program. Such care always begins when the health care provider has performed a diagnostic triage to rule out “red flags” of serious disease and diagnosed the presence or absence of a nerve root problem. Both the risks of traditional symptomatic focused care the benefits of reactivation focused care must be incorporated into a BPS report of findings. It is not enough to supervise exercise training like in a gym, but truly patient-centered care progresses from clinically supervised therapeutic exercise ends when independent function is restored.

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