HistoryA 41-year-old right-handed male pre-

sented for post-surgery elbow rehabilitation.The patient fell from a roof, landing on con-crete and shattering his left elbow at impact.After diagnostic testing at a hospital emer-gency department, he was sent to an ortho-pedic surgeon, who reconstructed his elbowusing surgical screws and hardware. Themuscles of his forearm, bicep, and tricep werereattached. The surgery was successful andthe patient was given medical clearance tobegin rehabilitation.

Clinical PresentationThe patient presented with his left

elbow in a brace bent at 90°. He had swelling,inflammation, “tightness and weakness,” andmanaged only a few degrees of motion in alldirections.

Clinical impression: He had muscle im-balances with severely limited ranges of mo-tion and flexibility, decreased stability, and acompensatory upper cross syndrome. Areasof deficit included tight, overactive muscleson the involved side, inhibited or weak mus-cles on the opposite side, round shoulders,anterior head translation, winged scapula onthe involved side, and less than 5° of motionin flexion, extension, pronation, and supina-tion, with markedly decreased propriocep-tion.

Functional testing included posturalanalysis, proprioception testing, muscle test-ing, and range-of-motion testing

FindingsThe patient initially presented with

round shoulders, winging of scapulae, and el-evation of shoulders. He demonstrated weaklower and middle trapezius, neck flexors, ser-ratus anterior, triceps, anconeus, pronator,and supinator. There was diminished propri-oception on the left side, which becameworse when the patient closed his eyes. Healso demonstrated tight biceps, brachialis,brachioradialis, upper trapezius and levatorscapulae, sub occipitals, pectoralis major andsternocleidomastoidious (SCM). Myofascialtrigger points were noted in the SCM and le-vator scapulae. There were inhibited spinalstabilizers, specifically the multifidus.Strength differences were greater than expect-ed values. Shallow breathing was present.

DiagnosisThe patient’s diagnoses at the initial

presentation were joint stiffness, upper crosssyndrome, abnormal posture, muscle imbal-ances, muscle incoordination, and muscleweakness.

TreatmentRehabilitation concepts: The specific re-

habilitation program design was based on thespecific adaptation to imposed demands(SAID) principle, Sherrington’s law of recip-rocal inhibition, neurologic crossover effect,and neuromuscular overflow (physiologic).

Primary focus, clinical goals: The reha-bilitation program was designed to increasestrength of the lower and middle trapezius,neck flexors, serratus anterior, triceps, an-coneus, pronator and supinator; stretch thebiceps, brachialis, brachioradialis, uppertrapezius, levator scapulae, sub occipitals,

44 cchhiirrooppuubb..ccoomm • November 2006

A low-tech rehab program improved apatient’s muscle balance, endurance,and joint stability

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upper-extremity movement patterns. Focus was also onresolving noted tightness/weakness syndromes so that pa-tient tolerance for sedentary and light activities was possi-ble without upset.

To address joint dysfunction, manipulation was per-formed as needed. Sequential EMS using VMS burst andinterferential was again utilized for 30 minutes to reducethe symptoms, improve circulation, and diminish spasms.Ultrasound was performed again using Medic Ice, andmechanical traction was again performed. The tractionwas performed to patient comfort, increasing the amountof force each week. A combination of PIR, PNF and flex-building muscle energy techniques were again used.

The patient began performing strengthening exercis-es utilizing low weight and high repetitions protocol on auniversal gym. The patient also began performing exerciseon an elliptical walker for 15 minutes, followed by 15minutes on a Cardioglide. These two devices put the armthrough a full range of motion with resistence(Sherrington’s law of reciprocal inhibition). Gym Ball,upper extremity, core, and postural stability exercises wereperformed to complete the routine. Office treatment pro-tocols were performed three times per week. Home pro-tocols are still performed daily. The patient is nowperforming the Wristiciser exercises on both the injuredand uninjured upper extremities.

Stage 3, long-term goals: During this phase of treat-ment, the focus continued with core stabilization of the

46 cchhiirrooppuubb..ccoomm • November 2006

pectoralis major and SCM; activate spinal stabilizers suchas multifidus; increase proprioception; and correct thespinal and extremity biomechanics.

Stage 1, passive care protocols (short-term goals):Initially, the primary focus of treatment was to address theacute nature of the injury postsurgery so that more ag-gressive rehabilitation could be performed with minimalupset to the patient. The patient showed favorable out-come, through increased flexibility and reduction in theonset and duration of pain and inflammation.Manipulation was performed as needed to address jointdysfunction. Sequential electrical muscle stimulation

(EMS) using variablemuscle stimulation(VMS) burst and inter-ferential was utilizedfor 30 minutes to re-duce the symptoms,improve circulation,and diminish spasms.Ultrasound was per-formed for 10 minutesusing Medic Ice as aconduction mediumto decrease inflamma-tion, improve flexibili-ty, and break upadhesions. Mechanicaltraction was per-formed, focusing onfull extension of theelbow. The tractionwas performed to pa-tient comfort, increas-ing the amount offorce each week. Acombination of post-isometric relaxation(PIR), proprioceptiveneuro-muscular facili-

tation (PNF) and flex building muscle energy techniqueswere utilized to stretch the short, tight muscles, activatethe inhibited muscles, and strengthen the weak muscles(Sherrington’s law of reciprocal inhibition).

The patient was taught correct breathing patterns,beginning from the lower abdomen and ending in theupper chest. Correct breathing patterns activate spinalstabilizers. The patient was shown how to use aDynasplint to flex and extend his elbow (neuromuscularoverflow). This was performed three times per day, to pa-tient comfort, for 20 minutes, increasing the force of trac-tion on a weekly basis. The patient was instructed toperform upper extremity exercise protocols using theWristiciser at home primarily on the uninjured side (neu-rologic cross-over effect). Office treatment was adminis-tered five times per week, while home care was performeddaily. After office treatment and home care, Medic Ice wasused daily to control symptoms.

Stage 2, intermediate goals: During this period oftreatment, focus was on core and postural stabilization ofthe upper kinetic chain to develop proper cervical and

Case Report

Zinovieff ProtocolTiming for the exercise is 3 seconds

contraction /6 seconds relaxation. Initial 10repetitions maximum (RM) = IRM/2

Set 1: The exercise is performed at theinitial 10 RM value (if this is the first sessionfollowing the evaluation), or at the 10 RMvalue calculated from the previous exercisesession. The patient will perform up to 11repetitions at this weight. Number of repeti-tions completed is entered. Patient will restfor 1 minute.

Set 2: Patient will perform 10 repeti-tions at 3/4 of the 10 RM. Patient will restfor 1 minute.

Set 3: Patient will perform 10 repeti-tions at 1/2 of the 10 RM. If the patient wasable to achieve more than 10 repetitions forthe first set, the computer will add oneweight unit for the next exercise session. Ifthe patient achieved fewer than 10 repeti-tions, the computer will decrease the resist-ance by one weight unit for the next session.Otherwise the weight will remain the same.

Pictured are the lateral (above) and A-P view of the patient’s surgi-cally repaired elbow.

ed protocols in both planes, using all three ring sizes. Thepatient progressed to Body Blade exercises in the X, Y &Z planes using both hands, for two minutes each. The pa-tient was then transitioned to one-handed Body Bladeprotocols, in all three planes, for two minutes. The finalprogression was to perform the Otis Ring and Body Bladeprotocols while standing on balance boards.

Discharge to Home CarePatient capacity for occupational, recreational, and

social activities was restored. Following discharge, the pa-tient was advised of the benefits of a home care program.The patient was provided with specific self-care stretchesand exercises, as well as the Wristiciser and a Gym Ballthat are safe to perform without direct supervision. Thepatient was to return for additional care, if function de-creased or symptoms reoccurred. CP

GGeeoorrggee KK.. PPeettrruusskkaa,, DDCC,, DDAACCRRBB, has 25 years of experiencein chiropractic and rehabilitation, with emphasis in personalinjury and worker’s compensation cases. Contact him at acrbdoc@verizon.net.

Jodelle Lapinski and Heather Petruska edited this article.

48 cchhiirrooppuubb..ccoomm • November 2006

upper-kinetic chain, with the progression of more chal-lenging exercises. The goal is to improve the functionalstability of the upper kinetic chain such that patient tol-erance for more aggressive and stressful activities werepossible without upset (SAID principle). Patient progresswas continuously monitored through periodic function-al re-evaluation and was discharged when progressreached a plateau. Biomechanical manipulation shouldbe performed as needed to address joint dysfunction.The patient continued to perform endurance cross-train-ing using an elliptical walker and a Cardioglide for 30minutes.

The patient also continued performing strengtheningexercises using Zinovieff protocols progressing toMcQueen on a universal gym. Gym ball protocols contin-ued to be performed with a whole body focus. In additionto the above exercises, Otis Ring work training was addedin the transverse and horizontal planes, for two minutesusing all three ring sizes. Otis Ring is a hollow ring withtwo metal balls, and the patient spins the ring.

The patient then transitioned to both clockwise andcounter-clockwise training, with all three sizes of the OtisRings in the transverse and horizontal planes for two min-utes each. The next transition was to perform one-hand-

Case Report

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