According to research, approximately 80 percent of the population will experience acute back pain at least once in their lifetimes. The statistics unfortunately amount to tremendous financial burdens from the medical system as well as from the workforce in lost employee hours and loss of productivity.
Among the many types of complications which cause extension related low back pain, some of the most common include: spinal disc herniation and bulges; degeneration of the spine; annular tears; ligament sprains; muscle strains, particularly in the quadratus lumborum; osteoarthritis; rheumatoid and ankylosing spondylitis; facet joint sprains; and stress fractures, pars defects and spondylolisthesis.
However, bone injuries causing extension related low back pain can be a series of progressive disorders or pathologies along the lumbar spine, caused by the excessive amount of uncontrolled lumbar spine extensions among many athletes. These could basically occur due to a postural, gradual onset of repetitive trauma, most frequently associated with sports, for instance, gymnastics.
Two specific demographic groups experience the most extension related low back pain among the general population: the first group includes individuals who stand for prolonged periods of time, such as retailers, military, security guards, etc. Standing for extended periods of time normally forces the pelvis to begin shifting into an anterior tilt angle, placing compressive forces against the facet joints of the lumbar spine as these will also begin to shift towards a position of extension following the pelvic tilt; and the second group includes athletes who participate in extension sports, such as gymnastics, tennis, swimming, diving, football, volleyball, basketball, track and field, and cricket fast bowlers, and experience sports injuries. This may be more distinct in sports which include extension/rotation.
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With normal extensions of the lower back, also referred to as backwards bending, the facet joints come close to each other and compress, a natural biomechanical movement. However, if the extension ranges are excessive, the movements will forcefully compress the structures, damaging the cartilage surfaces within the facet joints. Sports like gymnastics, tennis or football, may all involve excessive and uncontrolled extensions of the body.
While unlikely, a bone stress response or a stress fracture could cause an isolated extension injury. Instead, sudden, forced extension injuries commonly damage pre-existing bone stress responses. In the same manner, if an individual stands for extended periods of time and the pelvis migrates into an anterior tilt, the facet joints are then placed under low load compression but for prolonged periods of time.
With continued, uncontrolled loading, stress is then shifted from the facet joint to the bone beneath it. This will initially manifest as a stress reaction on the bone. The stress on the bone may then develop into a stress fracture if not properly corrected. This type of fracture is also referred to as a pars defect, or spondylolysis.
Researchers believed that stress fractures were due to a congenital defect which occurred during an athlete’s teenage years. However, studies have now concluded that this type of issue most likely develops through years of overuse into extension positions, particularly among young athletes involved in the mentioned extension sports. Furthermore, one-sided pars defects tend to occur more commonly in sports that also involved a fundamental of rotation, such as tennis serving or fast bowling in cricket.
Stress fractures generally also affect its opposite side, leading to bilateral stress fractures, where the stress is then transferred to the spinal disc in between the affected levels. The shift of one vertebrae over another is most commonly known as spondylolisthesis, ranging from mild to severe.
Spondylolisthesis presents bilateral pars defects which may be the result of constant stress against the bilateral pars in extension sports. This is believed to be an independent pathology which develops in the early growth stages of an individual as this pathology is frequently diagnosed among the ages of 9 to 14 years of age. If they experience symptoms in later years as a result of participation in extension sports, the defects may have been present within the individual from a young age but manifested asymptomatically. As a result of quick growth spurts in teenagers and due to the increased amounts of training teenage athletes are involved in, there’s a possibility that a dormant variety of spondylolisthesis may present itself as an acute onset of extension related low back pain in the athlete’s later teenage years.
Spondylolisthesis is commonly found as L5 slips on the S1 vertebra of the spine and the condition can be graded according to its degree of slippage: grade 1, up to 25 percent; grade 2, from 25 to 50 percent; grade 3, from 50 to 75 percent; and grade 4; up to 75 percent and over.
The progression of bone stress reactions tends to follow the following continuum: first, facet joint irritation occurs; second, a pars interarticularis stress response develops; third, stress fractures manifest to the pars; fourth, a pars defect, or spondylolysis develops; and last, congenital spondylolisthesis or as a result of activity, occurs due to participation in extension sports.
A landmark publication related to spondylolysis and spondylolisthesis was presented by Researchers and they classified these injuries as follows: type I: dysplastic, where congenital abnormalities of the L5 vertebra or the upper sacrum allow anterior displacement of L5 on the sacrum; type II: isthmic, a lesion which occurs in the pars interarticularis. This can be sub-classified as lytic, representing a fatigue fracture of the pars, with elongated but intact pars, or as acute fractures; type III: degenerative, secondary to long-standing intersegmental instability with associated remodeling of the articular processes; type IV: traumatic, where acute fractures occur in the vertebral arch other than the pars; and type V: pathological, due to generalized or focal bone disease affecting the vertebral arch.
The vast majority of spondylolysis and spondylolisthesis injuries are of the type II, isthmic variety. The above stages can be referred to as posterior arch bone stress injuries, or PABSI.
Spondylolysis develops along the pars interarticularis of the lumbar spine. It’s most common at the level of the L5 vertebra, approximately occurring in 85 to 90 percent of cases. It has a high asymptomatic prevalence in the general population. However, particularly in young athletes but also in other athletes, it is a common cause of chronic extension related low back pain. In young athletes, the condition is often known as active spondylolysis.
Active spondylolysis is common in almost every sport. Sports like gymnastics, diving and cricket, present a much higher risk of developing the condition due to the extension and rotation nature of these sports. From an active spondylolysis to a non-union type of spondylolisthesis, these have been linked to a higher incidence of lumbar disc degeneration.
Through screening and imaging, early detection can help highlight the development of these conditions during the bone stress phase and, if it is detected and managed in time, the further complications can be avoided due to the healing capacity of the pars interarticularis in its early stages.
Teenagers and young adults are more frequently diagnosed with PABSI, or posterior arch bone stress injuries as a result of the rapid growth of the spine through growth spurts, characterized by a delay in the motor control of the muscle system during this time. Furthermore, it is believed that the neural arch becomes stronger over time, explaining the low incidence of bone stress reactions in middle aged athletes.
Spondylolysis is considered to occur the most among the young athletic population than in the general population. Studies in gymnasts, tennis players, weightlifting athletes, divers and wrestlers, all demonstrate a higher incidence of spondylolysis compared with the general population of similar ages
Common Sports Causing PABSI
The well-known tennis serve actually creates excessive extension and rotation forces which may be a contributing factor for injury. Also, a forehand shot may produce high levels of rotation/extension. The more traditional forehand shot involves increased amounts of weight or load which then shifts through the legs into the torso and arms. A more favored forehand shot now involves facing the ball and generating the force of the shot using hip rotation and lumbar spine extension. This action does increase the speed of the ball but it places more extension and compressive loads on the spine, which can potentially lead to an increased degree of stress against the bones and other structures of the body.
A golfing tee shot is believed to be one of the most probable component behind the development of injuries, as the follow-through of the shot involves a considerable amount of spine rotation with some degree of spine extension.
Fast bowlers in cricket are the most susceptible to injury. Complications generally occur on the opposite side to the individual’s bowling arm. As the front foot engages on the plant phase, the pelvis suddenly stops moving while the spine and torso continue to move forward. When the particular bowling action rotation is combined with extension, this may place large forces on the posterior arch of the vertebrae. Over 50 percent of fast bowlers will experience a pars stress fracture, with young players being the most vulnerable. Cricket authorities have implemented training and competition guidelines to prevent these injuries by limiting the number of bowls in training or games.
Because gymnastics and dancing involves a considerable amount of repetitive spine extension, especially backflips and arabesques, athletes who participate in these may be highly prone to suffer from injury as well. It has been suggested that almost all Olympic level gymnasts have experienced a pars defect. Certain limits have been developed, regarding how many hours young gymnasts can train to avoid the repetitive and constant loading of the spine.
Through diving, spine extension injuries occur among athletes, primarily off the spring board and on water entry.
As with contact sports such as the NFL, rugby and AFL, specific fundamental skill sets are required to execute spine extensions under load, resulting in injury.
The more common field events to cause injury during field event include the high jump followed by the javelin throw. Both of these sports create enormous ranges of spine extension and under considerable load, these may commonly lead to injury.
Clinical diagnosis of PABSI in athletes
Posterior arch bone stress complications may manifest as asymptomatic injuries. Research indicates that these have been displayed among the general population without experiencing symptoms of back pain. However, many individuals usually report deep and usually unilateral, or one sided, symptoms of back pain. Additionally, the pain may radiate into the region of the buttocks. Extension movements or backward bending movements have demonstrated to aggravate symptoms of back pain due to posterior arch bone stress injuries, or PABSI. This is generally described as a gradual progression of pain or may be initiated by one acute episode of back pain from an extension movement.
Upon clinical examination, individuals or athletes with PABSI report pain which may be obtained with a one-leg extension/rotation test, known as the Stork Test, which is conducted by standing on the leg of the affected side. In addition, the patient will experience tenderness over the site of the fracture as well as postural faults, such as excessive anterior tilt and/or pelvic asymmetry.
The one-legged hyperextension test, best known as the Stork Test, has been suggested to be pathognomonic, or specifically characteristic, for active spondylolysis. A negative test was described to effectively exclude the diagnosis of a bone stress type injury, thus making radiological investigations unnecessary.
However, researchers examined the connection between the one-legged hyperextension test and gold standard bone scintigraphy and MRI. They found that the Stork Test was neither sensitive nor specific for active spondylolysis. Moreover, it poorly predicted the presence of injury. Therefore, a negative test cannot exclude active spondylolysis as a possible cause and a high degree of suspicion for PABSI must be suspected in young athletes involved in extension sports which describe symptoms of extension related low back pain but are asymptomatic on the Stork test.
Researchers suggest that the poor relationship between imaging and the one-legged test may be due to a variety of factors. The extension test would be expected to transfer a considerable amount of extension force onto the lower lumbar spine as well as placing significant pressure on the pars interarticularis, stressing other areas of the lumbar spine, such as the facet joints and the posterior lumbar discs. This may subsequently cause pain and the development of other disorders, such as facet joint arthropathy and lumbar disc disease.
According to studies, grade 1 spondylolisthesis tends to be asymptomatic while grade 2 and other lesions tend to manifest alongside leg pain or without leg pain. On examination, a palpable slip may be apparent.
Not all individuals or athletes suffering from PABSI will show positive characteristics or positive signs on testing. As a result, radiological visualization is essential as a part of a proper diagnosis. The imaging modalities available in the diagnosis of bone stress injuries include:
Conventional radiology, a type of test which is not very sensitive but it is highly specific. Its restrictions are partially due to the direction of the pars defect. Spondylolisthesis can be viewed on a lateral film X-ray. If the plain film appears normal for spondylolysis, then a bone scan, or SPECT, may be required.
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Planar bone scintigraphy, or PBS, is highly sensitive but not very specific. Single photon emission computed tomography, or SPECT, improves sensitivity as well as specificity of PBS than simple radiographic studies. Correlating studies between PBS and conventional radiology have demonstrated that scintigraphy is more sensitive. Individuals with positive SPECT scans should follow up with a reverse gantry CT scan to assess if the lesion is active or old.
Computed tomography, or CT, scans are considered to be more sensitive than conventional radiology and are believed to have a greater specificity than SPECT. Regardless of the type of cross-sectional image utilized, CT scans provide information on the condition of the defect, such as an acute fracture, unconsolidated defect with geodes and sclerosis, pars in process of consolidation or repair. The reverse gantry view can evaluate this condition better. Repeated CT scans can be utilized to monitor the progress and healing of a pars defect.
Magnetic resonance imaging, or MRI, is a technique which demonstrates distinct changes in the signal at the level of the pars. This is identified as stress reaction and can be categorized into five different degrees of activity. MRI can be useful for evaluating components that stabilize isthmic lesions, such as intervertebral disc, common anterior ligament, and associated lesions. The MRI, or magnetic resonance imaging, is not as specific or sensitive as SPECT and CT combination.
Therefore, the current gold standards of analysis for athletes with extension related low back pain are: bone scintigraphy with single photon emission computed tomography, or SPECT, if positive; and limited reverse-gantry axial computed tomography.
There are various restrictions to utilizing the previously mentioned modalities to diagnose injuries, including the intravenous injection of radioactive tracer and the young athlete’s exposure to ionizing radiation. MRI has many advantages above bone scintigraphy, pertaining to the non-invasive nature of the imaging and the absence of ionizing radiation. MRI changes in active spondylolysis involve bone marrow edema and fracture.
Although, it is much more difficult to detect the alterations of active spondylolysis with MRI. Detecting pathologies through MRI depends on the perception of contrasting differences of signals when compared with normal tissue. Moreover, for active spondylolysis, this interpretation involves a small are of bone along the pars interarticularis, which is surrounded by many other structures. Apart from stress fractures in other regions of the body, the small area of the pars interarticularis could make the detection of these alterations more difficult.
Computed tomography has the ability to differentiate between acute and chronic fractures and this differentiation may be an essential determinant to heal fractures. Although MRI may be equivalent to computed tomography in detecting fractures, its inability to determine fracture age reduces its usefulness. Accordingly, in subjects with pars interarticularis fractures detected by MRI, it may still be necessary to perform thin computed tomography slices to determine whether a fracture is acute or chronic, a crucial element in fracture resolution.
Chiropractic for Athletes with Back Pain
After an athlete has determined the source of their extension related low back pain, there are several treatments available for them to find relief from their symptoms. Chiropractic care is one of the most popular alternative treatment options available to alleviate spinal complications. After careful diagnosis of the root cause of an individual’s symptoms, a chiropractor will generally utilize a series of spinal adjustments and manual manipulations to correct any misalignments of the spine, or subluxations, helping to eliminate the irritation or inflammation of the structures surrounding the affected region of the spine, ultimately reducing or eliminating the individual’s painful symptoms.
Additionally, a chiropractor may recommend a series of stretches and exercises according to the individual’s severity of injury, to speed up the rehabilitation process as well as increase the individual’s strength, flexibility and mobility. Chiropractic care is an effective, alternative treatment option for many types of injuries or conditions, primarily focusing on those surrounding the spine, to help restore an athlete’s original health after experiencing complications which manifest as extension related low back pain.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
By Dr. Alex Jimenez
MEET THE STAFF
These canons of professional ethics are based upon fundamental principles of moral and professional behavior and recommended for all doctors of chiropractic and chiropractic assistants. The following basic principles should be guiding factors in the practice of chiropractic and upheld at all times:
Consider the well-being of the patient. The primary effort and ultimate goal is for the greatest good of our patients.
- Dr. Alexander D. Jimenez D.C., C.C.S.TChief Clinical DirectorPhone: 9155408444Email: firstname.lastname@example.org
Specializing in Severe Pain: Sciatica, Neck-Back Pain, Whiplash, Headaches, Knee Injuries, Sport Injuries, Dizziness, Poor Sleep, Arthritis. We use advanced proven therapies focused on optimal mobility, health, fitness, and structural conditioning. We use Patient Focused Diet Plans, Specialized Chiropractic Techniques, Mobility-Agility Training, Cross-Fit Protocols and the "PUSH System" to treat patients suffering from various injuries and health problems.
Message from: Dr. Alex Jimenez D.C., C.C.S.T
( Biography and my promise to you )
My name is Dr. Alex Jimenez, I am Chiropractic Doctor specializing in advanced therapies focused on total joint health, strength training and complete fitness conditioning. We use patient Focused Diet Plans, Advanced Chiropractic Techniques, Agility Training, Cross-Fit and the PUSH System to treat patients suffering from various injuries and health problems. Our goal too is to help your body heal itself naturally. When your body is truly healthy, you will arrive at your fitness level and proper weight efforlessly. We want to help educate you on how to live a new and improved lifestyle. Our doctors have spent over 25+ years researching and testing methods with thousands of patients. We strive to create fitness and better the body through researched methods and total programs...
My goal too is to help the body heal itself naturally. When your body is truly healthy and balanced, you will move pain free and ultimatly arrive at your optimal fitness levels and proper weight effortlessly. We want to help educate you on how to live a new and improved lifestyle. Our doctors have spent over 25 years researching and testing methods with thousands of patients. We strive to create fitness and better the body through researched methods and total programs. These programs are natural, and use the body's own ability to achieve goals of improvement, rather than introducing harmful chemicals, controversial hormone replacement, surgery, or addictive drugs. We want you to live a life that is fulfilled with more energy, positive attitude, better sleep, less pain, proper body weight and educated on how to maintain this way of life.
The focus on spinal and skeletal adjustments is what makes doctors of chiropractic unique in their approach to treating patients with spinal complaints. This hallmark chiropractic adjustment, however, is not the only procedure a chiropractor may employ in managing a patient's care. I am very proud to bring my patients a variety of treatment options beyond the typical scope of care. With the advances in physical therapies and modalities we bring El Paso option that better aid in the rehabilitation process. Tissue healing is a wonderful process that begins the moment an injury occurs. How the injury is managed determine the final outcome in terms of healing. It is critical we implement immediate procedures as soon as we can in order to gain optimal recovery. The old day of let it rest until it gets better is not the only option.
Letting it rest may even be an irresponsible approach considering what we now know. The implementation of active and movement based treatments have clearly shown increased and improved outcomes in many instances.
As a doctors focused on the greater good for a patient, we must assess each patient individually and apply the appropriate protocols. It is also very important to denote, that El Paso has fine doctors in many specialties of healing and repair. The direct relationship we have with specialist of these disciplines is clearly what allows us to bring the highest quality of care to our patients.
My promise to my patients is clear for all to read here. I, with Gods help, will do what ever it takes to assist you in your recovery. I too will draw upon all the specialist in this town to find you the collaborative care that is required with the disorders being tended to.
With Great Regards to you.Read moreRead lessEducation:
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Driven by the passion of doing what is in the best interest of the patient, I wake up every morning with the drive to help those in need. The claims process for health care is full of pits, valleys and difficult obstacles designed to strike fear in those in need. My duty is to do what is within the confines of the law, "what ever it takes" to get those involved to pay attention to those who need help. That is what I am honored to do for our patients.
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Daniel Alvarado is the owner and the top trainer at PUSHasRx® CrossFit Fitness Facility. Since becoming a Trainer Daniel has kept up to date on many continuing educational classes, ensuring that his clients receive the most comprehensive and advanced training. Working directly with the Doctors, he develops and collaborates on care plans that are patient specific. No patient ever gets the same clinical protocol. His expert clinical kinesiology experience spans over 2 decades. He has trained injured patients and NCAA National Champion Athletes. His technical ability to create programs that are clinically sound and second to none. He too has used his physical therapy and recovery experience to take broken top tier athletes into strict recovery protocols assisting them to achieve highly competitive national championships. He certainly will not admit it but, he is a top national champion trainer. Daniel, also develops youth programs that are sport specific to aid young athletes achieve great success. His mastery of clinical recovery is applied applied to all patients and top tier athletes alike. All patient programs are specifically designed with patient focused recovery priorities. He is happily married to beautiful Victoria Alvarado has one child. He enjoys strength training, movies, singing, conducting, writing poetry and being a CrossFit champion. Just a way cool dude. We think you will agree.Read moreRead less
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Sandra has been working at Injury Medical & Chiropractic Clinic for over 5 years. As the head Licensed Massage Therapist, she manages and directs critical aspect of clinical care. The patients love her ability to make you laugh while removing those pesky trigger points causing pain. She is able to relax and bring comfort to all she touches. There just simply is no patient that escapes her talented touch. Trained in advance myofascial techniques, she is an integral part of patient recovery. You will never see anything but a kind smile and resolute persona ready to correct your condition and aid in your recovery. She definitely enjoys helping people, has 1 dog and loves movies. She loves flowers too.Read moreRead less
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Big Mike was born and raised in El Paso and is an excellent personal trainer and CrossFit coach. Mike works hand in hand with each patient’s clinical care plan in order to achieve optimal outcomes. A trusted clinical representative of the PUSHasRx System along with his advance protocols. Mike not only trains the injured and recovering. Mike is a sincere human that has great talent of brining out the best in every individual he works with. He will never admit it, but we will share with you a secret. He with his God given talents trains the greatest athletes and champions in El Paso. Many champions in our community know of his commitment. As a youth, he also played football (wide receiver), basketball, and track at Bel Air High School. Educated in Clinical Human Kinesiology at UTEP and loves playing football and basketball with his little nephews in his free time. Mike has three sisters and one brother, most of which live nearby in El Paso. When he’s not watching the Cowboys or Spurs play, he’s usually lifting, sleeping or watching movies. We are blessed to have this soul on our team.Read moreRead less
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Alexander Isaiah Jimenez leads the power and agility education programs for the high school athletes. While still studying for his medical degree he provides physical performance testing in order to collaborate with clinicians. He is gifted in creating physical performance programs no matter what the clinical presentation is. As national fitness champion and collegiate wrestler, he too understands what performing at high levels entails. He too has had to recover from debilitating injuries only to return better then before an win national titles. He understand how the recovery process is different for clients, patients and extreme athletes. We are blessed to have his counsel.Read moreRead less
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Ethan was born and raised in El Paso and is one of our most outgoing and friendly coaches. Ethan earned his nickname “rampage Ethan” from his years at El Dorado High School, where he played inside linebacker. He has placed twice in the Strongman Competition and also recently competed in the Desert Games with his fellow PUSH Athletes as a team and placed 4th overall! Ethan is currently pursuing his Bachelor’s Degree in Kinesiology at UTEP. His focus on clients is obvious to all. Ethan is able to manage very large groups of individuals like no other. His awareness of the dangers while exercising is his greatest concern. When he’s not coaching or studying for class, he likes to spend time with his family (who are here in El Paso) or with his weimaraner puppy. Fun fact: Ethan loves any food with sprinkles (especially donuts with sprinkles) and is a diehard Seattle Seahawks fan.Read moreRead less
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Andres has been at PUSHasRx for two years. He brought his company Recovery and became the official juicer. Andy will fix you right up. Andres, will make sure that your nutritional recovery programs fits within your standards. Also, there is great care in making sure the nutritional requirement are clinically met. Patients and high performance athletes depend on high performance nutritions. Upon your completion of the physical medicine portion of therapy you will be offered specialized organic recovery drinks and supplementation to help aid in your recovery. You will be confident that from your pushing to recovery, you will be taken care of.Read moreRead less
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ylene has been working with us for over 4 years. In her spare time she enjoys working out and running. She has 2 dogs and loves movies. Iylene is extremely aware of body mechanics and mindfully watches rehabilitation movements. She is always standing ready to assist and respond to client needs. Her commanding voice is always clear to all, no matter what floor you are on. Iylene is always ready and willing to answer any question you may have regarding fitness and recovery.Read moreRead less
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Most early-rising PUSHasRx members know Rick well as a fantastic coach who focuses strongly on form and will always make you laugh. He was born and raised in El Paso and loves to train his athletes and coach CrossFit. Rick is a very diligent, kind and considerate trainer. He is always mindful of client techniques and aware of client goals. When he’s not coaching, Rick loves to work on cars, especially his ’69 Chevelle (his next car will hopefully be a ’69 Charger). He not only became a certified Automotive Mechanic at 17, but while working on his certification at EPCC, he won 1st place in a bench competition when he was 16 (approx. 56 reps at 155#). His favorite movements are clean & jerks and snatches. He loves oreos (eats them every night), loves watching the CrossFit games, and loves his three bulldogs. He spent one year full-time personal training before he started coaching CrossFit two years ago. He is CrossFit Level 1 Certified and hopes to get his Level 2 Certification soon. Rick has competed in several competitions, including WOD for Toys in 2014, where his team placed 1st.Read moreRead less
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Adam has been at Injury Medical & Chiropractic Clinic for about a year. He enjoys designing and various forms of art. A story teller by trade he can see things people don’t see until his masterpieces are revealed. Adam is a director of many medias using the top graphics, audio and video medias to tell the story of our patient. Modest to the core, you would never know what he is about to create. We are blessed to have his talents telling the world about Chiropractic using any and all medias available.Read moreRead less
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We've been blessed to use our methods with thousand of El Pasoans over the last 27 years. This has allowed us to improve health and restore true fitness through researched non-surgical methods and wellness programs. These programs are natural and use the body's own ability to achieve goals of improvement, rather than introducing harmful chemicals, controversial hormone replacement, surgery, or addictive drugs. We want you to live a life that is fulfilled with more energy, positive attitude, better sleep, less pain, proper body weight and informed on how to maintain this way of life.
As an extension to dynamic rehabilitation, we too offer our patients, disabled veterans, athletes, young and elder a diverse portfolio of strength equipment, high performance exercises and advanced agility options. We are very proud to have teamed up with the cities premier therapist and trainers in order to provide high level competitive athletes the option to push themselves to their highest abilities within our facility.
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