By Scott A. Martin D.C.

 

This 8 hour course on Spinal Exercise will include the following specific topics;

1. An Overview of the Specifics & Goals in Considering an

In-Office Spinal Exercise Program [ 1 hour ]

2. A Review of the Basic Anatomy of Skeletal Muscles
   [ 1 hour ]
3. A Review of the Basic Spinal Structures [ 1 hour ]
4. Clinical Case Management for the Spinal Exercise Patient

[ 1 hour ]

5. ICDM Coding for Using Spinal Exercise in Office [ 1hour ]
6. Spinal Exercise Training [ 2 hour ]
7. Aerobic Exercise in a Spinal Exercise Program [ 1 hour ]
8. Conclusion

 

OVERVIEW:

The goal of this class, is to give the practitioner another tool to utilize in the clinical case management of his/her patients. The spinal exercise program/class is a tool, which if administered correctly, will not only add depth to the patient’s treatment plan, but will provide the physician with a profitable, time efficient way to add spinal exercise to the patient’s treatment plan.

This online seminar is set up to provide the practitioner with a simple, comprehensive, step-by-step method by which a chiropractor can add an in-office, spinal exercise program to their clinic. This seminar will make the implementation of a spinal exercise program easy for you and your staff on Monday morning.

The class is set up to give the chiropractor a thorough working knowledge of a spinal exercise program/class.  It will give the practitioner the tools and know how to develop the case management protocols to determine the clinical necessity for a spinal exercise program for each patient. We will give you some parameters to determine if and when the patient is ready for the class, along with the basics on how to prepare your patients for a program/class on spinal exercise, and give the practitioner a general look at potential forms that may be used for a program/class of this nature. It will also prepare you and your staff for the adding of this type of a spinal exercise program/class to your schedule in a time efficient way, and answer as many of the various questions you may have so as to assist you in this process.

Spinal exercise rehab should be an integral part of the patient’s treatment protocol.  Many of the various spinal problems that occur in a patient’s case are negatively impacted when inadequate spinal muscle strength, power, and endurance are present.  If lack of flexibility, dynamic joint instability, or incorrect biomechanics and poor muscle control were important factors in the etiology of the injury, and we do not address these through spinal exercise rehab in their treatment plan, we limit their ability to heal, and very often will add to their length of time it takes to heal.

Very often in the busy chiropractic practice, it is difficult to address spinal exercise rehab on a one-on-one basis, so a spinal exercise rehab program/class offers a viable option to meet your patient’s needs and yet not take away from your precious time as a physician. 

The time and setting of the class can allow for a relaxed atmosphere that is an attractive way to insure patient compliance with this type of class. I also recommend you either add something to drink or eat prior to the class so that the patient will not be distracted from the information that you will be giving them.  A popular time to perform this class can be at the lunch hour, and with the addition of food can make a positive substitute to their typical routine. It can also serve as a way that you and the staff can have a business lunch on the class.  Tax write-offs are a welcome thing in whatever appropriate manner we can obtain them.

It will take a certain period of time to properly implement this type of class, and it will be wise to have a laid out timeline to help you prepare for your first class.  You may desire to break up the responsibilities of certain portions of the class to your various staff members, for instance you as the physician will be best suited to plan out the various spinal exercises that you desire to teach, while your staff may handle the arrangements for food, copying of various forms, the scheduling of the patients, the preparation of the classroom, an explanation of any fees that are needed to be collected or filed with insurance.

You as the physician will need to make it a habit to prescribe the spinal exercise class to those who have need.  This is best to be coupled with the objective findings that you have found in the various evaluations that would support such a class, for example, limited range of motion, weakness of various muscle groups, loss of various spinal curves and spinal segment integrity of the spine on radiographs, noted muscle atrophy, and any associated trigger points that may be present.  As you form the patient’s initial treatment recommendations or an update recommendation for the patient, this prescription should be added as the patient shows need and sufficient progress to be able to handle this type of care, but you as the physician need to pay close attention to the objective findings and the progress that the patient is making to help you determine when you should make a prescription for such a class as this.  As you become more sensitive to the patient’s ability to handle exercise within a given patient case management plan, then prescribing this will be just an extension of the natural progress in care. 

The class does require some space, but very often there are places in the community were you may deliver such a class.  Wherever you plan to set up the class, you may find it is an opportunity to reach out to the community, and have a spinal exercise class for individuals that are not your patients, but are just interested in improving their spinal health.  Some attention should be taken with the individuals that are interested in taking such a class, because with any type of exercise, you always have a risk of injury for wide range of reasons.  If you have adequate space in your practice, it may only require a slight moving around of the furniture for adequate space.  Another factor that you will need to consider is the number of patients that you can handle taking through the various spinal exercise procedures, and the financial remuneration from this number.  In a class such as this, it may be wise to have additional assistance from a certified trainer/s that way, the trainers will be able to fine tune the positioning of the exercises while you explain them.

Overall, this type of class will give you real strength, no pun intended, to prepare your patients for spinal exercise rehab.  It will also create a basis from which your patients may be able to ask of you, the physician any questions, either in the class or in future appointments relevant to spinal exercise rehab.  You may desire to break down this class into an upper body, cervical/thoracic section and a lower body, lumbar/sacroiliac section.  The many options you will have will almost be limitless, and give you better patient management overall.

A Review of the Basic Anatomy of Skeletal Muscles

“Over 600 muscles make up nearly half of the weight of the human body.”1 Of the 600 muscles, there are quite a few that make up the neck, low back, thoracic, pelvis and leg, some of these include:  

In the Posterior Aspect of the Neck and Thoracic Spine

Superficially: Trapezius,   Splenius Capitus, Semispinalis Capitus, Splenius Cervicus, Rhomboideus Minor, and Romboideus Major 

Deep: Rectus Capitus, Superior Oblique,

Inferior Oblique, and the Levator Scapula

In the Anterior Aspect of the Neck

Sternocloidomastoid, Scalenus, Sternohyoid, Omohyoid,and Platysma

In the Anterior of the Thoracic / Lumbar Spine

Rectus Abdominis, Internal Oblique, and External Oblique

In the Anterior Aspect of the Upper Leg

Quadratus Femoris, Vastus Lateralis, Vastus Medialis, Sartorius, Gracilis, Adductor Longus, Adductor Brevis, Pectineus, and Iliopsoas

chart #1

chart  #2

In the Posterior Aspect of the Thoracic spine

Erector Spinae, Latissimus Dorsi, Spinalis, Thoracis, Romboideus Major, Longissimus Thoracis

In the Posterior Aspect of the Low Back

Erector Spinae, Latissimus Dorsi, Gluteus Maximus, Gluteus Minimus, Piriformis, Gemellus Superior and Inferior, Internal Obturator, Quadratus Femoris,

chart#3

In the Posterior Aspect of the Upper Leg

Biceps Femoris, Iliotibial Band, Semitendonous, Semimembranous, Adductor Magnus, Gracilis, Vastus Lateralis

In the Posterior Aspect of the Lower Leg

Gastrocnemius, Soleus, Peroneus Longus, Extensor Digitorum Longus, Achilles Tendon, Popliteus, Peroneus Longus, Peroneus Brevis, Tibialis Posterior, Plantaris, Flexor Digitorum Longus,Flexor Hallucis Longus

  

chart #4

 For all intensive purposes, we will not be referring to the muscles individually, but we will make reference to them either as groups of muscles or as a single muscle that represents the group of muscles.  As we try to convey concepts to our patients, it can get very confusing to them if we utilize each individual name for the muscles, for example just try to remember how confusing it was in the anatomy lab in school how difficult it was trying to figure out which muscle was which.

Muscle Structure: [skeletal muscles consist of densely packed groups of elongated cells known as muscle fibers held together by fibrous connective tissue.

Chart 5

Numerous capillaries penetrate the connective tissue to keep muscle supplied with the abundant quantities of oxygen and glucose needed to fuel muscle contraction.” The threadlike cells of the muscle fibers can be up to 1 foot long. Within these muscle fibers you have myofibrils that are thinner fibers which are made up of both thick and thin contractile myofilaments. The myofilaments in each myofibril are divided transversely by Z bands along the length of the muscle fiber into units called Sarcomeres. It is through these units that neural impulses stimulate contraction. Each thin myofilament consists mainly of actin, a protein, and tropomyosin, another protein that can inhibit contraction. Along each tropomyosin molecule is a complex of three globular protein molecules called troponin.  The thick filament’s main component is the protein myosin. Myosin molecules look rather like golf clubs, with their long tails and oval – shaped heads.]2

Muscle Contraction: [in a relaxed muscle the thick and thin filaments overlap a little.  When a muscle contracts, the thick filaments slide farther in between the thin filaments, rather like interlacing fingers, and draw closer to the Z bands.  This action shortens both the myofibrils and the entire muscle fiber.  The more shortened the muscle fibers are, the greater the contraction in the muscle as a whole.]3

Chart # 6&7

Clinical Case Management

To determine the clinical necessity for a spinal exercise class for a specific patient, the physician should be performing various evaluations throughout the examination process. This examination process would include the initial exam, any follow-up exams, daily soap note evaluations that went along with the recommended treatment, and any special diagnostic evaluations. The actual need is based on your clinical findings from your examinations. The AMA Guides to the Evaluation of Permanent Impairment fifth edition state (in the) “physical examination of non-musculoskeletal areas, (and) since a targeted neurologic assessment is needed for individuals with back and neck problems, the physician must have a good grasp of basic neurologic examination techniques and principles.  Guided by the history, the physician should focus on spine-related physical findings, such as range of motion, reflexes, muscle strength and atrophy, sensory deficits, root tension signs, gate, and the need for assistive devices.”5 Under this guide, and with a focus of our topic being presented, we will put our attention on the portions of the evaluation that will be assistive in determining when a spinal exercise class would be merited.  When performing your initial exam, a visual range of motion procedure should be performed.  The cervical spine and the lumbar spine should be evaluated. When evaluating other various joints of the body that you desire to offer a spinal exercise class for, you would need to do a range of motion study of that associated area.  For example, if shoulder exercise is a joint that you plan on covering, you would need to have a baseline visual range of motion study of the shoulders for each patient that you plan on having attend the class.  For all intensive purposes, I am going to stick to the evaluation, prescription, and implementation of a spinal exercise program that is limited to the cervical, thoracic, and lumbar spines. Once a visual range of motion study has been performed, and restrictions, pain, and alterations to the smooth arc motion have been noted, a dual inclinometric evaluation to determine the specific amount of restrictions would be merited.  The AMA guides state “when measuring range of motion, the examiner should obtain at least three consecutive measurements and calculate the mean (average) of the three.  Measurements should not change substantially with repeated efforts.  If the average is less than 50°, three consecutive measurements must fall within 5% of the mean; if the average is greater than 50°, three consecutive measurements must fall within 10% of the mean.  Motion testing may be repeated up to six times to obtain three consecutive measurements that meet these criteria.  If after six measurements inconsistency persists, the spinal motions are considered invalid.  The measurements and accompanying impairment estimates may then be disallowed, in part or their entirety.”6 This gives us some food for thought clinically, an inclinometry study that is performed on your patients by various assistants or you as the physician adds in the potential for readings/measurements that won’t be considered clinically diagnostic.  There are tools on the market that will only take readings that fit this AMA criteria.  Examples of these may include the Myo-logic and J-tech. Inclinometric devices.  Infrared units that do not have cumbersome wires makes it easier to perform the evaluations.  I am not supporting any specific company or product, but only wish to give you some ideas to consider when purchasing such a unit.  The value of doing this procedure not only gives you very strong evidence for the clinical necessity of a flexibility class, but it also is a billable procedure.  The ICDM code for this procedure is 95851. You may need to refer to the new ICD10 coding for any changes that may have occurred as a result of the implementation of these new codes. Typically a report is sent in conjunction with this procedure.  Very often in units like the ones mentioned above will print out a report for you, and will reduce the required time that it would take you to produce such a report.  A

– 59 modifier code may be needed to accompany this code if you are performing this procedure in conjunction with other non-E/M services on the same day. The – 59 modifier indicates to the insurance company that the procedure is separate and distinct from other procedures you perform on the same visit.

Upper and lower extremity manual muscle grading is another evaluation that you would want to perform in either your initial evaluation or update evaluations.  The information you gain will give you an idea if the patient has any neurological deficit, muscular wasting/atrophy, or muscular facilitation/limitations which could be affecting their overall strength, power, endurance, and spinal stability overall.  Subjective resistive muscle strength analysis using the AMA guides to grading for example 0-flaccid to 5-normal will be important in determining the need for spinal exercise class.  A score of three or four in any individual manual muscle strength evaluation is sufficient to also establish a clinical necessity for comparative electronic/computerized muscle testing.  Studies have shown that a muscle strength loss of 30% is needed before the average practitioner will detect a difference.  Once again with a procedure like this, you as the practitioner will see a more accurate determination of the various muscular weaknesses noted. With these devices intra-examiner reliability can still be a problem, because of the general placement of the unit on the patient.  Great attention and care should be taken when considering a device of this nature.  Some devices will have a built-in accuracy based on the percentages allowed in the variableness of the consecutive contractions taken for a specific muscle.  This will reduce some of the intra-examiner reliability problems and improve your ability as the physician to evaluate muscle strength.  As a practitioner it is always more valuable to have as specific clinical information as we can according to the tools available to us.  With that said another value to this procedure, is that this is also billable to insurance, and the ICDM code for this procedure is 97750.  A report should also be sent with such a procedure, and the – 59 modifier code may also be noted if you are performing other procedures in the same visit.  Remember the – 59 code indicates that you are doing a separate and distinct procedure from any other procedures being performed on that same visit.

We are not trying to cover the entire evaluation procedure that you as the physician will be performing on your patients, but are only focusing on examination procedures that will be assistive to you in determining the clinical necessity for a spinal exercise class.

Radiographic evaluation is another method to determine the clinical necessity for a spinal exercise class.  In review of the cervical, thoracic, and lumbar radiographic evaluations, certain findings are consistent with the need to recommend a spinal exercise class.  These findings include a loss of curvature on the lateral x-rays in either the cervical or lumbar spine.  Other findings as noted on the APLC, APT, or APL spinal x-rays views would include any lateral list or scoliosis noted in the spine.  The most definitive radiographic findings in regards to recommending a spinal exercise class is noted on the lateral flexion and lateral extension radiographic views of either the cervical or lumbar spine.  This finding is also noted in the AMA Guides to the Evaluation of Permanent Impairment the fifth addition.  The finding is known as “loss of motion segment integrity.”  Any translation of the vertebrae in the lateral flexion or lateral extension view either posteriorly or anteriorly in regards to the vertebrae above it or below it may be indicative of a loss of motion segment integrity at those vertebral segment levels .  The AMA guides more definitively qualify the specifics on what amount of translation of the vertebrae is actually considered to be a loss of the motion segment integrity.  A motion segment of the spine is defined as two adjacent vertebrae, the intervertebral disc, the apophyseal or facet joints, and the ligamentous structures between the vertebrae.7  Loss of motion segment integrity is defined as an anterior to posterior or posterior to anterior translation of one vertebrae over another that is greater than 3.5 mm in the cervical spine, greater than 2.5 mm in the thoracic spine, and greater than 4.5 mm in the lumbar spine.8 Does this mean that any translation less than this amount is clinically insignificant?  I do not believe this is the case, but great care should be taken to correlate all the clinical findings including the ones noted above when determining the clinical necessity for a spinal exercise class. When the amount of translation is less than the parameters for the definition of a loss of segment integrity, the amount should still be noted in the patient’s records.  Another factor that also should be taken into consideration is timing, when should the patient be involved in a spinal exercise class?  If an amount greater or even equal to these figures is noted, then it would be wise to wait on recommending a spinal exercise class to the patient, until additional radiographic studies are performed with your associated update examinations.  If the newer radiographic studies show sufficient improvement along with possible positive changes to their various pain scales, for example, neck pain disability index, Oswestry low back pain index and the other examination findings then at that time a spinal exercise class may be indicated.  You as the physician will need to correlate all the findings to determine the most appropriate time for such a class for the patient.

These are the only clinical findings that we are going to utilize to determine the clinical necessity for a spinal exercise class for your patient.  It does not mean that other findings cannot assist you in determining the clinical necessity for such a class, but these findings are very definitive and assistive for you the physician to determine your patient’s needs in this matter.

ICDM Coding for a Spinal Exercise Class

At this time for the spinal exercise class we will cover the actual coding process that you can use for patient reimbursement.  The nice thing about this is that the coding is pretty straightforward.  [The code that you would want to use is 97150 which is therapeutic procedure(s), group (2 or more individuals). According to the 2008 16^th Annual Chiro Code Desk Book this type of therapeutic procedure/s include CPT codes 97110 – 97139.  If any of these procedures are performed with two or more individuals, then only 97150 is reported.  Do not code the specific type of therapy in addition to the group therapy code.]9 Group therapy procedures involve constant attendance of the physician or therapist, but by definition does not require one-on-one patient contact by the physician or therapist.

The other portion that we must consider with coding is time.  [In 2000 an effort to control fraud and abuse of costs, CMS adopted a policy of rounding to the nearest 15 minutes.  Accordingly, 8 to 23 minutes of hands on care would be considered as 1 – 15 minute unit of care, 24 to 38 minutes would be two units, etc. so with the class, you may very well be looking at anywhere from two to four units of the 97150 code.]10 Each insurance company will have its own limitations, so it is wise to determine how they would handle this.  For example, some insurance companies may only cover two units of the 97150 code, so you may be required to only code for the two units.  It is best when doing your first verification for insurance to ask about such a question, and then you can note it in the patient’s file, and this will help with your future communications with the insurance carrier especially if there is ever a question you have it documented.  As a matter of habit, you may desire to tape any or all of your insurance phone verifications so that the specifics of your communication\questioning may be established at any time in the future. Also proper documentation in the patient’s file is required for any time-based codes, so you’ll want to make sure that you document the time, date, location, and any physician to patient encounters or communications.

[The RVU of 97150 is .48; to give you a comparison that has real merit to compare to, 98940 which has a RVU of .68.  The typical therapeutic exercise code of 97110 has a RVU of .76.]11 You may look at the RVU of the 97150 code and think the value of it is not worth it, but if you’re adjustment charge for the 98940 code is $45, than the approximate value of the 97150 code would be approximately $30.  This is only an example, and you would need to determine your fee schedule based on your region and unique circumstances.  When establishing your fee structure for this type of procedure it will be wise in considering these RVU comparisons.  The profit or advantage for you will be the fact that you are not able to give a thorough class without spending anywhere from 30 minutes to two hours, so multiple units of the 97150 code would be used in this manner.  The other advantage of the class setting is that you can make it a specific time with a specific number of patients that way your efficiency is greatly increased and you’re not trying to fit all this information about flexibility into a small bite of time in the patient’s regular visit. A cash basis setting works well with this, also because it can be easily put into the overall treatment plan, and be added to any prepayment savings that you have. You may want to refer to your state chiropractic board to determine any parameters regarding to any discounts in your fee structuring.

When you consider utilizing the DVD either in conjunction with a spinal exercise class, or separately by itself, the code that you would want to utilize is 99071

“Educational supplies, such as books, tapes, and pamphlets, provided by the physician for the patient’s education at cost to the physician” 12

There are a few codes that you may be tempted to utilize, [97110 is a therapeutic procedure code that by definition is to develop strength and endurance, range of motion and flexibility, in one or more areas, and is also a time-based code.  Therapeutic exercise incorporates one parameter (strength, endurance, and range of motion or flexibility) to one or more areas of the body.  Examples include, treadmill (for endurance), iso-kinetic exercise (for range of motion), lumbar stabilization exercise (for flexibility), and a gym ball (for stretching and strengthening).]13 While this procedure\code would seem that it fit perfectly, the problem lies in that it requires one on one patient contact by the physician.  In a group setting you will not have direct one-on-one patient contact by the physician in a mode where you can either log the time or specifically document this.

The 97110 code is a good code for any follow-up visits with the patient on a one-on-one basis.  You may need to go over the individual muscle group strengthening procedures with the patient on either a special delineated appointment of this nature or this could be incorporated into your visit of which other treatments including an adjustment, therapy, activities of daily living, or even a re-examination.  Depending on how in-depth you want to get with your recommended treatment plan, you may want to build this component as a follow-up with the patient to insure compliance, and proper technique.  Since this code is a time-based code, the same principle of one unit being equivalent to 8 minutes to 23 minutes of one-on-one patient and physician time.  This needs to be documented to be established.  If your time is less than eight minutes with the patient, for example the patient has some questions on two or three different strengthening procedures, and it only takes you short period of time to go over it with them.  It is necessary for you to code a – 52 modifier which basically states that you are doing less than a full unit of this code.  You’ll still need to document the time in the patient records, and this code usually comes with a reduced rate. 

The 97112 code is another code that you may be tempted to use. [The code is for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture , and\or proprioception for sitting and\or standing activities in one or more areas. An example includes proprioceptive neuromuscular facilitation (PNF)].14

The 97112 code is also a one-on-one patient and physician code, so because you will be in a group setting this code would not be the recommended code for such a circumstance.  Again if in future visits you desire to make any clarifications, increased patient compliance, answer any patient questions, or further delineate any specific strengthening procedures, this code may be utilized. 

There is only one exception that I have seen in clinical practice, if when you are initially verifying insurance, and the insurance company states that they do not cover the 97150 code, you’ll need to ask if either the 97110 or the 97112 code may be utilized in place of the 97150 code.  It would be wise to explain exactly the setting of the spinal exercise class.  It would also be wise to be taping the verification process in this situation.  That way there is no question in the communication process.  You also would need to determine based on your spinal exercise class type, for example whether you plan on teaching just spinal exercise and / or aerobic exercise to the patient so that you’ll know whether you should utilize 97110 and /or 97112.  The Chiro Code Desk Book can be a good resource to assist you in this manner.  The board of chiropractic examiners in your state and/or chiropractic association in your state will be another great resource in this area.  It’s much better to find out advanced any limits or restrictions that may apply.

When the patient comes in for their initial visit, and you’re verifying their insurance, it can be very helpful for you to add this additional component to an initial verification form when determining if this service is a covered charge.  This will assist you in determining how you will communicate to the patient their financial responsibility.

Since the implementation of the ICD10 codes there may be changes to these codes, so you will need to contact your board or association to determine any new codes that are necessary for such a class setting.

Spinal Exercise Training

[A common definition of therapeutic exercise is a prescription of bodily movement that tends to correct an impairment, improve a musculoskeletal function, or maintain a state of well-being.  Such an exercise may vary from mild to vigorous, from general activities to highly selected activities restricted to specific muscles and actions.  Therapeutic exercise prescribed without competent patient evaluation, diagnosis, and based upon an understanding about mechanics may be inadequate if not detrimental to the patient.]15

There are four components of muscle conditioning:

1. Muscle strength
2. Muscle power
3. Muscle endurance
4. Motor re-education

[Strength is the maximum tension that can be exerted during muscle contraction.  Endurance is the ability to contract the muscle for an extended period of time.  Power is the rate of work accomplished per unit of time.  Thus, power rather than strength is the better index of muscular function.]16

[Increase strength of the muscle fiber and its hypertrophy is the result of the stimulus from tension during contraction.  Maximum tension is most effective in causing an increase in strength, yet the time factor is insignificant. (For example,) A 6 second contraction is equal to a 45 second contraction as far as strength development is concerned.  One maximal tension of each muscle fiber per day creates an adequate stimulus to increase strength; however, during complete inactivity, strength is lost at the rate of 5% a day.  During progressive resistance exercise, a 5 repetition bout at 50% of 10 maximum repetitions and a 10 repetition bout at 100% of 10 maximal repetitions appear to be equally as effective as more sophisticated progressive exercise regiments.]17

[Endurance exercises, conversely, our low resistance and high-repetition exercises (hundreds of time each day until fatigue is reached).  The load should be between 15% and 40% of maximal strength.]18

[Muscle that function under no-load, even if they are exercised for hours upon end, increase little in strength.  At the other extreme, muscles that contract at or near their maximal force of contraction will develop strength very rapidly even if the contractions are performed only a few times each day.  Experiments on muscle building have shown that six maximal or nearly maximal muscle contractions performed in three separate sets three days a week give approximately optimal increase in muscle strength and without producing chronic muscle fatigue.]19[… Muscle strength increases about 30% during the first six to eight weeks but reaches a plateau after that time.  Along with this increase in strength is approximately an equal percentage increase in muscle mass, which is called muscle hypertrophy.]20  [Most of the hypertrophy results from increased diameter of the muscle fibers, but this is not entirely true because greatly enlarged muscle fibers can split down the middle along their entire length to form entirely new fibers, thus increasing the number of fibers as well.]21

[The changes that occur inside the hypertrophy muscle fibers themselves include 1. increased numbers of myofibrils, proportionate to the degree of hypertrophy; 2. increased numbers and sizes of mitochondria; 3. as much as 25 to 40% increase in the components of the phosphagen metabolic system, including both ATP and phosphocreatine; 4. as much as 100% increase in stored glycogen; and 5. as much a 75 to 100% increase in stored triglyceride (fat).  In addition, the enzymes required for the oxidative metabolic system are increased, increase in the maximum oxidation rate and efficiency of the oxidative metabolic system as much as 45%.]22

[All muscles have varying percentages of fast twitch and slow twitch muscle fibers.  For instance, the gastrocnemius muscle has a higher preponderance of fast twitch fibers, which gives it the capability of very forceful and rapid contraction of the type used in jumping.  On the other hand, the soleus muscle has a higher preponderance of slow twitch muscle fibers and therefore said to be the muscle that issues to a greater extent for prolonged lower leg muscle activity.  The basic differences between the fast twitch and the slow twitch fibers are the following:

1. Fast twitch fibers are about two times as large in diameter.
2. The enzymes that promote rapid release of energy from the phosphagen and glycogen – lactic acid energy systems are two to three times as active in fast twitch fibers in comparison to slow twitch fibers, thus making the maximal power that can be achieved by fast twitch fibers as great as two times that of the slow twitch fibers.
3. Slow twitch fibers are mainly organized for endurance, especially for generation of aerobic energy.  They have far more mitochondria than the fast twitch fibers.  In addition, they contain considerably more myoglobin, a hemoglobin-like protein that combines with oxygen within the muscle fiber; and even more important, myoglobin increases the rate of diffusion of oxygen throughout the fiber by shuttling oxygen from one molecule of myoglobin to the next.  In addition, the enzymes of the aerobic metabolic system are considerably more active in slow twitch fibers than in fast twitch fibers.
4. The number of capillaries per mass of fibers is greater in the vicinity of slow twitch fibers than in the vicinity of fast twitch fibers.

In summary, fast twitch fibers can deliver extreme amounts of power for short periods of time.  On the other hand, slow twitch fibers provide endurance, delivering prolonged strength of contraction over much longer periods of time.]23

[Two basic principles of muscle conditioning are: 1. Specific adaptation to impose demand (SAID) 2.  Overload]. In “Specific Adaptation to Imposed Demand”, the training program must attempt to adapt the individual to the demands imposed during performance.  The strengthening program should be specific to the type of injury and the demands of the sport.  The type of muscle contraction and the speed and intensity of exercise will cause specific training affects.  If a patient exercises at submaximal levels, for a lengthy period of time, the recruitment of motor units will be limited to slow oxidative fibers in contrast to high intensity, brief bouts of training that recruit mainly fast twitch motor units.  Specificity of function means that in the more advanced stages of rehabilitation, the athlete/ (patient) must simulate the task required in the sport / (activity) to ensure optimal neural patterning and correct timing of all the muscle groups involved in the action.

In the principle of overload, a muscle must be overloaded in order to gain increases in strength, power or endurance.  Muscle is constantly being broken down and resynthesized.  With stress, muscle will adapt to the increased loading and become stronger, more powerful or developed improved endurance, depending on the nature of the stress.  A muscle can be overloaded in a number of ways:

1. Increase the speed of movement
2. Increased resistance
3. Increase the number of repetitions
4. Increase the frequency or duration of workouts
5. Decrease the recovery time between workouts
6. Alter the form of exercise
7. Alter the range through which a muscle is being worked

The most common error in muscle conditioning is doing too much too soon.  A high repetition, low resistance regimen should be used initially.  A gradual progression to a low repetition, higher resistance program performed less frequently as progress is made. As function and strength improve, progression to faster, functional and eccentric exercises may be beneficial in the advanced stages.]24

[As rapid strength gains occur before hypertrophy occurs, initial improvement in strength in response to exercise is thought to be related to increased neuromuscular facilitation.  The following factors will help maximize strength gains during rehabilitation:

1. Adequate warm-up to increased body temperature and metabolic efficiency
2. Good control performance of the exercise
3. Pain-free performance of exercise
4. Use of a slow, pain-free pattern initially with little or no resistance to develop a good base for neural patterning to occur
5. Comprehensive stretching program to restore/maintain full range of motion
6. muscle strengthening throughout the entire range of motion available]25

The three main types of exercise used in muscle conditioning are:

1. Isometric 2.  Isotonic 3.  Isokinetic

[An isometric exercise occurs when a muscle contracts without associated movement of the joint on which the muscle acts.  Isometric exercises are often the first form of strengthening exercise used after injury, especially if the region is excessively painful or if the area is immobilized.  They are commenced as soon as the athlete / (patient) can perform them without pain. … Ideally, isometric exercises are held for 5 to 6 seconds with the rest of 10 to 20 seconds.  They should be performed frequently during the day in sets of 10 to 20 repetitions.  The number of sets will vary at different stages of the rehabilitation program. The quality of exercise is more important than the quantity.  Isometric exercises should be carried out at multiple angles if possible, as strength gain is fairly specific to the angle of the exercise with approximate 15% overflow effect on either side.]26

[Isotonic exercises are performed when the joint moves through a range of motion against a constant resistance or weight. Isotonic exercises may be performed with free weights, such as dumbbells or sandbags or with weight devices.  The use of free weights has a number of advantages.  Exercises with free weights result in strengthening of both the primary and synergistic stabilizing muscles as well as providing stress on ligaments and tendons.]27

Isotonic exercises may be:

[Concentric-a shorting isotonic contraction in which the origin and insertion of the muscle’s approximate.  The individual muscle fibers are shortened during concentric contraction.]28

[Eccentric-a lengthening isotonic contraction where the origin and insertion of the muscles separate.  The individual muscle fibers are lengthened during eccentric contraction.]29

[Isokinetic exercises are performed on devices with a fixed speed and a variable resistance that is totally accommodative to the individual throughout the range of motion.]30 For this final exercise class, we will not be recommending this type of exercise due to the nature and type of apparatus/machine that is required

We have covered a lot on the components of muscle conditioning and exercise, but now we will focus on giving you the physician direction on how to bring it all together in a class setting.  If you desire to get more in depth relevant to muscle exercise physiology, injury rehabilitation, sports exercise, and topics of this nature you may desire to go online and Google the topics that are of interest to you.  In regards to the material that we’re about to cover, and the exercises that are given, you may be able to obtain this software through our website for a discounted price, or you may visit their website at Phases Rehab. It is our desire to give you the tools you need at the most affordable price, so you are able to start and maintain a class of this nature in your office. 

The next four pages will cover who should perform spinal exercise, when, why, and how to exercise in this program.  The pages will also cover the spinal exercise initially, the progression of spinal exercise, the maintenance portion in a spinal exercise program, and some additional information on how both aerobic exercise fits and spinal flexibility also fits in.  The next two pages will help you document for the insurance carrier and your patient’s file the specifics that you performed a spinal exercise class with the patient, and you even have an evaluation sheet where the patient can give you positive feedback on how your presentation came across to each patient.

SPINAL EXERCISE

Who Should Perform Spinal Exercise

You have been prescribed this program because your spinal problems are such that you’d benefit from strengthening the various regions of the spine.  It also means that your present spinal condition has responded well enough to be ready to perform spinal exercise on a regular basis.   Although each person would benefit from having a stronger spine, not every individual can handle a spinal exercise program, so please inform your physician if you have any increased episodes of pain or new symptomatology either while you’re doing the exercises or at a later time after you have completed the exercises.  In this case, your spinal conditions may need to progress further prior to you continuing with this program.

Note: If you have had any recent physical problems or surgery, particularly of the joints and muscles that you have not told your physician about, or if you have been inactive or sedentary for some time, please consult your physician before you start a strengthening program.

When to Exercise

Spinal Exercise is best performed after you have stretched and prepared your muscles for activity. If you have not been through the flexibility class/DVD, it will be important for you to obtain some instruction on how to safely and correctly perform various spinal flexibility exercises.  Once you have had opportunity to stretch and adequately prepare your muscles for exercise, then you’re ready to perform the various spinal exercises recommended. 

Why Exercise

Exercise will help you in a wide range of ways.  Not only will it help you feel stronger overall, but the aerobic exercise will also assist you in having a better level of energy, and an overall feeling of well-being.  It will also:

–    Assist you in stabilizing the spine and previously damaged joint and soft tissue structures

–    Help to reduce various pain syndromes

–    Increases range of motion, by creating a balance in the associated muscle structures.

–    Increased power and strength in the associated muscles

–    Make daily activities easier due to increased stamina/endurance in the muscles

–    Decrease joint degeneration from increased muscular stability of the joint

–    Exercise helps reduce depressive episodes

–    Promotes circulation.

–    It feels good.

–    Aerobic exercise improves cardiovascular health

–    Increases fat metabolism and thus helps in weight management

–    Improves your daily physical performance.

How to Exercise

There are certain specifics that you will need to pay attention to as you perform the various spinal exercises, so no further irritation or damage is caused to the associated spinal structures, muscles,  ligaments, and soft tissue by improper positioning in the various exercises we will cover in this program:

–    Do not ascribe to the thought that “no pain no gain.” The various spinal exercises should not 

   cause pain.

–    Any exercise that causes pain should be stopped and then communicate this fact to your  

   physician.

–    Don’t add any additional number of sets of exercises until you are able to perform the number of

    sets that you are at without pain for at least five consecutive exercise sessions.

–    Pay attention to the proper positioning of each exercise

–    Each exercise should be performed in a smooth rhythmical motion, no jerking or quick motions,

   don’t rush thru the exercises it may cause further injury to the spinal structures

–    Give yourself at least 20 to 30 seconds between each set of exercises

–    Make sure you breathe continually while doing the exercises, don’t hold your breath

–    Listen to your body “Review the Overtraining Syndrome” handout

–    Finish with another period of spinal flexibility

SPINAL EXERCISE INITIALLY

When you begin to exercise, assume the proper starting position, then perform one set of 8 to 10 repetitions of each exercise, with at least a 20 to 30 second rest between each exercise. If you have pain in any specific exercise, discontinue that specific exercise until you talk to your physician, then go on to the next exercise in order. Perform these exercises three to five times per week. 

SPINAL EXERCISE PROGESSION

As you continue to perform the various exercises daily, and once you are able to perform each exercise with no pain for one complete week of exercise, then you should add an additional set of 8 to 10 repetitions of each exercise to your spinal exercise workout. When you increase the number of sets to two sets of each exercise, then again when you reach a point where you have no pain in each exercise for one week, then add a third additional set of 8 to 10 repetitions each exercise to your workout. Continue adding an additional set of each exercise until you are able to perform three sets of each exercise without pain. 

SPINAL EXERCISE MAINTAINENCE

Once you have reached three sets of each exercise without pain for one month, then you can consider yourself to have reached a point of stability.  Like any exercise, if you quit you will lose the ground you’ve gained after a period of time.  From this point it is best to continue the various spinal exercises, but you may desire to vary the number of repetitions in each set, or either increase or decrease the number of overall sets, and/or increase the amount of tension/resistance that you utilize in each exercise.  This helps reduce the accommodation of the muscles to the exercises.  Accommodation is the process by which your muscles get use to the various loads that are put on them and thus the positive return that you once noted with spinal exercise will level off.  By varying the number in each set, or the number of sets, or the resistance/tension in the rep you will reduce the likeliness of the accommodation process.

AEROBIC EXERCISE

When you couple the spinal exercises with an aerobic exercise component, you will see a tremendous increase in the progress you see. You’ll also see many added benefits to your endurance/stamina, cardiovascular health, and you’re overall well-being.  You should follow the structure and goals that are set out on the “Aerobic Exercise” handout.  It is also recommended that you perform the aerobic exercise on a schedule 3 to five times per week.  You may find it easier to perform the aerobic exercise on one day, and then perform the spinal exercise on the next day.  Alternating these components of the exercise program will help to keep it interesting and less taxing on you.

SPINAL FLEXIBILITY

Spinal flexibility is an essential component of the spinal exercise program.  You should perform spinal flexibility procedures before and after you perform your spinal exercises and aerobic exercise.  Because flexibility is an elongation of a muscle and exercise is a contraction of the muscle, or a shortening of the muscle, it is important to stretch before and after exercise.  Another consideration is that when you exercise you increase the oxygen to the muscles so you will feel more relaxed after you exercise, but again since you’re exercising or shortening the various muscles you are in more of a contracted state, so after exercise with the increased oxygen in the muscle it is an optimal time to stretch.  With this being the case, it is helpful to stretch twice as long immediately after you have exercised.

GROUP FLEXIBILITY / SPINAL EXERCISE CLASS

 

PATIENT: _________________________________________________

 

Date of Class: _____________________________File#: ___________

 

Time: from _________ to __________

 

Total # of 15 min units of 97150 ____________ (group therapeutic exercise) 

In efforts to insure proper handling of your health related conditions please read the below statement and sign at the bottom of the page.

I attended this group flexibility class for the time mentioned above and the information about who should stretch, when to stretch, why to stretch, how to stretch has been gone over and I understand the information presented.

The individual stretches were presented to me and demonstrated so that I understand how to properly perform these at home, also any questions I had were answered to my satisfaction.

I also understand if I have any further questions relevant to this material, I may ask them in any future appointments that I have with the clinic.

 

Signed: ______________________      Dated: ______________________

EVALUATION

Group Flexibility / Exercise Class

LECTURE SERIES

 

NAME: __________________________TELEPHONE: ____________________

 

ADDRESS: ______________________________________________________

 

CLASS ATTENDED: _______________________________________________

 

DATE: ___/___/___

Did you enjoy the class? ____________________________________________

Did the presentation keep your attention? _______________________________

Would you like to attend another class on a different topic if it were offered?

CIRCLE:    nutrition weight loss painmanagement

 spinal exercise/strengthening  Flexibility   Aerobic exercise 

What would you change in the presentation if you could?

___________________________________________________________________________________________________________________________________________________________________________________________________________________

What were the strong points of the class for you? _________________________

________________________________________________________________________________________________________________________________

Overall on a scale from 1-10 (1-3 poor, 4-7 average, 8-10 excellent), how

would you grade the class presentation today? ___________________________

Would you like us to contact you when one of the classes are presented?  

YES / NO

Spinal Exercise Log
Exercise Name	Date	#of sets	Pain		Spinal	Spinal
		8-10 reps	Yes	No	Pre Flexibility	Post Flexibility

 

The next four pages will cover some specific exercises that you will find helpful in developing your spinal exercise program / class. These exercises you may find in the Phases Rehab computer program that you may obtain online at Phases Rehab.

Aerobic Exercise

Aerobic exercise is also an important key in an effective spinal exercise class.  It may be seen as an optional portion of the class, but if ignored it could lead to many complicating factors in the patient’s efforts to obtain a more stable spine through spinal exercise.

Why is this the case?  Well, let’s first take the fact that each of our patients come in to the office in many different various levels of health, and if we do not take this into consideration, we may be assuming that their level of health is adequate to do exercise when in fact it is not.

[Cardiac failure falls into three physiological classifications  low cardiac output, pulmonary congestion, and systemic congestion. Low cardiac output usually occurs immediately after a heart attack. If the attack is mainly right-sided, this may be the only symptom.  If the acute heart attack is mainly left-sided, concurrent pulmonary congestion almost always occurs along with the low cardiac output.  Symptoms include, generalized weakness, fainting, and symptoms of increased sympathetic activity such as high heart rate, thready pulse, cold skin, and sweating.  Systemic congestion can occur alone in pure right-sided heart chronic heart failure.  In this condition there is no pulmonary congestion, and if sufficient fluids have been retained in the blood to prime the heart sufficiently the heart may pump a normal cardiac output.  Obviously, all these classes of heart failure can occur together or in any combination.]31

This is not a class on determining cardiac failure or insufficiency, but by understanding the fact that the various patients that may come in have a wide range of cardiac health, and this class being focused on exercise we must take this into consideration. As the treating physician, we need to determine whether the patient can actually handle a program of this nature.  In light of this along with the above-noted paragraph we will consider a topic known as “cardiac reserve.”  [The maximum percentage that the cardiac output can increase above normal is called the cardiac reserve.  In the normal young adult cardiac reserve is 300 to 400%.  In the athletically trained person it is occasionally as high as 500 to 600%, whereas in the asthenic person it may be as low as 200%.  As an example, during severe exercise the cardiac output of the normal healthy young adult can rise to about five times normal; this is an increase above normal 400% that is, a cardiac reserve of 400%.  Any factor that prevents the heart for pumping satisfactorily decreases the cardiac reserve.  This can result from ischemic heart disease, primary myocardial disease, vitamin deficiency, damage to the myocardium, valvular heart disease, and many other factors. The diagnosing of low cardiac reserve is typically evaluated by the “Exercise Test.”  So long as people with low cardiac reserve remain in a state of rest, they probably will not know they have heart disease.  However, a diagnosis of low cardiac reserve can usually be made easily by requiring a person to exercise either on a treadmill or by walking up and down steps.  The increased load on the heart rapidly uses up the small amount of reserve that is available, and the cardiac output fails to rise high enough to sustain the bodies new level of activity.  The acute effects are: 1. Immediate and sometimes extreme shortness of breath resulting from the heart’s not pumping sufficient blood to the tissues, thereby causing tissue ischemia and creating a sensation of air hunger.  2.  Extreme muscle fatigue resulting from muscle ischemia, thus limiting the person’s ability to continue with exercise. 3.  Excessive increase in heart rate because the nervous reflexes overreact in an attempt to overcome the inadequate cardiac output.  These tests are typically performed by cardiologists and cannot be made with ease in most clinical settings.]32

See the graph for various cardiac reserves from different various conditions:

Chart 20

In light of this, you’ll want to take an additional history relevant to any prior heart disease, or familial history of cardiovascular disease, and either prior to the class, or before the patient starts his/her spinal exercise program, it may be wise first to evaluate each of the patients that you are considering for this type of class. Test their resting heart rate initially, and then have them perform a mild period of exercise for example, three to five minutes of walking, bicycling, or some type of similar exercise, then immediately take their heart rate again.  You should repeat this process one minute after the exercise is complete.  You as the physician want to take notice of any undue stress that the patient exhibits during this time, and any great increase to the heart rate.  The one minute post heart rate will give you at least the baseline of how quickly the heart is able to recover from this type of exercise.  Once you have performed this, if you have any questions whether the patient could handle an exercise program or not based on their poor performance in this evaluation you may desire to hold off on recommending a spinal exercise class for this patient.  Supplementation for the heart, and subsequent evaluations in the future, after they have progressed further with the other various chiropractic care, you may be able to safely recommend this program for their continued progress. 

Another way you may evaluate the patient’s present cardiovascular health status is by comparing their present resting heart rate to a general guide.  See the attached chart:

Chart#21 Below

 

[Aerobic training is performed to increase aerobic capacity or fitness.  The aerobic capacity of an individual may be defined as the ability to utilize the body’s glycogen stores via the aerobic metabolic pathway.  An individual’s aerobic capacity is measured by the maximum oxygen consumption, better known as the Vo2 max-the max amount of oxygen an individual is able to utilize and one minute per kilogram of body weight.  Aerobic training is aimed at increasing this aerobic capacity.  The athlete is unable to monitor oxygen consumption directly during training; however, it is possible for the athlete to monitor heart rate, which appears to correlate well with oxygen consumption, and at least during submaximal activity.  Aerobic training effects can be gained by maintaining a heart rate of between 70 and 85% of the maximum heart rate of the individual.]33 Please note this reference is being recommended for well-trained athlete.  For the patient that typically comes in our office they will benefit from 50% to 70% of the maximum heart rate for the individual.  [The effects of aerobic activity on muscle include an increase in the mitochondria of skeletal muscles, increased glycogen storage in muscles, increased availability of free fatty acids and increased vascularity of muscle.  Cardiovascular effects include decreased heart rate and blood pressure with increased cardiac stroke volume.]34

We will cover the specifics of an aerobic exercise portion for the spinal exercise class below. It will be presented as if you were teaching it to your patient’s. You may desire to use it as a template for your class, or if you choose to use the DVD in place of the class it will be a great adjunct to the DVD. You may even desire to break up the class into two parts, one being the spinal exercise class, and the other an aerobic exercise class. This could greatly increase the financial reimbursement by having two classes. 

AEROBIC EXERCISE

 NAME:__________________________DATE:_____________FILE NO._________

In determining your aerobic exercise goals it is important to understand what you are trying to accomplish and set your goals accordingly. You need to be able to evaluate your progress as you go. 

Goal #1: The first goal that we desire is for you to be able to exercise for the length of time recommended for cardiovascular exercise, and the specific number of times per week you should aim for. Our recommendations are for walking or treadmill, although you may use any of the cardiovascular machines i.e.: stair stepper, Nordic track, etc., or other various exercises including running, bicycling, or swimming.

We have chosen walking because of the adaptability of this exercise to almost any circumstance you may have.  If you have not been exercising, we recommend you start slow and build up. We do not want you to be a weekend warrior with your exercise. For the beginner, we recommend you starting with 5-10 minutes in your initial week, and then add 5-10 minutes per week until you reach 30 to 45 minutes of total exercise each time.

The first 5-10 minutes should be a warm-up, and your walking should be a slightly slower pace during this time. Your last 5 minute should be a cool down and it also should be at a slower pace. Your goal for this aerobic exercise should be; Exercise 3 to 5 times weekly for at least 30 to 45 minutes each time.

The “220 Rule” Is a method for you to evaluate your target heart rate. The formula is as follows:

[220 – Resting Heart Rate – Age x (50%, 60%, or 70%) + Resting Heart Rate = Target Heart Rate]

Goal #2: In whatever aerobic exercise you perform, your goal should be to exercise at an

intensity level that keeps you at your target heart rate. If your exercise intensity leaves your heart rate below your target heart rate, pick up the pace. If your heart rate is above your target heart rate by 15 beats or more slow down your pace.

In order to be able to do this, you will need to learn to take your pulse in either your brachial pulse or carotid pulse. When you plan to exercise, prior to starting you need to take your resting pulse, then after your initial warm-up you need to monitor your heart rate, adjusting your level of intensity of exercise according to your target heart rate, and then at the end of your exercise, just prior to your cool down, you need to stop – take your pulse then wait one (1) minute ,and retake your pulse.

Once you have these pulses, if you subtract the initial pulse after you stop exercising from the pulse you take one minute after you stop exercising. The difference gives you an indicator how healthy your heart is. The larger the difference is the more efficient the heart. By doing consistent aerobic exercise over a long period of time, you should see your heart getting stronger.

 A Typical Aerobic Exercise Schedule

1. Initially start with Flexibility to prepare your muscles for activity 5-10 minutes
2. Start “Warm-up exercise”  (slower pace) 5-10 minutes
3. Continue with “Aerobic exercise” at your Target heart rate  (monitoring your heart rate throughout) for 15-30 minutes
4. When Aerobic Exercise is complete STOP
   1.check pulse initially   2.wait one minute recheck pulse   3.subtract the two
5. Then continue exercising in the “Cool down”  (slower pace)  5-10 minutes
6. Then finish with post exercise Flexibility to stretch you out from your exercise. 10-15 minutes.

Your total time to exercise will take you 45 minutes to 75 minutes each time.

THE OVERTRAINING SYNDROME 

Emotional Warning Signs

1. Increase in nervousness or depression.
2. Inability to relax.
3. Desire to quit training, skip training sessions or quit during competition.
4. A mental attitude of “I don’t care.”
5. A drop in academic performance or in job performance.

Body Warning Signs

1. Extreme muscle soreness and stiffness the day after a hard training session.
2. A gradual increase in muscle soreness from training session to training session.
3. Decreasing body weight, when no effort to decrease body weight is being made.
4. Inability to complete a training session that in his present physical condition it is reasonable to assume that he should be able to complete.
5. A sudden increase or gradual increase in resting heart rate. The resting heart rate should be taken at the same time each day and under the same conditions.
6. Lowered general physical resistance as shown by a continuous cold, headaches, etc.
7. Loss of appetite.
8. Swelling of the lymph nodes in the neck, groin or arm pits.
9. Constipation or diarrhea.
10. Unexplained drop in athletic performance.

When signs of overtraining are present it is advisable to suspend training for one to several days or to decrease the intensity and/or duration of training for one to several days. If strong signs of overtraining are present, it is possible that the athlete may have to spend days or possibly weeks at a decreased level of strenuousness in training, until his/her physical condition recovers sufficiently to resume the level of vigorous training can be continued. 

In conclusion, a spinal exercise class can add to the depth and quality of your patient’s treatment plan.  By taking the time to get your chiropractic assistants to be on board and to aid you in this process, the actual setup and transition time should move smoothly and efficiently.  The proper coding, patient handling, and patient clinical management should be easy to follow utilizing the information in this class.  The at-home patient DVD and the phases rehab computer program will also assist you in delivering this information on spinal exercise in a methodical precise and logical manner.  As we stated earlier, you may desire to break down the class into two components, one on the actual spinal exercises and the other on the aerobic exercise portion.  You may also find that you like to break down the spinal exercise portion into a cervical spinal exercise, thoracic spinal exercise, and a lumbar spinal exercise class.  If you keep it in either one or two classes the financial renumeration will be less, but setting up and maintaining the schedule most likely will be easier.  This type of class can make it much easier for you as the busy physician to implement spinal exercise into your patient’s treatment plan protocols.  As a side note, it is important to couple a well thought out flexibility program with a program of this nature.  You may want to refer to the class we offer called “Practical Flexibility” We hope that you found this informative, profitable, and assistive to you.  

Bibliography
 

1, 2, 3     The Human Body, Charles Clayman MD, 1995,
pp. 50-54.

4  Textbook of Medical Psyhology, Guyton 1986 p.124.

5, 6, 7, 8 Guides to the Evaluation of Permanent Impairment (5th Edition)Linda Cocchiarella MD, Gunnam B.J. Anderson MD, 2001, p. 374, 399, 378, 379

9,10,11,12,13,14 2008 16th Annual Chirocode Desk Book, DH Leavitt, 2007 p. 104C, 99C, 102C, 110C,116C,102C,102C

15,16,17,18Basic Chiropractic Procedural Manual, R.C. Schafer DC.,F.I.C.C. pp.484,486 

19,20,21,22,23Textbook of Medical Psyhology, Guyton 1986 p.1013 

24-30  Clinical Sports Medicine, Peter Brukner, Karim Khan,  pp. 132-135.

31,32Textbook of Medical Psyhology, Guyton 1986 pp.312-313. 

33,34 Clinical Sports Medicine, Peter Brukner, Karim Khan, pp 74.                  

CHARTS / GRAPHS

 

1-6The Human Body, Charles Clayman  pp. 50-52.

7Textbook of Medical Psyhology, Guyton 1986 pp.120

8Anatomical Charts, 1990 Whiplash Injuries  

9-12,14  Grant’s Atlas of Anatomy 8^th ed. fig. 5-21,5-20, 5-17, 5-19, 5-31A James Anderson

13,15 Gray’s Anatomy, pp. 224, 236. Henry Gray

16-19Phases Rehab. Computer Program

20 Textbook of Medical Physiology pp.313. Guyton

21Y’s Way to Physical Fitness, Golding 1989

Test

“Practical Spinal Exercise”

1. A Spinal Excercise class if administered correctly will add depth to the patient’s treatment plan.

TrueFalse

2. Very often in the busy chiropractic practice it is easy to address spinal exercise on a one on one basis.

TrueFalse

3. A popular time to perform this class can be at the lunch hour, and with the addition of food can make a positive substitution to their typical routine.

TrueFalse

4. Skeletal muscles consist of densely packed groups of elongated cells known as:

a) myofilamentsc) actin

b) myosind) muscle fibers

5. The myofilaments in each myofibril are divided transversely by Z bands along the length of the muscle fiber into units called:

a) sarcomeresc) troponin

b) tropomyosind) actin filament

6. The thread like cells of the muscle fibers can be up to 1 foot long.

TrueFalse

7. Each thin myofilament consists mainly of _____________ a protein, and _____________, another protein that can inhibit contraction.

a) myosin, sarcomerec) golf clubs, tails

b) active, tropomyosind) Z-bands, myofibrils

8. Over 600 muscles make up nearly ______________ of the weight of the human body.

a) 25%c) half

b) 40%d) 3/4

9. Which muscle is not included in the muscles of the anterior aspect of the neck

a) sternocloidomastoid musclec) omohyoid muscle

b) Platysma muscled) Popliteus muscle

10. Once a visual range of motion study has been performed, and restrictions, pain, and alterations to the smooth arc motion have been noted, a __________________  __________________ evaluation to determine the specific amount of restriction would be merited.

a) spinal reflexc) dual inclinometric

b) muscle strengthd) computerized muscle

11. The AMA guides state “When measuring range of motion, the examiner should obtain at least three consecutive measurements and calculate the mean (average) of the three.

TrueFalse

12. If the average (range of motion) is less than 50 degree, three consecutive measurements must fall within 20% of the mean.

TrueFalse

13. If the average (range of motion) is greater than 50 degrees, three consecutive measurements must fall within ________________ of the mean.

a) 5%c) 15%

b) 10%d) 20%

14. The ICDM code for a computerized R.O.M. study is:

a) 007c) 95851

b) 98941d) – 59

15. Studies have shown that a muscle strength loss of 30% is needed before average practitioner will detect a difference.

TrueFalse

16. The – 59 code indicates that you are doing a ___________________ and __________________ procedure from any other procedures being performed on that same visit.

a) combined, disjointedc) small, large

b) separate, distinctd) unique, similar

17. Loss of motion segment integrity is defined as an anteroposterior  motion of one vertebrae over another that is greater than ______________ mm in the cervical spine, greater than 2.5 mm in the thoracic spine, and greater than 4.5 mm in the lumbar spine.

a) 1.0 mmc) 3.5 mm

b) 3.0 mmd) 4.0 mm

18. The code that you would want to use in a group spinal exercise class is 97150 which is therapeutic procedures, group (2 or more individuals).

TrueFalse

19. In 2000 in an effort to control fraud and abuse of costs, CMS adopted a policy of rounding to the nearest 15 minutes. Accordingly, _______________ minutes of hands on care would be considered as 1 – 15 minute unit of care, 24 to 38 minutes would be two units

a) 8 to 23c) 15 to 20

b) 10 to 15d) 7 to 22

20. The 97110 code is a good code for any follow-up visits with the patient on a one on one basis.

TrueFalse

21. A – 52 modifier basically states that you are doing more than a full unit of this code.

TrueFalse

22. The ligament in front of the vertebral bodies is known as:

a) Posterior Longitudinal Ligament

b) Interspinous ligament

c) Anterior Longitudinal ligament

d) Ligamentum Nuchae 

23. The 97112 code is another code that you may be tempted to use. The code is for neuromuscular, reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities in one or more areas.

TrueFalse

24. The RVU of 97150 is ___________________ while 98940 has a RVU of ________________

a) .22, .33c) .84, .96

b) .48, .68d) .21, .32

25. I enjoyed the class and the information given

TrueFalse