(VERY IMPORTANT!)

YOU MUST Read the instructions noted below Before starting your class.

1. When you desire to Start your class, simply click the “Begin Session” button. The session will start and the countdown timer will be initiated.
2. The Server “Times Out” Every 30 Minutes!
3. To ensure you get credit for all your “Logged Time”, you Must click the “Log Time” button at the Top of the “Unit Study Page” every  20-25 minutes.

    (VERY IMPORTANT!)

4. If you fail to click the “Log Time” button every 20-25 minutes, even though the countdown timer continues, the server will “Timeout” and you will lose your session time back to the last time you clicked the  “Log Time” button.
5. When you desire to Stop your class, simply click the “End Session” button. The session will update itself and you will be able to close the program without losing any of the “Log Time” you have gained to that point.
6. When you desire to Continue, simply log into “My Account,” then click on “My Online Classes” from the “My Account” tab on the top menu, and then click the “View Unit” for the class you desire to study. From there simply click the “Begin Session” button and once again the countdown timer will be initiated. (Remember to log time every 20-25 minutes)
7. Once you have completed all the required time for the class you will be able to take the quiz. Simply click on the “My Account” button on the top menu, and click on “My Online Classes” and click the “Take Quiz” button to view and take the quiz.
8. The Quiz on the bottom of the Unit Study Page is the actual quiz you will take at the end of the class, so it may be helpful to answer the questions as you go. If you fail the test, you will have to contact us to retake the class and the test again. 
9. It will be helpful to print out a copy of the class with the quiz to study.
    (Simply right click with your mouse anywhere on this page and then select “print” from the menu that comes up)

10. Once you have taken the quiz and passed it your certificate will be available, you can click on the link to your “Certificate.” You can view your certificate by clicking on “My Account” button on the top menu, then go to “My Quizzes” to see the link for your certificate. To Print the certificate, you first open the certificate and then right-click your mouse and select print from the menu. (Side note: it is your responsibility to send a copy of your certificate to the board of chiropractic in your state. We do not send a copy of the certificate to your board. Further, it is also your responsibility to make sure that the online class you take is approved for each state that you desire to get credit in.)

Practical Spinal Flexibility

By Scott A. Martin D.C.

This 6 hour course on flexibility will include the following specific topics;

1. An Overview of the Specifics & Goals in Considering an in Office Spinal Flexibility Program  [ 1 hour ]
2. A Review of the Basic Anatomy of Skeletal Muscles
   [ 1 hour ]
3. Clinical Case Management for the Spinal Flexibility Patient
   [ 1 hour ]
4. ICDM Coding for Using Spinal Flexibility in Office [ 1hour ]
5. a. The Who, When, Why, and How to Stretch & b. The Three types of Stretching: Ballistic, PNF, and Static [ 1 hour ]
6. Specific Flexibility Poses Reviewed [ 1 hour ]
7. Conclusion

---

1. 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 flexibility program/class is a tool that if administered correctly, will not only add to the depth to the patient’s treatment plan, but it will provide the physician with a profitable, time efficient way to add flexibility to the patient’s treatment plan.

This online seminar will be set up to provide the practitioner with a simple, comprehensive, step-by-step method by which he or she can set-up an in office flexibility class. This seminar will make implementation of a spinal flexibility program easy for you and your staff in your office on Monday morning, or whenever the next day is after you take this class.

The class is set up to give you a thorough working knowledge of a flexibility program, and assist you as the physician to develop the case management protocols to determine the clinical necessity for each patient. We will give you some specific parameters to determine when the patient is ready for the class, and the basics on how to prepare your patients for a class, and give the practitioner a general look at forms that may be needed for a class of this nature, while preparing you and your staff for the adding of a flexibility class to your schedule in a time efficient way. Finally we will try and answer as many of the typical various questions you may have to assist you in this process.

Flexibility should be an important part of the patient’s treatment protocol.  Many of the various spinal problems that occur in a patient’s case are dramatically impacted when adequate flexibility is not present. On the flip side, your patients will experience a tremendous decrease of their symptoms when adequate flexibility is present. Many of our patients have a wide range of scar tissue, adhesions, and inflexibility associated with their various spinal problems\traumas, so when we fail to address this 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 flexibility on a one-on-one basis, so a flexibility class offers a viable option to meet your patient’s needs and yet not take away from your precious time as a physician.  We also have plans to have a flexibility video/DVD that could go in place of a flexibility class for those that do not like to speak in a public setting.  A class of this nature also can represent a great practice building tool by allowing you to invite family members, friends, and those in the community that may need your services.  For a wide range of reasons it often seems easier to go to a flexibility class, and meet a physician this way, rather than meeting the chiropractic physician on the first visit when he or she decides reluctantly decides to come in to your office. When the prospective patient sees your knowledge and skill, it can very often open up an opportunity for you to listen to their history and even in brief determine if chiropractic care may be of value to them.

The time and setting of the class can allow for a relaxed atmosphere that is an attractive way to ensure patient compliance with this type of class.  I also recommend that you add either something to drink or eat prior to the class, so that the patients will not be distracted by hunger from the information that you will be giving. A popular time to perform this class can be at the lunch hour, and with the addition of food, it can make a positive substitution from their typical lunchtime routine.  It can also serve as a way that you and the staff and can have a business lunch on the class.  Tax write-offs are a welcomed 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 each portion of the class to your various staff members, for instance you as the physician will best be suited to plan out the various stretches that you desire to teach, while your staff may handle the arrangements for the food, copying of the various forms, the scheduling of the patients, the preparation of the classroom, and 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 flexibility 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, and any associated trigger points that may be present.  As you form the patient’s initial treatment plan recommendations or an update recommendation plan for the patient, this should be added to any of these recommendations as the patient shows a clinical need for flexibility.   Once you as the physician get used to prescribing this, very often the only thing you will be lacking is extra seats for the quantity of patients that you have, or the number of videos\DVDs that you will need to have for the patients.

The class does require some space, but very often there are various places in the community where you may deliver such a class.  Wherever you plan to set up the class, you may find it as an opportunity to reach out to the community and have a flexibility class for people that are not even your patients.  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 flexibility procedures, and the financial return from such an amount.

Overall, this type of class will allow you a wide range of flexibility, no pun intended, to provide for your patients an in depth level of information in regards to the stretching process in the spine.  It will also create a forum from which your patients may ask questions to you, the physician, in regards any portion of the flexibility process.  You may even desire to break down this class into two parts, an upper body\cervical and thoracic section along with a lower body\lumbar and sacroiliac section.  A personal trainer may be utilized to show the various positions while you as a physician place the patients in the proper positions. The many options you have will almost be limitless, and give you better patient management overall.

---

2. A Review of the Basic Anatomy of Skeletal Muscles

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

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

Muscles in the anterior aspect of the neck– Sternocloidomastoid, Scalenius, Sternohyoid, Omohyoid, and Platysma

Muscles in the anterior portion of the thoracic / lumbar spine– Rectus Abdominis, Internal Oblique, and External Oblique

Muscles in the anterior portion of the upper leg– Quadratus Femoris, Vastus Lateralis, Vastus Medialis, Sartorius, Gracilis, Adductor Longus, Adductor Brevis, Pectineus, and Iliopsoas

Muscles in the posterior aspect of the neck– Superficially: Trapezius, Splenius Capitis, Semispinalis Capitis, Splenius Cervicis, Rhomboideus Minor, and Romboideus Major      ( Not Visualized Here ):– Deep: Rectus Capitus, Superior Oblique, Inferior Oblique, and the Levator Scapulae

Muscles in the posterior aspect of the Thoracic spine– Erector Spinae, Latissimus Dorsi, Spinalis Thoracis, Romboideus Major, Longissimus Thoracis

Muscles 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,

 

Muscles in the posterior portion of the upper leg– Biceps Femoris, Iliotibial Band, Semitendinosus, Semimembranosus, Adductor Magnus, Gracilis, Vastus Lateralis

Muscles in the posterior portion 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

3. Clinical Case Management

To determine the clinical necessity of a flexibility 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 specific 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. 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 flexibility 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 flexibility training for, you would need to do a range of motion study of that associated area.  For example, if shoulder flexibility is a region 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 flexibility program that is limited to the cervical, thoracic, and lumbar spine. 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 Inclinometry 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. They 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.”14 This gives us some food for thought clinically, an inclinometry study that is performed on your patients by you the physician or one of your various assistants adds to the potential for obtaining 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. An example of this type of device includes the dual inclinometry product from J-tech, probably the leading company for many years in this type of equipment. Inclinometric devices that are Infrared units that do not have cumbersome wires makes it easier to perform the evaluations. 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.  Typically a report is sent in conjunction with this procedure.  The J-tech product 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 from 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 range of motion/flexibility.  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 a flexibility class.  A score of three or four in any individual manual muscle strength evaluation is sufficient to also establish a clinical necessity for electronic/computerized muscle testing. A computerized muscle testing product is also available through the J-Tech company. 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 specific muscle.  This will reduce some of the intra-examiner reliability problems and improve your ability as the physician to evaluate muscle strength. The J-Tech company has this type of built-in accuracy within the products they sell. As a practitioner, it is always important to have as specific clinical information as we possibly 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 examinations 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 flexibility class.

Radiographic evaluation is another method to determine the clinical necessity for a flexibility class.  In review of either the cervical or lumbar radiographic evaluations, certain findings will be consistent in determining the need for a flexibility class.  These findings include, on the lateral x-rays of either the cervical or lumbar spine a loss of normal curvature.  Other findings as noted on the AP cervical or lumbar spine radiographs would include any scoliosis noted or even any lateral lists to the spine.  The most definitive radiographic finding is noted on the flexion and extension radiograph of either the cervical or lumbar spine.  This finding is also supported by the AMA Guides to the Evaluation of Permanent Impairment the fifth edition.  The finding is known as “loss of motion segment integrity.”  Any translation of the vertebrae in the flexion or extension view either posteriorly or anteriorly in regards to the vertebrae above it or below it has the potential for this loss of motion segment integrity.  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 disk, the apophyseal or facet joints, and ligamentous structures between the vertebrae.15  Loss of motion segment integrity is defined as an anteroposterior motion 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.16 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 flexibility class.  It should also be noted if the amount of vertebral translation is less than the above parameters this should 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 flexibility class?  If an amount of vertebral translation is greater or even equal to these figures regarding a loss of motion segment integrity, then it would be wise to wait on recommending a flexibility class to the patient, until additional radiographic studies are performed with your associated update examinations that show an  improvement with the the loss of segment integrity.  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 flexibility 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.

4. ICDM coding of the Flexibility Class (We are not going into the new ICDM-10 Coding in this section. You will need to refer to your newest ICDM-10 manual for any crossover coding and review any limitations your state board has regarding the use of Therapeutic Exercise codes.)

In this section, we will cover is the actual codes 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 16th 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.  Group therapy procedures involve constant attendance of the physician or therapist, but by definition do 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 in 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.]  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 code for only 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, so if there is ever a question you have it documented.  As a matter of habit you may desire to tape your insurance verifications so that the specifics of your communication\questioning may be established at anytime. Also proper documentation in the patient’s file is required for any time-based code.  So you’ll want to make sure that you document the time, date, location, and any physician to patient encounters \ communications for services.

5a. Who, When, Why, and How to Stretch

You will find these questions answered on the following three pages.  They are set up in such a format that they may be copied and utilized in your flexibility class.  These questions are answered in such a manner that they address the patient’s concerns and not yours as the physician.  We have already covered the physicians concerns in the case management section, but it does contain good information to get well acquainted with prior to your first flexibility class. The resource for these pages came from the book, “Stretching” by Bob Anderson. The pages present a very concise and to the point answers and explanations for each of these questions that your patient may very well ask. (See additional pages with the title marked “FLEXIBILITY”.)

---

   5b. Three Types of Stretching: Ballistic, (PNF), and Static

These three types of stretching are also covered on the next three pages, along with a brief description of how the static stretch is broken down into an easy stretch, developmental stretch, and drastic stretch.  This is also set up in a format to be copied for a flexibility class.

Ballistic stretching is a type of stretching that I describe as bouncing, it can cause further damage to the muscle and connective tissue.  The proprioceptive neuromuscular facilitation (PNF) is a type of flexibility that is quite helpful when the typical static flexibility/stretching seems to be less effective.  Clinically, it is easier and safer for the physician or other trained clinician to perform this type of procedure in an office or clinical setting.  More one-on-one training is needed to better explain the procedure/s with this type of flexibility.  Another variable with this type of flexibility is the fact that it also requires an additional individual to assist with the various procedures.  Static stretching is the type of flexibility that is most often taught in a flexibility class of this nature. We will try to apply an easy to learn methodology with the patient being able to do the various procedures by themselves.

---

       6. Specific Flexibility Poses Reviewed

After the next three pages marked, “FLEXIBILITY” you will find three additional pages with diagrams/pictures that represent various stretches.  In a typical flexibility class, initially the first three pages marked, “FLEXIBILITY” are gone over 1^st with the various patients attending the class, so they will have a good basis on which they can then perform these various stretches.  Following the initial 3 pages of information given, the number of stretches, and the type of stretches on the following three pages represent approximately the amount of stretches that can be gone over in a 1 to 11/2 hour class.

The diagrams/pictures come from a computer program called Phases Rehab.  This program can be found online.  There is a wide range of stretching procedures, exercise procedures, and various rehab procedures all in picture format so that you can formulate your own unique flexibility class.  There are other sources for these types of diagrams/pictures.  Please refer to your own local chiropractic supply distributor for information relevant to this.

You’ll also find a flexibility class attendance sheet and a flexibility class evaluation sheet that I recommend you have the patient fill out, sign, and date.  These two forms will help you maintain adequate patient records and keep you aware of how your patient perceives the value of the class to be.

---

FLEXIBILITY

Who Should Stretch

Everyone can learn to stretch, regardless of age or flexibility. You do not need to be in top physical condition or have specific athletic skills. Whether you sit at a desk all day, dig ditches, do housework, stand at an assembly line, drive a truck, or exercise regularly, the same techniques of stretching apply. The methods are gentle and easy, conforming to individual differences in muscle tension and flexibility. So, if you are healthy, without any specific physical problems, you can learn how to stretch safely and enjoyably.

Note: If you have had any recent physical problems or surgery, particularly of the joints and muscles, of if you have been inactive or sedentary for some time, please consult your physician before you start a stretching or exercise program.

When to Stretch

Stretching can be done any time you feel like it: at work, in a car, waiting for a bus, walking down the road, under a nice shady tree after a hike, or at the beach. Stretch before and after physical activity, but also stretch at various times of the day when you can. Here are some examples:

–     In the morning before the start of the day.

–     At work to release nervous tension.

–     After sitting or standing for a long time.

–     When you feel stiff.

–     At odd times during the day, as for instance, when watching TV, listening to music, reading, or sitting and talking.

Why Stretch

Stretching, because it relaxes your mind and tunes up your body, should be part of your daily life. You will find that regular stretching will do the following things:

–     Reduce muscle tension and make the body feel more relaxed.

–     Help coordination by allowing for freer and easier movement.

–     Increase range of motion.

–     Prevent injuries such as muscle strains. (A strong, pre-stretched muscle resists stress better than a strong, un-stretched muscle.)

–     Make strenuous activities like running, skiing, tennis, swimming, cycling easier because it prepares you for activity; it’s a way of signaling the muscles that they are about to be used.

–     Develops body awareness.

–     Promotes circulation.

–     It feels good.

–     Helps prevent further joint damage.

–     Reduces stress on associated joint structures.

–     Increases blood flow to muscles being stretched and thus increases oxygen to muscles.

–     Increases length of muscles.

–     Reduces stress on joints, ligaments and tendons and helps reduce injuries in these areas.

–     Relieves muscle soreness.

–     Improves your physical performance.

How to Stretch

There are three (3) types of stretching:

–     Ballistic (or bouncing) Stretching: Uses the momentum of the body to produce the stretch. This type of stretch is not recommended.

–     Proprioceptive Neuromuscular Facilitation (PNF): Involves the contraction and relaxation of the muscle groups being stretched, and also involves the use of a partner. This type is good for enhancing sports performance.

–     Static Stretching: Gradually lengthens the muscle through the joints’ range of motion. This type of stretching is highly recommended.

We will describe below static stretching. Your doctor also may recommend Proprioceptive neuromuscular facilitation as a part of your in-office rehabilitation. One must understand that stretching/flexibility is an elongation of a muscle whereas exercise i.e., walking, involves contraction or shortening of muscles.

Stretching is easy to learn. But there is a right way and a wrong way to stretch. The right way is a relaxed, sustained stretch with your attention focused on the muscles being stretched. The wrong way (unfortunately practiced by many people), is to bounce up and down, or to stretch to the point of pain: these methods can actually do more harm than good.

If you stretch correctly and regularly, you will find that every movement you make becomes easier. It will take time to loosen up tight muscles or muscle groups, but time is quickly forgotten when you start to feel good.

The Easy Stretch

When you begin a stretch, spend 10-30 seconds in the easy stretch. No bouncing! Go to the point where you feel a mild tension, and relax as you hold the stretch. The feeling of tension should subside as you hold the position. If it does not, ease off slightly and find a degree of tension that is comfortable. The easy stretch reduces muscular tightness and readies the tissues for the developmental stretch.

The Developmental Stretch

After the easy stretch, move slowly into the developmental stretch. Again, no bouncing. Move a fraction of an inch further until you again feel a mild tension and hold for 10-30 seconds. Be in control. Again, the tension should diminish; if not, ease off slightly. The developmental stretch fine-tunes the muscles and increases flexibility.

Breathing

Your breathing should be slow, rhythmical and under control. If you are bending forward to do a stretch, exhale as you bend forward and then breathe slowly as you hold the stretch. Do not hold your breath while stretching. If a stretch position inhibits your natural breathing pattern, then you are obviously not relaxed. Just ease up on the stretch so you can breathe naturally.

Counting

At first, silently count the seconds for each stretch; this will insure that you hold the proper tension for a long enough time. After a while, you will be stretching by the way it feels, without the distraction of counting.

The Stretch Reflex

Your muscles are protected by a mechanism called the stretch reflex. Any time you stretch the muscle fibers too far (either by bouncing or overstretching), a nerve reflex responds by sending a signal to the muscles to contract; this keeps the muscles from being injured. Therefore, when you stretch too far, you tighten the very muscles you are trying to stretch! (You get a similar involuntary muscle reaction when you accidentally touch something hot; before you can think about it, your body quickly moves away from the heat.)

Holding a stretch as far as you can go or bouncing up and down strains the muscles and activates the stretch reflex. These harmful methods cause pain, as well as physical damage due to the microscopic tearing of muscle fibers. This tearing leads to the formation of scar tissue in the muscles, with a gradual loss of elasticity. The muscles become tight and sore. How can you get enthused about daily stretching and exercise when these potentially injurious methods are used?

Many of us were conditioned in high school to the idea of “no gain without pain.” We learned to associate pain with physical improvement, and were taught that “…the more it hurts, the more you get out of it.” But don’t be fooled. Stretching, when done correctly, is not painful. Learn to pay attention to your body, for pain is an indication that something is wrong.

The easy and developmental stretches, as described on the previous page do not activate the stretch reflex and do not cause pain.

This Diagram Will Give You an Idea of a “Good Stretch”:

 

	A STRETCH
An Easy Stretch	The Developmental Part of Stretching	A Drastic Stretch
(hold for 20 – 30 seconds)	(hold for 30 seconds or longer)	(do not stretch in the drastic stretch)

 

The straight line diagram represents the stretch which is possible with your muscles and their connective tissue. You will find that your flexibility will naturally increase when you stretch, first in the easy, then in the developmental phase. By regularly stretching with comfortable and painless feelings you will be able to go beyond your present limits and come closer to your personal potential.

GROUP FLEXIBILTY / EXCERCISE 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 / Spinal Strengthening Cardiovascular 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

---

7. In conclusion, whether you already utilize exercise rehabilitation in your office or not, a flexibility class or program will add greater depth to your patient’s treatment plan. It will provide you with an opportunity to develop a consistent methodical approach to teaching flexibility. This program will aid with increasing your patient’s compliance at home.

You as the physician will get a better understanding of your patient’s comprehension as they attempt to maneuver in and out of these flexibility positions. You will be able to have a good baseline of your patient’s education on this topic for each patient who attends, and as you couple this with actually seeing the patient maneuver in and out of the positions, you will be able to determine approximately the amount of additional assistance they will need in their future appointments.

The most commonly asked question after a class is: “Do you have a DVD of this class that we can get for home?” In the future I hope to have a DVD or link available for your patient’s review. Keep an eye out on our website and your e-mail for this potential upcoming resource.

I don’t know of many other programs or procedures that have such a good impact on your patient’s well-being which is also so time effective as a spinal flexibility class. It does not take much time from the doctor or the staff and yet you have such a great return on investment for everyone involved.

By adding a flexibility class by itself and utilizing the various testing procedures like computerized R.O.M and computerized muscle testing and then following up with 1–2 units of one on one therapeutic exercise to answer any questions you are adding quite significantly to your bottom line. Doing the right thing for you patients never looked so good.

Bibliography

 

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

3.            Textbook of Medical Physiology, Guyton 1986 p.124.

4.            The Human Body, Charles Clayman MD, 1995, pp. 50-54.

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

2008 16th Annual Chirocode Desk Book, DH Leavitt, 2007 p. 97, 95,

96 – 102, 94

14     Stretching, Bob Anderson, 1980, pp. 10-14

 

Illustrations

 

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

4             Textbook of Medical Physiology, Guyton 1986, p. 120.

---

Test

Practical Flexibility

1. A flexibility 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 flexibility 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) actin, 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 are 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 tree.

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 anterior to posterior  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 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. Ballistic Stretching is a type of stretching described as:

a) contraction/relaxationc) bouncing

b) steady elongationd) rhythmical

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