(VERY IMPORTANT!)
YOU MUST Read the instructions noted below Before starting your class.
- When you desire to Start your class, simply click the “Begin Session” button. The session will start and the countdown timer will be initiated.
- The Server “Times Out” Every 30 Minutes!
- 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!)
- 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.
- 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.
- 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)
- 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.
- 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.
- 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) - 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 Rehab
By Scott A. Martin D.C.
This 12 hour course on Spinal Flexibility and Spinal Exercise will include the following specific topics ;
- We will set the stage for adding a practical spinal rehab program in the form of a spinal flexibility and spinal exercise class in the chiropractic clinical setting. [ 1 hour ]
- We will go over a review of the basic spinal anatomy of skeletal muscles. [ 1 hour ]
- We will go over a review of the basic spinal structures that are involved in such a program. [ 1 hour ]
- We will consider the factors in the clinical case management of adding a spinal flexibility and spinal exercise class to the individual patient’s care plan. [ 1 hour ]
- We will consider some of the factors regarding coding and compliance for the addition of a spinal flexibility and a spinal exercise class into the chiropractic setting. [ 1 hour ]
- We will review the various considerations in regards to the Who, Why, When, Where and How to Stretch [ 1 hour ]
- We will consider the three types of stretching, and the specifics of each type of classification of stretching: Ballistic, PNF, and Static Stretching. [ 1 hour ]
- We will consider the specifics of spinal flexibility and its place in the chiropractic setting in the form of a spinal flexibility class. [ 1 hour ]
- We will consider the specifics of spinal exercise and its place in the chiropractic setting in the form of a spinal exercise class. [ 2 hours ]
- We will consider the specifics of adding aerobic exercise in the chiropractic clinical setting in the form of an in office exercise class. [ 2 hours]
- 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 flexibility class and spinal exercise class are tools, 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 flexibility and spinal exercise to the patient’s treatment plan.
This class 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, spinal flexibility and spinal exercise class. These classes will make implementation of both a spinal flexibility and spinal exercise program easy for you and your office on Monday morning.
The class is set up to give you a thorough working knowledge of a spinal flexibility and spinal exercise class. It will give the practitioner the know how on how to use the proper procedure codes, determine the relative value units of this type of care so you can establish an appropriate fee-for-service, assist you as the physician to develop the clinical case management protocols to determine the clinical necessity for the patient, give you some parameters to determine if and when the patient is ready for the class and the basics on how to prepare your patients for a class, give the practitioner a general look at forms that may be needed for a class of this nature, prepare you and your staff for the adding of both a flexibility and spinal exercise class to your schedule in a time efficient way, and answer as many of the various questions you may have two assist you in this process.
Many of the various spinal problems that occur in a typical patient’s case are dramatically impacted when inadequate spinal flexibility, muscle strength, power, and endurance are present.
If a lack of flexibility, dynamic joint instability, incorrect biomechanics and poor muscle control were important factors in the etiology of the patient’s case and or injury, and we do not address these through spinal flexibility and spinal exercise in their treatment plan, we may limit their ability to heal properly and in a timely manner. It can also potentially cause the patient to heal in such a manner as to form a more permanent problem for the patient. On the flip side, when spinal flexibility and spinal exercise are addressed in the patient’s treatment plan your patients can experience a significant decrease of their symptoms and a reduction of the time it takes to reach maximum chiropractic improvement, while going thru their care with you.
Very often in the busy chiropractic practice, it is difficult to address spinal flexibility and spinal exercise rehab on a one-on-one basis, so a spinal flexibility and spinal exercise rehab class offers viable options 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 adding 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 the staff and you yourself 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 flexibility procedures and 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, and 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 flexibility and 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 flexibility and or 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 where 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 flexibility or 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 flexibility or 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 flexibility and 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 flexibility procedures and exercises while you explain them.
Overall, this type of classes will give you real flexibility and strength, no pun intended, to prepare your patients for spinal flexibility and spinal exercise rehab. It will also create an opportunity for your patients to be able to ask any questions of you, the physician, either in the class or in future appointments relevant to spinal flexibility or 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 various options you will have will be almost limitless, and gives you better patient management overall.
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 thread like 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
[The interaction of Myosin and Actin Filaments binds strongly with each other in the absence of tropomyosin and troponin, and in combination with the presence of magnesium and ATP both of which are normally abundant in the myofibril, but one of the globular proteins in troponin has a strong affinity for actin, another globular protein of troponin has a strong affinity for tropomyosin, and the third globular protein of troponin has an affinity for calcium ions. If the troponin-tropomyosin complex is added to the actin filament, this binding does not take place. In the presence of large amounts of calcium ions, the inhibitory effect of the troponin-tropomyosin on the actin filaments is itself inhibited as soon as the actin filaments become activated via the calcium ions, it is believed that the heads of the cross bridges [the face of the golf club] from the myosin filaments immediately become attracted to the active sites of the actin filament, and this in some way causes contraction to occur.]4 You may desire to review your past physiology textbooks for a more in depth look at muscle physiology.
Chart #1
Chart #2 & #3
“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 anterior aspect of the neck-Sternocloidomastoid, Scalenus, Sternohyoid, Omohyoid,and Platysma muscles
In the anterior of the Thoracic / Lumbar spine– Rectus Abdominis, Internal Oblique, and External Oblique muscles
chart #4
chart #5
In the anterior 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 Capitus, Semispinalis Capitus, Splenius Cervicus, Rhomboideus Minor, and Romboideus Major muscles
Deep in the posterior aspect of the neck: Rectus Capitus, Superior Oblique,
Inferior Oblique, and the Levator Scapula muscles
In the posterior of the Thoracic spine– Erector Spinae, Latissimus Dorsi, Spinalis Thoracis, Romboideus Major, and 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, and Quadratus Femoris
chart #6
In the posterior of the upper leg– Biceps Femoris, Iliotibial Band, Semitendonous, Semimembraus, Adductor Magnus, Gracilis, Vastus Lateralis
In the posterior 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 #7
For all intensive purposes, we will not be referring to these individually, but we will make reference to them either as groups or as a single muscle that represents the group. As we try to convey to our patients, it could 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 trying to figure out which muscle was which.
Basic Review of Spinal Structures
In review of the various spinal structures our focus will be on the articular surfaces. The main reason for this will be because most soft tissue injuries occur between the interface of the articular surfaces of the bones, the associated soft tissue, the connective tissue, and the nearby muscle structure, and if you’re going to prescribe either a spinal flexibility or spinal exercise class it will be helpful to identify and qualify the location and severity of the injury. This is not a class on spinal trauma nor anatomy, but it will help to set the stage for determining the when, how, why, where, and what to do in regards to a spinal flexibility or spinal exercise class.
Of course the most basic review is the fact that there are seven cervical vertebrae, 12 thoracic vertebrae, and five lumbar vertebrae. The skull, two iliums, sacrum, along with the coccyx to round out the rest of the spinal structures.
The Atlas and Axis vertebrae or the C1 and C2 spinal segments have a very unique appearance. The superior and inferior articular facets of C1 form joints between the condyles of the occiput and the C1 vertebrae and the superior articular facet of C2 with the inferior articular facet of C1. The plane line of these joints is close to parallel to the ground. The Dens process of C2 forms an articular surface with the anterior arch of C1. From the inferior articular facets of C2 through the superior articular facets of C7 there are joints formed called facet joints. The next joints we will cover are the uncovertebral joints from the C2 through the C7 vertebrae. They are formed from the most lateral aspects of the vertebral bodies both superiorly and inferiorly. Of course the last joint that will be cover in the cervical spin is the intervertebral disc joint which joins the vertebral body of the vertebrae above to the vertebrae body below from C2 to C7. The thoracic vertebrae are also made up of 12 pairs of facet joints and the 12 intervertebral disc joints. The transverse process of the thoracic vertebrae form an articular surface bilaterally with the 12 pairs of ribs. The lumbar vertebrae are comprised of five pairs of facet joints and five intervertebral disc joints; the last of which forms an intervertebral disc joint with the superior articular surface of the sacrum. The lateral aspects of the sacrum form an articular surface with the iliums making up the sacroiliac joints. The last spinal joint being that of the apex of the sacrum forming articulation with the coccyx.
These vertebrae and articular surfaces are held in place by ligaments. The ligament in front of the vertebral bodies is known as the anterior longitudinal ligament. The ligament in the posterior aspect of the vertebral body inside the spinal canal is known as the posterior longitudinal ligament. The ligament between the spinouses of two associated vertebrae is known as the interspinous ligament. The ligament that extends from between the spinouses in the posterior aspect of the occiput and continues to run posterior and inferior in the cervical spine is known as the Ligamentum Nuchae. It then turns into the super spinous ligament in the thoracic and lumbar spine. The intervertebral discs are composed of the outer rings known as Anulus Fibrosus, and the inner portion known as the Nucleus Palposis. The Ligamentum Flavum extends from the superior articular facet of one vertebrae to the base of the pedicle on the vertebrae above it. Capsular ligaments surround the facet joints encapsulating them.
chart # 8
chart #9
chart # 10&11
chart # 12 & 13
The ligament between the transverse processes and the ribs include the lateral costo-transverse ligament, the posterior costo-transverse ligament, and the superior costo-transverse ligament.
chart # 14 & 15
Clinical Case Management
To determine the clinical necessity for a spinal flexibility or 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 flexibility or 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 flexibility or exercise class for, you would need to do a range of motion study of that associated area. For example, if a shoulder 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 flexibility and 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 make 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 or exercise 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. Very often in ROM units like the ones mentioned above, they will print out a report for you, and that 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 strength grading is another evaluation that you would want to perform in either your initial evaluation or update evaluation. 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 for grading muscle strength, for example, a grade of 0-flaccid to 5-normal will be important in determining the need for a spinal flexibility and or 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 a comparative electronic/computerized muscle testing evaluation. 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 flexibility and spinal exercise class.
Radiographic evaluation is another method to determine the clinical necessity for a spinal exercise class. In review of either the cervical or lumbar radiographic evaluations, certain findings will be consistent in determining the need for a spinal exercise class. These findings include on the lateral x-rays of either the cervical or lumbar spine, a loss of the normal curvature as typically seen on this view. 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 addition. 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 disc, the apophyseal or facet joints, and ligamentous structures between the vertebrae.7 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.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 flexibility or exercise class. It should also be noted if the amount is less than the above parameters 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 flexibility or 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 flexibility or 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 flexibility or 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 flexibility or 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 Flexibility or Spinal Exercise Class
At this time, for the spinal flexibility and spinal exercise classes 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 straight forward. [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.]9 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 one 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 set of 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 or it may be the patient’s responsibility for any additional units charged. It is best when doing your first insurance verification to ask about such a question, and then you can note it in the patient’s file, and note this on your insurance verification forms this communication with the insurance carrier, so if there is ever a question you have it documented. As a matter of habits you may desire to tape any of your insurance verifications so that the specifics of your communication or questioning may be established at anytime. Proper documentation in the patient’s file is required for any time-based code. So you will want to make sure that you document the time, date, location, and any physician to patient encounters and communications.
[The RVU of 97150 is .48; to give you a comparison that has real merit to let’s compare to, 98940 which has a RVU of .68, and 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 you have preset, 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.
When you consider utilizing the Online Videos of the Spinal Flexibility and Spinal Exercise classes either in conjunction with the In-person Spinal Flexibility or Spinal Exercise Class, or separately by themselves, 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 gymnastics ball (for stretching and strengthening).]13 While this procedure code would seem that it fits 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 way 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 flexibility or 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, and 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 one 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 to physician code. Because you will be in a group, this code would not be the recommended code for such a circumstance. Again if in future visits your desiring to make any clarifications, increase patient compliance, answer any patient questions, or further delineate any specific flexibility or strengthening procedures, this code may be utilized.
There is only one exception that I have seen in clinical practice, and this should be used with caution. 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 flexibility and or 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 the type of class you plan on teaching whether it is just a spinal flexibility or spinal exercise and / or an aerobic exercise class, so that you’ll know whether you should utilize the 97110 and /or 97112 code. The Chiro Code Desk Book can be a good resource to determine which code you should use to assist you in this manner. The board of chiropractic examiners in your state and the chiropractic association in your state will be good resources for questions in this area. It’s much better to find out in advance 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 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.
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 of text marked “FLEXIBILITY”.)
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. It applies an easy to learn methodology with the patient being able to do the various procedures by themselves.
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, or 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 Stretching (or bouncing): 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 of stretching 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 the static stretch below. Your doctor may also 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 longer you stretch the more benefits you will notice.
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 can cause pain, as well as physical damage due to the microscopic tearing of the muscle fibers. This tearing leads to the formation of scar tissue in the muscles, with a gradual loss of elasticity in the muscle being stretched. The muscles will also become tight and sore. How can you get enthused about daily stretching and exercise when these potentially injurious methods are used? so no bouncing!
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.
Specifics on Flexibility
In the next four pages you will find diagrams/pictures that represent various stretches. In a typical spinal flexibility class, initially the first three pages marked, “FLEXIBILITY” are gone over with various patients attending the class, so they will have a good basis on which they can then perform the various stretches. Following the initial 3 pages of information given, the number of stretches, and the type of stretches on the following 4 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 on our website or 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 and or exercise 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.
The diagrams have a brief description of the actual flexibility procedure being performed. Additional information is given to help you, as the physician, to give instructions on how the procedures are to be performed. For example, how many sets and reps to perform, how long you are to hold the various procedures, how long to rest in between, and how often you are to perform them in the week. There is a calendar to even be more specific on dates to perform and or the history of how often they performed the procedures.
The various diagrams can assist you in the class, to help you show the procedures without you having to get into the procedure yourself, and as you go around assisting the patient’s, with the procedures, they very often will be referring to the diagrams to try to follow along.
Each stretching procedure typically will be explained, and then it is beneficial to have each of the patients get into the position with the physician tweaking the patient’s position so they can feel the stretch.
You may want to either perform the stretch / exercise yourself as they watch or you may want to have an assistant with you to put into the various positions, so that you will be able to show the procedures more clearly.
Remember to have fun with it. No one wants to listen to someone that is stale or melancholy. I will often have my class on the busiest day, because I am the most pumped up for such a class.
The first four stretches I usually recommend to perform in the shower, and the rest I will typically recommend adding to the going to bed time or wake-up time. This will make adding this program easy, at list initially, for just about anyone’s lifestyle.
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:
- Muscle strength
- Muscle power
- Muscle endurance
- 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
[Increased 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 are performed by low resistance and high-repetition exercises ie: (hundreds of time each day until fatigue is reached). The load should be between 15% to 40% of maximal strength.]18
[Muscles 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 [the] optimal increase in muscle strength [yet] 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 [also] 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 hypertrophied muscle fibers themselves include: increased numbers of myofibrils proportionate to the degree of hypertrophy, increased numbers and sizes of mitochondria, as much as 25 to 40% increase in the components of the phosphagen metabolic system including both ATP and phosphocreatine, as much as 100% increase in stored glycogen, and as much a 75 to 100% increase in stored triglycerides or (fat). In addition, the enzymes required for the oxidative metabolic system are increased,[and thus you will see] an 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 muscles have a higher preponderance of slow twitch muscle fibers and therefore [is used for muscle contractions that allow] for prolonged lower leg muscle activity. The basic differences between the fast twitch and the slow twitch fibers are the following:
- Fast twitch fibers are about two times as large in diameter.
- 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 as in 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.
- 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 more importantly, this myoglobin increases the rate of diffusion of oxygen throughout the fiber by shuttling oxygen from one molecule of myoglobin to the next, also the enzymes of the aerobic metabolic system are considerably more active in slow twitch fibers than in fast twitch fibers.
- 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: Specific adaptation to impose demand (SAID) and 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:
- Increase the speed of movement
- Increased resistance
- Increase the number of repetitions
- Increase the frequency or duration of workouts
- Decrease the recovery time between workouts
- Alter the form of exercise
- 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 is made. As function and strength improve, progression to faster, functional and eccentric exercises may occur in the advanced stage.]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:
- Adequate warm-up to increase the body temperature and metabolic efficiency
- Good control in the performance of the exercise
- Pain-free performance of exercise
- Use of a slow, pain-free pattern initially with little or no resistance to develop a good base for neural patterning to occur
- Comprehensive stretching program to restore/maintain full range of motion
- muscle strengthening throughout the entire range of motion available]25
The three main types of exercise to use 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 each with a rest of 10 to 20 seconds (in between each set). 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 results in the 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 fiber shortens during concentric contraction.]28
[Eccentric-a lengthening isotonic contraction where the origin and insertion of the muscles separate. The individual muscle fibers lengthen during eccentric contraction.]29
[Isokinetic exercises are performed on devices and have a fixed speed with the variable resistance that is totally accommodative to the individual throughout the range of motion.]30 For this spinal exercise class, we will not be recommending this type of exercise due to the nature and type of machines that are 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. We also desire to support you through a patient in home video on Spinal Exercise that you resell to your patients for your own additional profit. This way you will be able to further increase your patient compliance with this portion of your care.
The next three pages will cover who should perform spinal exercise, and the when, why, and how to exercise in this program. The pages will also cover the spinal exercise (initially), the spinal exercise (progression), the spinal exercise (maintenance), some additional information on how aerobic exercise fits in, and how spinal flexibility also plays a part. You will also have a log sheet to chart your progress. The next two pages after that will help you document for the insurance carrier and your patient’s file, that you have performed a spinal exercise class for that given patient, and you’ll also have an evaluation sheet where the patient can give you positive feedback on how he or she felt that you presented the material in the class.
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 the 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 presently 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 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 8 to 10 set of each exercise, with 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 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 an additional set of 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 of 3 to 5 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 very 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. Also with this being the case, it is helpful for you to stretch twice as long after you have exercised.
SPINAL FLEXIBILITY CLASS / SPINAL EXERCISE CLASS GROUP
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 spinal flexibility class / spinal exercise class for the time mentioned above and the information about the who, when, why, and how for the specific class has been gone over and I understand the information presented.
The individual spinal stretches / spinal exercises 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 Spinal Flexibility / Spinal 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 pain management
spinal exercise / strengthening Spinal 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
The next four pages will cover some specific exercises that you may find useful to formulate a structure for the type of exercises that you may want to develop and use in your spinal exercise class. You can use the Patient Online Spinal Exercise Video in place of an in office Spinal Exercise Class or in combination with the class.
Each exercise on the On Line Spinal Exercise Video has been chosen so that the patient can start the program by simply going to Walmart and get the two gym balls and a couple of free weights that are there, one small one gym ball, one large one, and two free weights from 2-5 lbs. We specifically used the ones from Walmart for this purpose. It would be just as easy to sell them this durable medical equipment if you like, for additional profit to you.
Charts 21 – 24 Below
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 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, and 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 of 400% that is, a cardiac reserve of 400%. Any factor that prevents the heart from 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 #25
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 or 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, then 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#26 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 in 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, at least during submaximal activity. Aerobic training effects can be gained by maintaining a heart rate of between 70 to 85% of the maximum heart rate of the individual.]33 Please note that this reference is recommended for a 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 muscles include an increase in the mitochondria of skeletal muscle, 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 for you is to be able to exercise for the length of time recommended for cardiovascular exercise, and the specific number of times per week needed. 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 at 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]
Choose 50%, 60%, or 70% based on how often you exercise presently; Choose 50% – if you don’t exercise presently,
Choose 60% if you exercise – 3-5x’s per week, or Choose 70% for those individuals that exercise on a daily basis.
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 of 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
- Initially start with Flexibilityto prepare your muscles for activity 5-10 minutes
- Start “Warm-up exercise” at a slower pace for 5-10 minutes
- Continue with “Aerobic exercise” at your Target heart rate (monitoring your heart rate throughout) for 15-30 minutes
- When Aerobic Exercise is complete STOP
A. Check your pulse initially
B. Wait one minute then recheck your pulse
C. Subtract the two to see your cardiovascular efficiency
- Then continue exercising in the “Cool down” phase also at a slower pace for 5-10 minutes
- Then finish with your post exerciseFlexibility to stretch you out the muscles from your exercise. 10-15 minutes.
Your total time to exercise will take you 45 minutes to 75 minutes each time.
You will want to use your cardiovascular exercise log sheet to chart your progress
THE OVERTRAINING SYNDROME
Emotional Warning Signs
- Increase in nervousness or depression.
- Inability to relax.
- Desire to quit training, skip training sessions, or quit during competition.
- A mental attitude of “I don’t care.”
- A drop in academic performance or in job performance.
Body Warning Signs
- Extreme muscle soreness and stiffness the day after a hard training session.
- A gradual increase in muscle soreness from training session to training session.
- Decreasing body weight, when no effort to decrease body weight is being made.
- Inability to complete a training session that typically in their present physical condition it is reasonable to assume that they would be able to complete.
- 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.
- Lowered general physical resistance as shown by a continuous cold, headaches, etc.
- Loss of appetite.
- Swelling of the lymph nodes in the neck, groin or arm pits.
- Constipation or diarrhea.
- Unexplained drop in athletic performance.
When signs of overtraining are present it is advisable to suspend training for one or more days or to decrease the intensity and/or duration of the training for one or more days. If strong signs of overtraining are present, it is possible that the athlete / patient will have to spend days or possibly weeks at a decreased level strenuousness during training, until your physical condition recovers sufficiently to allow you to resume a more aggressive training schedule.
In summation, whether you already utilize spinal exercise rehabilitation in your office or not, a spinal flexibility and or spinal exercise class will add greater depth to your patient’s treatment plan. They will provide you with an opportunity to develop a consistent methodical approach to teaching spinal flexibility and spinal exercise.
- This program will help to increase your patient’s compliance at home. And you as the physician will get a better understanding of your patient’s comprehension as they attempt to maneuver in and out of these spinal flexibility and spinal exercise procedures. You will be able to establish a good baseline of education for your patients in these topics. 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.
- By taking the time to get your chiropractic assistants to be on board, and having them to aid you in this process, the actual setup and transition time should be less and it should move smoothly and efficiently.
- The proper coding, patient handling, and patient clinical case management should be easy to follow utilizing the information in this class.
- As we stated earlier, you may desire to break down the classes into two or three components, one or two on the actual spinal exercises and another on the aerobic exercise portion. You may also find that you would like to break down the spinal flexibility class into an upper spinal flexibility class, and a lower spinal flexibility class. Either way, your bottom line will increase according to the number of classes you add.
- If you add the online patient videos for “Spinal Flexibility” and “Spinal Exercise”, you will add a valuable additional resource for the patient. Typically, the most commonly asked question after a class is: “Do you have a DVD of this class that we can get for home?” The online videos will also be a benefit for those individuals that are unable to attend the class due to schedule conflicts. If you make the online videos an integral part of the program with each new patient, you will be giving the patient a resource they will be able to use for years.
- I don’t know of many other resources for your patients that are such a positive piece in the patient’s treatment plan. Especially since these don’t take much of the doctor’s or staffs’ time at all. Yet this resource gives such a great return on investment for everyone involved.
- By adding a spinal flexibility and or spinal exercise class along with the online videos 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.
- 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
15,16,17,18 Basic Chiropractic Procedural Manual, R.C. Schafer DC.,F.I.C.C. pp.484,486
19,20,21,22,23 Textbook of Medical Psyhology, Guyton 1986 p.1013
24-30 Clinical Sports Medicine, Peter Brukner, Karim Khan, pp. 132-135.
31,32 Textbook of Medical Psyhology, Guyton 1986 pp.312-313.
33,34 Clinical Sports Medicine, Peter Brukner, Karim Khan, pp 74.
CHARTS / GRAPHS
2,3 Textbook of Medical Psyhology, Guyton 1986 pp.1201,
4,5,6,7 The Human Body, Charles Clayman pp. 50-52.8Anatomical Charts, 1990 Whiplash Injuries
9-12,14 Grant’s Atlas of Anatomy 8thed. fig. 5-21,5-20,5-17, 5-19, 5-31A James Anderson13,
15 Gray’s Anatomy, pp. 224, 236. Henry Gray
16-19 Phases Rehab. Computer Program
20 Textbook of Medical Physiology pp.313. Guyton
21 Y’s Way to Physical Fitness, Golding 1989
Test
“Practical Spinal Rehab”
- A spinal flexibility and spinal exercise class if administered correctly will add depth to the patient’s treatment
True False
- The goal of the class is to teach you how to adjust properly?
True False
- Very often in the busy chiropractic practice it is easy to address spinal exercise on a one on one
True False
- The class does require some space, but very often there are places in the Community where you may deliver such a
True False
- 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
True False
6. Skeletal muscles consist of densely packed groups of elongated cells known as:
a) myofilaments c)actin
b) myosin d)muscle fibers
- The myofilaments in each myofibril are divided transversely by Z bands along the length of the muscle fiber into units called:
a) sarcomeres c) troponin
b) tropomyosin d) actin filament
- When a muscle contracts, the thick filaments, slide farther in between the thin filaments, rather like interlacing fingers, and draw closer to the .
a) Z bands c) calcium in the tissue
b) myofibrils d) Actin only
- Muscles in the anterior of the Thoracic / Lumbar spine are:
a) Rectus Abdominis c) External Oblique
b) Internal Oblique d) All of the Above
- The intervertebral discs are composed of the outer rings known as:
a) nucleus palposus c) Ligamentum Nuchae
b) Anulus Fibrosus d) interspinous ligament
- The Ligamentum Flavum as shown on chart # 9 is attached to the anterior vertebral body?
True False
- On the Chart # 15, the ligament that attaches the neck of the rib with the transverse process is:
a) Anterior Costo-Transverse c) Middle Costo-Transverse
b) Interspinous d) Two of the above
- The thread like cells of the muscle fibers can be up to 1 foot
True False
- Each thin myofilament consists mainly of a protein, and , another protein that can inhibit contraction.
a) myosin, sarcomera c) golf clubs, tails
b) actin, tropomyosin d) Z-bands, myofibril
- Over 600 muscles make up nearly of the weight of the human
a) 25% c) half
b) 40% d) 3/4
- Which muscle is not included in the muscles of the anterior aspect of the neck
a) sternocloidomastoid muscle c) omohyoid muscle
b) Platysma muscle d) Popliteus muscle
- 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 reflex c) dual inclinometric
b) muscle strength d) computerized muscle
- 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
True False
- If the average (range of motion) is less than 50 degree, three consecutive measurements must fall within 20% of the
True False
- If the average (range of motion) is greater than 50 degrees, three consecutive measurements must fall within of the
a) 5% c) 15%
b) 10% d) 20%
- The ICDM code for a computerized R.O.M. study is:
a) 007 c) 95851
b) 98941 d) – 59
- Studies have shown that a muscle strength loss of 30% is needed before average practitioner will detect a
True False
- The – 59 code indicates that you are doing a and
procedure from any other procedures being performed on that same visit.
a) combined, disjointed c) small, large
b) separate, distinct d) unique, similar
- 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
a) 1.0 mm c) 3.5 mm
b) 3.0 mm d) 4.0 mm
- The code that you would want to use for either class is 97150 which is therapeutic procedures, group (2 or more individuals).
True False
- 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 23 c) 15 to 20
b) 10 to 15 d) 7 to 22
- The 97110 code is a good code for any follow-up visits with the patient on a one on one
True False
- A – 52 modifier basically states that you are doing more than a full unit of this
True False
- The ligament in front of the vertebral bodies is known as:
a) Posterior Longitudinal Ligament c) Anterior Longitudinal ligament
b) Interspinous ligament d) Ligamentum Nuchae
- 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
True False
- The RVU of 97150 is while 98940 has a RVU of .
a) .22, .33 c) .84, .96
b) .48, .68 d) .21, .32
- Ballistic Stretching is a type of stretching that I describe as bouncing
True False
- The four components of muscle conditioning include:
a) Muscle Strength c) Muscle Power
b) Muscle Endurance d) All of the above
- All muscles have varying percentages of fast twitch and slow twitch muscle
True False
- Muscles that function under no-load, even if they are exercised for hours upon end, increase little in
True False
- Fast twitch fibers are about two times as large in diameter than slow twitch
True False
- Fast twitch fibers can deliver prolonged strength of contraction over much longer periods of
True False
- An isometric exercise occurs when a muscle contracts without associated movement of the joint on which the muscle
True False
- Concentric – a lengthening isotonic contraction where the origin and insertion of the muscles
True False
- I enjoyed the class and the information given
True False