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Navigating the

Active Care Maze

Influencing Longevity through Postural Correction

The Posture Connection

• Posture has become one of the most overlooked aspects of good health and longevity.

• Research has shown a clear and direct connection between poor posture and diminished quality and longevity of human life.

• Spinal pain, headache, mood, blood pressure, pulse, and lung capacity are among the functions most easily influenced by posture.

“You are only as young as

your spine.”

Jack LaLanne, DC

Anterior Head Movement

• As the head moves forward all measures of health status are significantly reduced.

• Rene Cailliet, Director of the Department of Physical Medicine and Rehabilitation, University of Southern California, concluded that forward head posture can add up to thirty pounds of abnormal leverage on the spine, reduce lung capacity by as much as 30%, which can lead to heart and blood vascular disease.

• He determined a relationship between forward head posture and the digestive system as well as endorphin production affecting pain and the experience of pain.

Imagine Your Head As A

Bowling Ball

• And your neck as the hand that holds that ball. Imagine letting the bowling ball sit in the palm of your hand with your arm tucked tight into your body.

• Slowly move your arm away from your body while continuing to palm the ball.

• The weight of the ball will put more and more stress on your arm as it moves away from your body until the weight causes failure or injury to occur.

According to Kapandji, Physiology

of the Joints, Volume III

• For every inch that the head moves forward in posture, it increases the weight of the head on the neck by 10 pounds.

• In the example to the left a forward neck posture of 3 inches increases the weight of the head on the neck by 30 pounds and the pressure put on the muscles increases 6 times.

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The British Regional

Heart Study

• As a part of the British Regional Heart Study scientists found that men who lost 3cm in height were 64% more likely to die of a heart attack than those who lost less than 1cm and that over the 20-year period of the study, men lost an average of 1.67cm.

• That height loss was associated with a 42% increased risk of heart attacks, even in men who had no history of cardiovascular disease.

Our Posture =

Our Emotional State

• We can tell a lot about a person from the way they carry themselves.

• For instance, picture the way someone stands when they are feeling depressed: mid-back and shoulders rolled forward, head hanging, gaze focused on the ground.

• Not exactly the picture of health.

Yoga gurus have

long said that it

is impossible to

be depressed

with your

armpits open.

Posture & Life Expectancy

• A group of scientists led by Dr. Deborah M. Kado wanted to see if there was any correlation between postural distortion and a person’s health.

• They started with the biggest health problem: death.

• They asked: “Was there any correlation between a person having a hyperkyphosis and having a decreased life expectancy?”

The Frightening

Long Term Effects

• Dr. Kado reported in the Journal of the American Geriatrics Society that persons with hyperkyphosis (hunched over – head and shoulders rolled forward) were two times more likely to die from pulmonary causes.

• They were also 2.4 times more likely to die from cardiovascular disease than those without poor posture.

Too Much Sitting

Can Shorten Your Life

• According to a study from the American Cancer Society the amount of time you spend sitting can affect your risk of death.

• Prolonged periods of sitting have a negative influence on key metabolic factors like triglycerides, high density lipoprotein, cholesterol, and a number of other biomarkers of obesity and other chronic diseases.

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To live a long, active,

energetic life, few things

matter more than posture.

This quote by Thomas

Meyers, Author of Anatomy Trains, says it all…

“Movement becomes habit,

which becomes posture,

which becomes structure.”

Postural Assessment is Key

• Postural assessment and correction is the key in the majority of non-traumatic neck pain.

• It's not uncommon to observe 2" of anterior head placement in new patients.

• Would you be surprised that your neck and shoulders hurt if you had a 12 pound bowling ball hanging around your neck?

Are You Passive

About Active Care?

• Your practice is filled with patients with acute and chronic conditions that are treatable and preventable with Active Care.

• And yet, according to a recent Chiropractic Economics survey, only 50% of DCs offer their patients ancillary services such as Active Care exercises or functional testing.

• Are you ready to do something about it?

Medical

NecessityObjective

Documentation of Positive Functional

Improvement

Fitness Center Drop Outs

• Studies show that 80% of new members stop going to their Fitness Center after only 3 weeks.

• Active Care provides an excellent opportunity for your practice to stand out in your community.

• Patients want to know what they can do for themselves to keep fit and healthy.

• They don’t want services that become stale or boring!

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The Solution

• Provide two types of care: pain relief and preventive management

• Pain relief is where chiropractic adjustments and physiotherapeutic modalities thrive; preventive management is where rehabilitation thrives.

From Pain To Performance

Rehabilitation

• Rehabilitation of the motor system is concerned with restoration of function, not merely pain relief.

• The ultimate goal of care is to improve a patient's physical performance capacity so that they can handle the demands of their activities of daily life or job.

The Continuum

• From Passive To Active Care

• How does a rehabilitation specialist approach conservative care?

• A continuum of care incorporating a gradual transition from passive to active care approaches is employed to facilitate the "weak link."

• Passive to Semi-Active to Active

Step 1: Prevention

• Ergonomic advice relaxation strategies, and general postural re-education

• A job analysis should uncover if keyboard, telephone, pushing, pulling, sitting, carrying, reaching, etc., demands are poorly controlled or unsafe.

• Passive

Step 2: Normalize Joint

Dysfunction

• Chiropractic Adjustments

• Joint Manipulation

• Passive

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Step 3: Restore Muscle Balance

• Trigger Point Therapy

• Passive

• Post-Isometric Relaxation (PIR) of overactive antagonist muscles

• Semi-active

• Self-stretches for the tight/overactive muscles

• Active

• Exercises to retrain proper motor control, coordination, strength and endurance

• Active

Step 4: Reprogram

• Coordinated Movement Subcortically

• Reflex activation of intrinsic stabilizers by Propriosensory Training

• Swiss ball; rocker/wobble board training

• Active

Therapeutic Procedures

Correct Coding for Active Care

Active Care

• Therapeutic Procedures are time-based codes.

• Billed in 15-minute units beginning with 8 minutes.

• The patient is active in the encounter.

• Require direct one-on-one patient contact by provider of the service.

97110 Therapeutic Exercises

• Develop one functional parameter: strength, endurance, range of motion, or flexibility

• Treadmill for endurance

• Isokinetic exercise for ROM

• Lumbar stabilization exercises for flexibility

• Stability ball to stretch or strengthen

97112 Neuromuscular

Re-education• This procedure may be

considered medically necessary for impairments which affect the body's neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity) that may result from disease or injury such as severe trauma to nervous system, cerebral vascular accident and systemic neurological disease -Aetna CPB 0325

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97530 Therapeutic Activities

• Used when multiple parameters are trained including balance, strength, and range of motion.

• Must be related to a functional activity with direct functional improvement expected.

• Use Outcomes Assessment Tools.

97150 Group Therapy

• When supervising more than one individual, for a service that requires direct supervision, use code 97150 for each patient.

• For example, if NMR is performed in a group setting, use code 97150 — do not use 97112 and 97150 at the same time.

• Billed once per session.

The Physical Examination

Documenting Medical Necessity

Be Data Driven

• An insurance adjuster must be able to see what you see with the patient.

• Include measurements, comparison data, test results, co-morbidity, unusual circumstances to paint a picture of what’s going on with the patient.

• In order to document your outcomes you must first decide which outcomes to track!

Muscular Dysfunction

• Most clinicians are extremely skilled in the analysis and treatment of joint dysfunction, but neglect the subject of muscular dysfunction.

• Most overlooked aspects of muscular dysfunction is muscular tightness.

• How can we give exercises without first testing for the tight muscles?

Muscle Imbalance

• Occurs in a systematic fashion

• Predictable shortening in muscles such as the upper trapezius, suboccipitals, erector spinae, iliopsoas and hamstrings

• Concomitant lengthening or inhibition occurs in the lower trapezius, deep neck flexors, deep abdominals and gluteals.

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Why is this so?

• Muscles which relate to the fetal position, static work postures or slumping become overactive or even shorten, while muscles which relate to the neuro-development of upright posture or dynamic joint stability tend to become inhibited or even weak.

• Modern society's emphasis on constrained postures and sedentary lifestyles promotes this imbalance between overactive and inhibited muscles.

Functional Postural

Analysis

Breakthroughs In Active Care

Upper & Lower

Crossed Syndromes

Navigating the

Active Care Maze

Sherrington’s Law

Of Reciprocal Inhibition

“The ON - OFF Law”

BICEPS = ON

TRICEPS = OFF

Facilitated = Tight/On/Short

STRETCH

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Inhibited = Weak/Off

STRENGTHEN

Posterior View

Lateral View

Upper Crossed Syndrome

Lower Crossed Syndrome

Facilitated Muscles

• SUBOCCIPITALS

• SCM/SCALENI

• LEVATOR SCAPULAE

• UPPER TRAPEZIUS

• PECTORALS

• ERECTOR SPINAE

• ILIOPSOAS

• HAMSTRINGS

• SOLEUS

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Inhibited Muscles

• NECK EXTENSORS: RECTUS CAPITUS

• DEEP NECK FLEXORS: L. CAPITUS/COLI

• SCAPULAR STABILIZERS: SERRATUS ANTERIOR

• ABDOMINALS

• GLUTEUS MAXIMUS/MINIMUS

• QUADRICEPS

Upper Crossed Posture

Flying Buttresses

“Gothic Shoulders”

Lower Crossed Posture

The “Beer Belly Posture”

Implementing Active Care

in a Busy Practice

5 Unskippable Steps

This Is Your Patient

• No Time

• No Insurance

• No Patience

• Stressed

• Overwhelmed

• Want their visit fast and fun!

Text Neck

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Sitting Disease

The Solution

1. Address Faulty Ergonomics

2. Correct Spinal Dysfunction

3. Stretch the tight muscles

4. Strengthen the weak muscles

5. Lock it in with Proprioceptive Training

1. Correct Ergonomics

ADL Instruction

2. Correct Spinal Dysfunction

• Manual Palpation

• Motion X-Ray

• Sigma Instrument

• Adjustments

3. Your Friend

the Foam Roller

Implementing Active Care in a Busy Practice

11

Tips for Effective Foam Rolling

• Fascia is a thick, fibrous web of tissue. As such, it can’t be released with a quick pass of the foam roller.

• You need to be slow and deliberate in your movements.

• Once you find a sensitive area, slowly work back and forth over the spot.

• Be gentle at first.

• Start with half your body weight, using your hands or other leg to adjust pressure, and slowly work into full body weight.

• The maximum amount of time you should spend on any one area is 20 seconds or so.

• After this, you only risk irritating the spot more than you’re helping it.

Neck Extensors

Thoracic Spine Extensors

Low Back Extensors

Hamstrings

Quadriceps

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4. You’ve Got to Love

TheraBand™ CLX Loops

Implementing Active Care in a Busy Practice

TheraBand™ CLX

• TheraBand™ CLX Consecutive Loops deliver versatility and ease of use that change how people experience exercise and rehab.

• It's all in the loops, which are versatile, and simple.

• According to multiple studies, the elastic resistance used in TheraBand ™ CLX Consecutive Loops is equivalent to weight training in strength curve, muscle activation, perceived exertion, and strength gain.

• The CLX loops provide multiple, unique grip and anchor options.

Cervical Extension

4. Lock It in with

Proprioception Training

Navigating the

Active Care Maze

13

One Leg Stand

• The doctor is near the patient.

• The patient stands on one leg; nonsupport leg is bent 60 degrees at the hip and 90 degrees at the knee so that the ankle is at the height of the support leg's knee.

• The patient maintains the position as long as possible.

• Time the duration the position can be held, i.e., until the patient moves the support foot, puts other foot down, or reaches out to grasp with the hand(s).

One Leg Stand

Normative Data

AGE

(years)

EYES

OPEN

(seconds)

EYES

CLOSED

(seconds)

20-59 29-30 21-28.8

60-69 22.5 10

70-79 14.2 4.3

Navigating the

Active Care Maze

Influencing Longevity through Postural Correction

Let’s Work It!

Upper & Lower Crossed Postural Analysis

Movement Pattern

Analysis

Muscle Imbalance & Dysfunction

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Muscle Dysfunction

• Usually secondary to joint dysfunction

• The key to facilitating a weak muscle is to begin by adjusting the spinal fixation

• If abnormal movement patterns are repeated long enough, the muscle imbalances will become memorized as a faulty motor program.

Movement Pattern Analysis

• There are predictable muscle imbalances present in most of the patients you see.

• Six movement pattern tests screen for the proper functioning of the majority of the clinically significant muscles we address.

Movement Patterns

• Sedentary lifestyle leads to an overuse of the postural, anti-gravity muscles.

• Shortening or tightness develops along predictable lines in muscles that "fight" to maintain static posture against gravity.

• Other muscles have as their primary function maintaining stability during dynamic activities.

• Since we generally are working in constrained postures without much variety of movement, these dynamic stabilizers are underused and weaken or even atrophy.

6 Movement Patterns

1. Prone Hip Extension

2. Hip Abduction

3. Trunk Curl

4. Seated Arm Abduction

5. Trunk Lowering From Push Up

6. Supine Neck Flexion

1. Prone Hip Extension

• Palpation of the posterior musculature reveals a pattern of contraction from caudad to cephlad

• Hamstrings then Gluteus maximus then Erector spinae

• Premature contraction of a muscle indicates overactivity

2. Hip Abduction

• Hip Hiking:Overactive Quadratus lumborum

• Ratcheting:Inhibited Hip Abductors

• Anterior leg excursion: Overactive Iliopsoas.

• Posterior leg excursion: Overactive Hamstrings.

• External Rotation: Overactive Piriformis

• Internal Rotation: Overactive TFL

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3. Trunk Curl

• Ratcheting: Inhibited Abdominals & Overactive Erector spinae

• Foot lift prior to 30°of Flexion: Overactive Iliopsoas

• Chin poking: Overactive SCM and Suboccipitals

4. Seated Arm Abduction

• Elevated shoulder girdle prior to 30°of Arm Abduction: Overactive Upper Trapezius and Levator scapulae

• Inhibited Serratus anterior and Lower Trapezius

5. Trunk Lowering From A

Pushup

• Winging of the scapula

• Inhibited Serratus anterior

6. Supine Neck Flexion

• Ratcheting: Inhibited Deep Neck Flexors and Scalenes

• Chin poking: Overactive SCM and Suboccipitals

Grade 0 – 3

• 0 = Normal Movement Pattern

• 1 = Restricted Range of Motion

• 2 = Restricted Range of Motion + Instability

• 3 = Restricted Range of Motion + Instability + Ancillary Muscle Recruitment

Let’s Work It!

Movement Pattern Analysis

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Post Isometric Relaxation

Rehabilitation Through Manual Therapy

Muscle Histology: Active

Components

• The muscle-tendon contains active (contractile) and passive (non-contractile) components.

• The active component is related to the interaction between the contractile proteins (actin and myosin) within the muscle fibers.

Muscle Histology:Passive

Components

• The passive components consist of the connective tissue within and around the muscle (perimysium, epimysium, endomysium, sarcolemma).

• Muscle Stretching Technique has its main effect on the passive elements.

Reciprocal Inhibition

• Muscle imbalances once formed are easily perpetuated by reciprocal inhibition.

• The tighter muscles continuously inhibit their weakened antagonists, thus perpetuating the problem.

• This reflex occurs at a spinal cord level.

Post Isometric Relaxation (PIR)

• PIR is a gentle muscle relaxation technique that can be used to restore a muscle to its maximum length without dynamic stretching.

• There should be no pain.

• The patient is asked to resist with only minimal force (isometrically) and to breathe in for 8-10 seconds.

• Give the patient the auditory cue, “Don’t let me move you.”

Post Isometric Relaxation (PIR)

• The patient is then told to “let go” (relax) and exhale slowly. It is important for the therapist to wait to feel the relaxation.

• The therapist could wait 10 to 20 seconds or longer as long as relaxation is taking place. Due to pure relaxation there should be an increase in the range of motion.

• If the patient has difficulty relaxing, hold the isometric phase for 30 seconds before having the patient “let go.”

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Post Isometric Relaxation (PIR)

• Usually three to five times is all that is necessary to obtain spontaneous stretch each session.

• Along with the breathing, having the patient look up (with the eyes only).

• This helps facilitate the inspiration, which facilitates the muscle.

• Have the patient look down during expiration to aid in relaxation.

Post Isometric Relaxation (PIR)

• The following script helps patients get the hang of it.

• Explain the purpose of the stretch: to lengthen the small but tightly knotted part of the involved muscle.

• "Stretching pulls the knot loose, and when you release the stretch, fresh blood flows through the painful area of muscle. This washes away the pain-causing chemicals trapped in the knot."

Sternocleidomastoid

Syndrome• SCM is one of the most

complex muscles in the body

• The pain referral pattern of the SCM includes pain over the cheekbone, in the forehead, on top of the head, in and behind the ear, over the chin, over the SC joint, over the forehead, and deep in the throat.

Iliopsoas Syndrome

• If one was limited to directing treatment to a single muscle, probably the most profound effects could result by treating the iliopsoas muscle.

• The iliopsoas muscle plays a primary role in determining postural faults and may have a profound effect on the stresses placed on the lumbar spine, ultimately resulting in discopathy.

Let’s Work It!

Post Isometric Relaxation

Functional Capacities

Evaluation

Navigating the

Active Care Maze

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When To Perform

Functional Tests

• As soon as the patient is out of the acute pain phase of care; when the goal of care transitions from pain relief to functional restoration.

• Retest at each re-eval and update care plan.

• Include a battery of tests, which are safe, inexpensive, time efficient, reliable, and comparable to normative databases.

Functional

Performance Tests

• Dynamic Strength & Endurance Tests

• Flexor : Extensor Ratio Testing

• Balance & Coordination Tests

• Range of Motion Testing

Doctor & Patient Motivation

• Functional tests identify the patient’s “weak link”.

• If a patient is less than 85% of normal for any specific test, then rehab training is required.

• These tests provide unmistakable evidence that the patient’s condition may be due to factors in the patient’s and not the doctor’s control.

Functional Capacities

• “Valid, reliable, safe, practical, and responsive measures of trunk strength and endurance.”

• 4 Tests

• Repetitive Sit-up

• Repetitive Arch-up

• Repetitive Squatting

• Static Back Endurance

Endurance

Arch Up, Sit Up, Squats

Alaranta et al: Non-Dynamometric Trunk Performance Tests: Reliability and Normative Data. Scan J. Rehab

Med 26: 211-215 1994.

Physical Performance Testing

• “Valid, reliable, safe, practical, and responsive measures of trunk strength and endurance.”

• 4 Tests

– Repetitive Sit-up

– Repetitive Arch-up

– Repetitive Squatting

– Static Back Endurance

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Functional Test Procedures

• Repetitive Sit-ups - Arch-ups - Squatting

– 50 reps maximum

– 2-3 seconds per repetition

– “If the motion becomes clearly jerky or asymmetrical, the test should be stopped”

• Static Back Endurance

– 240 seconds maximum

– “Test discontinued if aggravated by pain or muscle spasm.”

Functional Test Guidelines

• Patient warm-up for 5 minutes prior to beginning testing (bicycle/ergometer)

• Tests are retested in the same order• 1-minute interval between each test

• Tester may count repetitions aloud but should remain as neutral as possible

• Test terminated if patient told more than one time to correct trunk motion

• Patient informed about mild painful feelings in tested muscle groups during the couple of days following the maximal test.

Balance &

Coordination Tests

Navigating the

Active Care Maze

One Leg Stand

• The doctor is near the patient.

• The patient stands on one leg; nonsupport leg is bent 60 degrees at the hip and 90 degrees at the knee so that the ankle is at the height of the support leg's knee.

• The patient maintains the position as long as possible.

• Time the duration the position can be held, i.e., until the patient moves the support foot, puts other foot down, or reaches out to grasp with the hand(s).

One Leg Stand

Normative Data

AGE

(years)

EYES

OPEN

(seconds)

EYES

CLOSED

(seconds)

20-59 29-30 21-28.8

60-69 22.5 10

70-79 14.2 4.3

Range of Motion Testing

Navigating the

Active Care Maze

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Global Range of Motion

Normative Data

Region ROM Global

Cervical F + E + L/R LF + Rot

385 deg.

Th-Lumbar F + E + L/R LF 175 deg.

Let’s Work It!

Functional Performance Tests

Low-Tech

Rehabilitative Exercise

Procedures

Navigating the

Active Care Maze

Stability Trainers

• The aim of core stability training is to effectively recruit the trunk musculature and then learn to control the position of the lumbar spine during dynamic movements.

• Thera-Band® Stability Trainers are closed cell foam pads with an anti-slip ridged surface and oval foot fitting shape.

• These foam pads are very effective for balance training, rehabilitation of lower extremities, and for sports performance enhancement.

Scapular Stabilization

Wall Angels

• Stand against wall with feet shoulder-width apart.

• Gently press lower back against wall.

• Place back of elbows, forearms, and wrists against wall.

• Bring arms up and down slowly in a small arc of motion while keeping elbows in contact with wall. Flap “wings” 3 sets of 10 repetitions.

Therapeutic Exercise

Progression

• Pain-Free Range of Motion

• Isometric Exercises

• Stretching Exercises

• Spinal Stabilization

• Strengthen with Resistance Exercises Tubing & High Tech

• Neuromuscular Re-Education

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Resistance Tubing

• Resistance Tubing involves the use of an elastic band that provides resistance to the active muscles.

• Resistance exercise increases muscle strength and mass, bone strength and the metabolism.

• It increases muscle strength by putting more than the usual amount of strain on a muscle.

• This increased load stimulates the growth of small proteins inside each muscle cell that play a central role in the ability of the muscle to generate force.

Thera-Band

Thera-Band Rehab

& Wellness Station

Floor Unit

Multi-Planar Wall Unit

Pro Series™ Exercise Balls

Stability Trainers

Fixed Length Tubing

Accessories

4 Instructional Posters

Exercise Software

Let’s Work It!

Spinal Stabilization

Flexor : Extensor

Ratio Testing

Navigating the

Active Care Maze

Recurrence & Chronicity

• If the flexors and extensors are not in the proper ratio and a patient is given exercises to strengthen both the flexors and extensors in equal proportion, the exercise will reinforce this dysfunction.

• The literature states that a patient with a reversal of the normal Flexor:Extensor Ratio has a much greater likelihood of recurrence and chronicity.

• For this reason, the Flexor: Extensor Ratio must be addressed prior to exercise.

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The Flexor/Extensor Ratio

• The extensors muscles of the lower back should be approximately 30% stronger than the flexors.

• This ratio is 1 to 1.3.

• The extensors muscles of the neck should be approximately 40% stronger than the flexors.

• This ratio is 1 to 1.4.

• This is called the Flexor/Extensor Ratio.

The Reality Of Health

Club Exercise

• Walk into any Health Club and you’ll see many people doing abdominal workouts and very few people doing back extensor exercises.

• Why, because it's not fun – everybody wants an abdominal six-pack up front!

• Everybody wants one, but unless you have the proper ratio, you can exercise your abs all day and you’ll still end up with a chronic low back condition.

Assess The

Flexor/Extensor Ratio• A strengthening exercise protocol should

begin by assessing the patient’s Flexor/Extensor Ratio and this can be done in several ways.

• You can use computerized muscle testing equipment, such as JTech.

• You can use weight stack equipment to measuring the Ten Repetition Maximum (10RM) Weight. This is the amount of weight that a patient can comfortably perform ten repetitions of in both directions of the plane of motion being analyzed.

An Alternate Method

• The 10RM can by measured with resistance against tubing by counting the number of repetitions the patient can perform in each direction and then checking the ratio.

• This method can be tedious. • You can also measure the 10RM with

resistance against tubing by measuring the duration of time the patient can exercise in both directions of the plane of movement with a stopwatch.

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• Breakthrough Coaching has built a solid reputation over 20 years by making practice less complicated, more profitable and more fun.

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Navigating the

Active Care Maze

Influencing Longevity through Postural Correction