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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 Necessity

Objective 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 NeuromuscularRe-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 LawOf 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

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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

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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)

EYESCLOSED

(seconds)20-59 29-30 21-28.860-69 22.5 1070-79 14.2 4.3

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Navigating the Active Care Maze

Influencing Longevity through Postural Correction