chiropractic assistant: physical exercise training · 2 purpose of physical exercise training. •...

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Chiropractic Assistant: Physical Exercise Training

By

Steven G. Yeomans, DC, FACO

404 Eureka St.

Ripon, WI 54971-0263 920-748-3644 (O)

920-748-3642 (F)

[email protected]

Purpose of physical exercise training

• Goal 1: To provide you with an easy to learn format of physical exercise training.

Purpose of physical exercise training.


• Goal 2: To be able to apply this information in your clinic setting and implement exercise training into the patient’s treatment plan.

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Purpose of physical exercise training.


• Goal 2: To be able to apply this information in your clinic setting and implement exercise training into the patient’s treatment plan.

• A Pre-test and post test format will be used.

Delegation to unlicensed Persons

• Chir 10.01 Definitions

• Chir 10.02 Delegation of adjunctive services to unlicensed persons

• Chir 10.03 X-ray Services

• Chir 10.04 Patient History

• Chir 10.05 Physiological Therapeutics

Chir 10.01 Definitions

• 1) Adjunctive Service: preparatory or complementary to the chiro adjustments

–Does NOT include: making a Dx, analyzing a diagnostic test, or making a chiro adjustment

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– Does NOT include: making a Dx, analyzing a diagnostic test, or making a chiro adjustment

• 2) Preliminary Patient History



– Does NOT include: making a Dx, analyzing a diagnostic test, or making a chiro adjustment

• 2) Preliminary Patient History

• 3) Unlicensed person: no valid license to practice chiropractic

Chir 10.02 …..all must be met

• 1) The DC maintains records of the CA’s successful completion of a board approved course covering the performance of the delegated service.

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• 2) The DC exercises direct supervision of the unlicensed person



• 2) The DC exercises direct supervision of the unlicensed person

• 3) The DC is ultimately responsible for the manner and quality of the service

Chir 10.05 Physiological Therapeutics

• Includes (but not limited to): heat, cold, light, air, water, sound, electricity, massage, and

physical exercise with and without assistive devices….” to perform the

delegated function to minimally acceptable chiropractic standards.”

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WHY EXERCISE???

Gross A, et al. Manipulation or mobilization for neck pain: A Cochrane Review. Manual Therapy 2010;15: 315-333. (2)

• A systematic review thru July 2009 of 27 RCTs (1805 subjects) to assess if manipulation (SM) or mobilization (MO) as a single-modal treatment improves pain, function, satisfaction, quality of life, & global perceived effect in adults with neck pain (NP).

• Results: There is moderate quality evidence that SM produces similar changes in pain, function & Pt satisfaction compared to MO for subacute or chronic NP

at short & intermediate-term follow-up (F-U), but benefits are not maintained over the long-term.

• There is low quality evidence that SM alone vs a control may provide immediate & short-term pain relief.

• Very low quality evidence at short-term follow-up that one SM technique is not superior to another for pain reduction for subacute NP.

Miller J, et al. Manual Therapy and Exercise for Neck Pain: A systematic review. Manual Therapy 2010, 14(4):334-354. (2)

• This Cervical Overview Group systematic review of 17 RCTs which met entrance criteria to assess if manual therapy including SM & MO combined with exercise improves pain, function, quality of life, global perceived effect, & Pt satisfaction for adults with neck pain (NP) with or without cervicogenic headache or radiculopathy.

• Major Findings: Manipulation or mobilization + exercise

produces a greater long-term improvement in pain &

global perceived effect compared to no treatment for chronic NP & subacute/chronic NP with cervicogenic headache.

• Manual therapy (SM or MO) + exercise produce greater short-term pain relief THAN EXERCISE ALONE.

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Miller J, et al. Manual therapy and exercise for neck pain: A systematic review. Manual Therapy 2010, 14(4):334-354.

• The combination of manual therapy + exercise produces greater improvements in pain, function, quality of life & Pt satisfaction compared to SM or MO alone for chronic neck pain.

• Conclusion: The combination of manual therapy + exercise = greater short-term pain reduction than exercise alone & longer-term changes across multiple outcomes than manual therapy alone.

Hurwitz E, DC, PhD, et al. Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone & Joint Decade 2000-2010. Task Force on

Neck Pain. Spine 2008;33:S123-52. (1)

• The best evidence synthesis suggests manual therapy (spinal manipulation &/or mobilization) + exercise are more effective than other strategies for patients with neck pain.

• For whiplash associated disorders & neck disorders without trauma evidence favors supervised exercise sessions with or without manual therapy over usual care.

• For both whiplash associated disorders and other neck pain

without radicular symptoms: Interventions that focus on regaining function ASAP are more effective than interventions that don’t focus on this.

Collins S. Demonstrating/documenting functional improvement. Dyn Chiro 2007;25(3) :38. (An expert in chiro insurance billing for the H.J. Ross Network)

(1)

• Denials on insurance claims often have the common reason that the DC has not demonstrated "functional improvement” – the buzz term in the Insurance Industry to determine necessity of treatment (Tx) & whether the claim is to be paid.

• The Centers for Medicare & Medicaid Services (CMS) specifically identifies functional improvement as the necessary tenet to justify chiropractic care.

• Functional improvement: is improvement in activity/function that can be measured.

• The common theme is measured change. Some of the best tools for functional improvement are outcome assessments (disability indexes) & functional capacity testing (e.g., QFCE).

• These instruments & tests help document functional deficits & functional improvement to judge necessity, effectiveness & continued usefulness of care.

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Chiropractic + Exercise =

• The “PERFECT MARRIAGE!”

LBP Guideline Requirements (7 Steps)

1) Diagnostic Triage

(rule out red flags)


1) Diagnostic Triage (rule out red flags)

2) Identify yellow flags and attend those that are manageable

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LBP Guideline Requirements (7 Steps) 1) Diagnostic Triage (rule out red flags)

2) Identify yellow flags and attend those

that are manageable

3) Reassurance/Advice


1) Diagnostic Triage (rule out red flags)


that are manageable


4) Provide Symptomatic Relief



that are manageable



5) Utilize Outcomes Management

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that are manageable




6) Promote Functional Restoration This is the goal of this course!



that are manageable




6) Promote Functional Restoration

7) Determine End Points of Care

• Local Control vs. Global Control vs. Dynamic Control

• Plane of Motion – Sagittal vs. Frontal vs. Transverse

• Open Kinetic Chain vs. Closed Kinetic Chain

• Strength, Endurance and Proprioception

• Type of Equipment – stability ball, resistance bands, wobble board, etc.

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• Stability is an entity with many parts.

• Once the stability of a system is established, the interest shifts to its performance.

• There is a general relationship between performance and energy cost, with more energy required to improve performance.

• Pushing, pulling, lifting, carrying, and torsional exertion are compromised when the spine bends causing “energy leaks”.

• “Core stability” training has been shown to be effective for both preventing and rehabilitating shoulders and knees.

• The results provided high level evidence that therapeutic exercise was beneficial for patients including people with conditions such as multiple sclerosis, osteoarthritis of the knee, chronic low back pain, coronary heart disease, chronic heart failure, and chronic obstructive pulmonary disease.

• Therapeutic exercise was more likely to be effective if it was relatively intense and there were indications that more targeted and individualized exercise programs might be more beneficial than standardized programs.

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WebExercises® Active Care Progression Model

Local Stability Neuromuscular Control

Global Stability Strength, Endurance, Proprio

Dynamic Stability Functional Task Specific Training

What if there was

one prescription

that could

prevent and treat

dozens of diseases,

such as diabetes,

hypertension and obesity?

Would you prescribe it to

your patients?

Certainly. -Robert E. Sallis, M.D., FACSM,

Exercise is Medicine™ Task Force Chairman

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02468

1012141618

Low CR

F*

Obese

Smoker

Hypertension

High Chol

Diabetes

Men

Women

Cooper Aerobics Center Longitudinal Study, 1970-2004. In progress

40,842 Men & 12,943 Women, ACLS

*cardio respiratory fitness

Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med

2009; 43:1-2.

http://www.humankinetics.com/acucustom/sitename/dam/069/physical_inactivity_presentation1.pdf

CRF:

Cardio-

respiratory

Fitness

What should we do

about this major

public health

problem?

Help people become and

stay more physically active!

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1. Begin with one to two beginner level exercises without equipment.

2. Prescribe one set of 10-12 repetitions of each exercise at first to improved compliance.

3. Exercise frequency should be daily as this establishes a routine for patients.

4. Instruct patients to cross off each date they complete the exercise on the printed handouts. By having to record each home exercise session they realize this is a necessary part of their treatment.

5. Patients should be asked weekly to demonstrate their exercises. Knowing they will be checked on their progress motivates them to exercise regularly.

6. Add more complex exercises with increased difficulty as patient’s strength and function improves.

Basic physical exercise terminology

• Isometric contraction:

–Resistance without movement

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• Isotonic contraction: –Resistance during movement


• Activities of daily living:

–ADL’s


• Range of motion:

– Spinal - Cervical, Thoracic, and Lumbar (C, T, L-ROM)

– Extremities – Upper and Lower Extremities (UE, LE)

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• Coupling: Combined movement

Coupled movement – combination of LLF and Rotation

30 T4-T11

L

38 T11 - L4


• Active: Patient performs the activity or movement

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Basic physical exercise terminology (Continued) Manual

Release Techniques - Hamstrings

Hamstrings with Abduction Hamstrings with Adduction

Eccentric Concentric

Basic physical exercise terminology (Continued)

• Active resistive: resistance applied to an action


• Passive: CA performs the movement to the patient

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• Static: Hold in one position for a specified time

– Similar to an isometric contraction


• Contract/relax: isometric followed by relaxation


• Contract relax agonist contract stretch (CRACS) :

Stretch a mm followed by a static contraction (repeated)

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• Proprioception: –balance and

coordination (visual, cerebellum, inner ear, dorsal columns/spinal cord)


• Open Chain: an exercise where no connection exists

– Eg: Squatting without a ball or wall slides


• Closed Chain: an exercise where a connection exists

– Eg: Squatting with a ball on a wall or wall slides

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• Concentric: exercise during muscle contraction/shortening

– Eg: Extending elbow from 90 degrees flexion


• Eccentric: exercise during muscle elongation

– Eg: Flexing elbow from full extension

Origins of Dysfunction

• Kinesiopathology

– Abnormal joint function.

• Neuropathology

– Abnormal nervous system function.

• Myopathology

– Abnormal muscle function.

• Histopathology

– Abnormal soft tissue function (microscopic).

• Pathophysiology

– Abnormal function of the spine and body.

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Soft Tissue Injury and Healing • Phases of healing

– Inflammatory – 72 hours • Swelling

– Proliferative/Repair phase – 6-8 weeks • Being of scar tissue formation.

– Remodeling Phase – 3-14 weeks /up to 1-2 years in severe injury. • Maturing of scar tissue.

– Contraction phase – Lifetime • Natural shortening of scar tissue.

Effects of Scar Tissue

• Decreased motion

• Decreased strength

• Increase in “Neurofibrils”-free nerve endings that increase tenderness and irritability.

Muscles of the spine

• Extrinsic

– Voluntary - respond to conscious thought

• Intrinsic

– Involuntary - do not respond conscious thought.

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Rehabilitation Defined

• Rehabilitation definition:

– The restoration of normal form and function after injury or illness.(Dorland’s medical dictionary 26th edition)

– Chiropractic-neuromusculoskeletal rehabilitation is trained through physical exercise.

Promote Functional Restoration

• Physical Exercise – When? Visit 1-3, case specific

– What? Flexion vs. Extension biased (ROM)

– How? Follow DC prescription (exercise forms)

– Week 2-4: add exercises prn (incl. Screen prn)

– Week 3+: Exercise screen

– Week 4+: Specific exercises based on screen

Physical Exercise concepts

Unconscious Dysfunction

Conscious Dysfunction

Conscious Function

Unconscious Function

Takes ~ 3 months to establish new automatic habit patterns

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The Pain cycle

Injury Repetitive Strain

Swelling &

Inflammation

Soft Tissue Pain Muscular Guarding (spasm)

DECONDITIONING

Joint Stiffness Gradual Muscle Weakness

Indications For Physical Exercise

Failure to reasonably respond

Deconditioning

Frequent recurrent episodes

Contraindications

• Cardiovascular

• Musculoskeletal

• Proprioception

• Age/debilitation

• Post-surgical (in certain cases or at different points of healing)

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Passive Care

• Dr Driven Techniques

–Manual Release Techniques (MRT’s)

•Contract Hold

•Reciprocal Inhibition

•Post-Isometric Relaxation

Active Care

• Patient driven approaches –Ice Williams’/McKenzie

Stabilization Proprioception progressive strengthening diet management stress management multidiscipline

discharge (PPD?)

Active or Passive?

• Massage therapy

• Spinal Manipulation

• Spinal Mobilization

• Passive ROM

• Active ROM

• Post-isometric Relaxation

• See next picture:

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Active or Passive Care?

Physical Exercise

“Contraindications”

“Prerequisites”

Contraindications

• Acute pain

• Damaged tissue

• Prolonged (>2-3 days) post-exercise recovery

• Unstable condition

• Hypertension (> 150/90 = careful!!!)

• SEE PAR-Q (Website – next slide) or Text

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Physical Activities PAR-Q

• (download from

http://uwfitness.uwaterloo.ca/PDF/par-q.pdf

• (must use the entire form as noted on the form and website)

PAR-Q

(Physical Activity Readiness Questionnaire)

YES or NO 1. Has your doctor ever said you have heart trouble?

2. Do you frequently have pains in your heart and chest?

3. Do you often feel faint or have spells of severe dizziness?

4. Has a doctor ever said your blood pressure was too high?

5. Has your doctor ever told you that you have a bone or joint

problem such as arthritis that has been aggravated by exercise,

or might be made worse with exercise?

6. Is there a good physical reason not mentioned here why you

should not follow an activity program even if you wanted to?

7. Are you over age 65 and not accustomed to vigorous exercise?

If you answered YES to one or more questions... (next slide)

PAR-Q

(Physical Activity Readiness Questionnaire)

If you answered YES to one or more questions... If you have not recently done so, consult with your personal physician by telephone or in person before increasing your physical activity and/or taking a fitness test.

If you answered NO to all questions...

If you answered PAR-Q accurately, you have reasonable assurance of your present suitability for an exercise test.





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What "qualifies" a patient for Physical Exercise?

• Failure to respond to passive care approaches (CMT, MRT’s, modalities, etc.) • Failure to respond to initial active care approaches (ADL mods, Williams / McKenzie home-based exercises, etc.)

Overview of Tracking Progress

• Subjective Outcomes - Spinal

– Oswestry LBPDQ

– Bournemouth Back & Neck

– Neck Disability Index

• Objective Outcomes - Spinal

– Physical Exercise Screen

– Aerobic

– Work Capacity Evaluation

Overview of Tracking Progress

• Subjective Outcomes - Spinal

– Oswestry LBDQ

– Bournemouth Back & Neck

– Neck Disability Index

– MANY OTHERS!

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The BACK Bournemouth Questionnaire

The following scales have been designed to find out about your back pain and how it is affecting you.

Please answer ALL the scales by circling ONE number on EACH scale that best describes how you feel:

1. Over the past week, on average, how would you rate your back pain?

No pain Worst pain possible

0 1 2 3 4 5 6 7 8 9 10

2. Over the past week, how much has your back pain interfered with your daily activities (housework,

washing, dressing, walking, climbing stairs, getting in/out of bed/chair)?

No interference Unable to carry out activity

0 1 2 3 4 5 6 7 8 9 10

3. Over the past week, how much has your back pain interfered with your ability to take part in

recreational, social, and family activities?


0 1 2 3 4 5 6 7 8 9 10

4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have

your been feeling?

Not at all anxious Extremely anxious

0 1 2 3 4 5 6 7 8 9 10

5. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy)

have you been feeling?

Not at all depressed Extremely depressed

0 1 2 3 4 5 6 7 8 9 10

6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or

would affect) your back pain?

Have made it no worse Have made it much worse

0 1 2 3 4 5 6 7 8 9 10

7. Over the past week, how much have you been able to control (reduce/help) your back pain on your

own?

Completely control it No control whatsoever

0 1 2 3 4 5 6 7 8 9 10

The NECK Bournemouth Questionnaire

The following scales have been designed to find out about your neck pain and how it is affecting you.

Please answer ALL the scales by circling ONE number on EACH scale that best describes how you feel:

1. Over the past week, on average, how would you rate your neck pain?

No pain Worst pain possible

0 1 2 3 4 5 6 7 8 9 10

2. Over the past week, how much has your neck pain interfered with your daily activities (housework,

washing, dressing, lifting, reading, driving)?


0 1 2 3 4 5 6 7 8 9 10

3. Over the past week, how much has your neck pain interfered with your ability to take part in

recreational, social, and family activities?


0 1 2 3 4 5 6 7 8 9 10

4. Over the past week, how anxious (tense, uptight, irritable, difficulty in concentrating/relaxing) have

your been feeling?

Not at all anxious Extremely anxious

0 1 2 3 4 5 6 7 8 9 10

5. Over the past week, how depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have

you been feeling?

Not at all depressed Extremely depressed

0 1 2 3 4 5 6 7 8 9 10

6. Over the past week, how have you felt your work (both inside and outside the home) has affected (or

would affect) your neck pain?

Have made it no worse Have made it much worse

0 1 2 3 4 5 6 7 8 9 10

7. Over the past week, how much have you been able to control (reduce/help) your neck pain on your

own?

Completely control it No control whatsoever

0 1 2 3 4 5 6 7 8 9 10

SCORING: Bournemouth Q.

• Formula: Patient score / Max. possible score

times (X) 100 = ______ % Disability

– EXAMPLE: – 1. 4/10; 2. 3/10; 3. 5/10; 4. 7/10; 5. 4/10; 6. 5/10; 7. 8/10 =

36 total / 70 x 100 = 51% Disability

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OUTCOMES ASSESSMENT RECORD

DATE

PAIN

FUNCTION

VAS

(Miscell.)

a. Now

b. Ave.

c. Range

CC______

Pain

Drawing

Options:

1. UE

2. CTS

3. Shoulder

4. Knee

Options:

1.

Headache

2. Dizziness

3. SCL-90R

4. ________

VAS

&

Neck

Disability

(NDI)

VAS &LB

Disability:

Oswestry

Roland M

Patient Satisfaction

PGIC

BASELINE

___/____/___

a._____/10

b. _____/10

c.___- ___/10

Physiological

1. Yes

2. No

1. _______%

2. Sx____%

Fn____%

3. ______%

4. ______%

1. T____; E____

Fnctn_______

2. T_____;P____

F_____;E____

3.

A_____;D____

4. ________

a._______/10

b. ______/10

c.___- ___/10

_________%

a._______/10

b. ______/10

c.___- ___/10

_________%

PROGRESS

___/____/___

a._____/10

b. _____/10

c.___- ___/10

Physiological

1. Yes

2. No

1. _______%

2. Sx____%

Fn____%

3. ______%

4. ______%

1. T____; E____

Fnctn_______

2. T_____;P____

F_____;E____

3.

A_____;D____

4. ________

a._______/10

b. ______/10

c.___- ___/10

_________%

a._______/10

b. ______/10

c.___- ___/10

_________%

_________%

___/____/___

a._____/10

b. _____/10

c.___- ___/10

Physiological

1. Yes

2. No

1. _______%

2. Sx____%

Fn____%

3. ______%

4. ______%

1. T____; E____

Fnctn_______

2. T_____;P____

F_____;E____

3.

A_____;D____

4. ________

a._______/10

b. ______/10

c.___- ___/10

_________%

a._______/10

b. ______/10

c.___- ___/10

_________%

_________%

Outcomes Assessment

• Why bother? Who benefits? – DC – Better / efficient management – Patient – Knows what to expect – Insurer – Knows DC is tracking progress – Malpractice buffer – Less risk d/t good

documentation – Outcomes based research - optional – Interdisciplinary marketing – optional – Internal QA – optimal care delivery

THREE STEPS TO BECOMING EVIDENCE-BASED

• Step 1: – Orientation to what outcomes assessment tools

(OATs) are available • (Oswestry Low Back Disability Questionnaire, Neck

Disability Index, Headache Disability Index, QVAS, Pain Drawing, Bournemouth Questionnaire, etc.)

–(See CD and Text)

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THREE STEPS TO BECOMING EVIDENCE-BASED (continued)

• STEP 2:

– Score the tool and write the score down the score on the Outcomes Assessment Record • See Exercise Screen Manual, pg 7

• See CD and Form on pg 644 Text

THREE STEPS TO BECOMING EVIDENCE-BASED (continued)

• STEP 3: – Repeat the SAME OATs at re-exams

–AND REVIEW THE SCORE RESULTS TO DETERMINE THE UPDATED TREATMENT PLAN

–At case conclusion determine value: (cost, no. of visits, OA scores/satisfaction) and compare between provider or groups – share knowledge!)

HOW TO IMPLEMENT AN EVIDENCE-BASED

DOCUMENTATION SYSTEM INTO A BUSY CLINICAL SETTING

1) Hold a CA staff meeting

– Insurer requirements of proving “medical necessity” (reimbursement link)

– For future comparison if re-injury occurs

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HOW TO IMPLEMENT AN EVIDENCE-BASED DOCUMENTATION SYSTEM INTO A BUSY CLINICAL SETTING

• 2) Give the new patient a clipboard – Includes all your intake forms on their first visit.

– DO NOT allow them to sit in your front office filling out forms for more than 15 minutes (pre-appointment time period – due to poor attention span which reduces the quality of the information).


• 3) Patient driven paper work stays with them the entire time they are in your office

– The clipboard follows the patient around from exam room to treatment room to x-ray room, to PT room. They may take home uncompleted forms if they do not finish them all (expect about a 50% return rate in which case, re-administer uncompleted forms at the 2nd visit).


• 3) Patient driven paper work stays with them the entire time they are in your office – The clipboard follows the patient around from exam room to treatment room

to x-ray room, to PT room. They may take home uncompleted forms if they do not finish them all (expect about a 50% return rate in which case, re-administer uncompleted forms at the 2nd visit).

– When you enter to examine the patient, THANK them for taking care when completing the forms, and the importance of tracking care accurately – to insure patient satisfaction.

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Front Office Set-up

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Treatment Room Set-up

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CPT coding for Physical Exercise

• Physical Medicine and Rehabilitation (97000+ codes).

– Modalities

• Supervised

• Constant attendance

–Therapeutic Procedures – Active Wound Care Management

–Tests and Measures – Other Procedures


• Therapeutic Procedures

– A manner of effecting change through the application of clinical skills and/or services that attempt to improve function.

– Physician or therapist required to having direct (one-on-one) patient contact.

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• Therapeutic Procedural codes

– 97110

• Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.


• What happens if I use a code lesser to or greater than 15 minutes?

– Use modifier –52 Reduced Services

• 7 minutes equals 97110-52

• 20 minutes equals 97110 and 97110-52

NOTE: A minimum of 8 minutes = 1 unit

(See Exercise Screen Manual)


• Therapeutic Procedural Codes

– 97112

• Neuromuscular reeducation of movement, balance, coordination, kinesthetic movement, posture, and/or proprioception for sitting and/or standing activities.

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– 97530

• Therapeutic activities, direct (1-on-1) patient contacted by a provider (use of dynamic activities to improve functional performance), each 15 minutes.



– 97535

• Self-care/home management training (activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in the use of assistive technology devices/adaptive equipment) direct 1-on-1 contact by provider, each 15 minutes


• Tests and Measurements

– 97750

• Physical performance test or measurement (musculoskeletal, functional capacity), with written report, each 15 minutes.

NOTE: USE THIS CODE WITH EXERCISE

SCREEN

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• Neurology and Neuromuscular procedures

– Muscle Testing

• 95831 – Muscle testing, manual (separate procedure) with report,

extremity (excluding canned) or trunk.


• Neurology and Neuromuscular procedures

– Range of Motion Testing

• 95851 – Range of motion measurements and report (separate

procedure); each extremity (excluding hand) or in each trunk section (spine).


• These are primarily CPT codes used in a chiropractic office for physical exercise training/rehabilitation.

• For more specific codes please see the 97000 and the 95000 series of codes in the CPT codebook

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Rehabilitation Documentation

• Most CPT codes are time dominant and need one-on-one interaction.


• Most CPT codes are time dominant and need one-on-one interaction.

• Because of this the following information needs to be documented and regular basis:



–Date

–Time entering the rehab area.

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– Date

– Time entering the rehab area.

–The physical exercise performed along with modifications made (sets, reps, resistance changes, etc.).


• Because of this the following information needs to be documented and regular basis: – Date – Time entering the rehab area. – The physical exercise performed along with

modifications made (sets, reps, resistance changes, etc.).

–Time exiting the rehab area. –Doctor/staff initials.

Rehab SOAP Note

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“Chiro-glyphics”

Abbreviation

Key

Rehab “Daily Exercise Log”

Objective Outcomes - Spinal

• Screen: Physical Performance

• Aerobic Capacity

• Work Capacity Evaluation

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Physical Exercise Screen

• Measures to assess deconditioning

• Include normative data to compare to patient results (determine % abnormal)

• Any screen where <85% is found constitutes deconditioning and requires rehab

• Use pre-exercise to establish the prescription and post-exercise to prove benefits






• Use as “proof” for establishing “medical necessity” - helps in obtaining insurance approval






• Use as “proof” for establishing “medical necessity” - helps in obtaining insurance approval

• Needed by the 2nd to 4th week, if home based exercises are not patient satisfying

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• Pre- and post VAS

• 7 Strength and endurance screens

• 6 Muscle length screens

• 5 Non-organic signs (Waddell LB)

• Spinal ROM (inclinometer - LB & C)

• Proprioception screen

• Aerobic screen

• Total of 23 physical performance screens / 40 min.)


• Test 1:

– Pre-screen VAS (0-10 scale): the patient marks on a 10 cm line anchored by “no pain” on the left and “maximum pain” on the right.

SWITCH TO EXERCISE SCREEN SLIDES

chiropractic assistant: physical exercise training · 2 purpose of physical exercise training. •...

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