If you are not performing rehabilitation in your clinic right now, you should consider doing rehab in the near future because it is these types of CPT^® codes that are getting doctors paid better by the insurance companies. The insurance companies pay better because the patients not only get better faster, but the patients stay better longer.

Most modern chiropractic offices have a physical therapy/rehab department/room that is dedicated to performing the therapeutic modalities or therapeutic procedures (see Table 1). There are three reasons doctors of chiropractic should be performing therapeutic procedures:  

1) business reasons—the reimbursement rate is very good for these codes

2) clinical reasons—the patients get well faster and stay well longer.^{1, 2}

3) insurance reasons—insurance companies readily acknowledge doctors who are using these procedures The CPT^® 2007 codebook defines therapeutic modalities and therapeutic procedures as:

Therapeutic Modalities—Any physical agent applied to produce therapeutic changes to biological tissue, including, but not limited to, thermal, acoustic, light, mechanical or electrical energy—essentially, the modalities such as Mechanical Traction, Ultrasound, Stim and Heat (MUSH). I call it MUSH because that it is what the insurance companies pay for these modalities—MUSH. There are two types of modalities: Supervised Modalities and Constant Attendance Modalities.

• Supervised Modalities—the application of a modality that DOES NOT REQUIRE direct (one on one) patient contact by the provider.

97010 Hot or Cold Packs

97012 Traction, Mechanical

97014 Electrical Stimulation, unattended 97018 Paraffin Bath

97022 Whirlpool

97024 Diathermy

97026 Infared

97028 Ultraviolet

• Constant Attendance Modalities—the application of a modality that REQUIRES direct, one on one, patient contact by the provider.

97032 Electrical Stimulation

97033 Iontophoresis

97034 Contrast Baths

97035 Ultrasound

97036 Hubbard Tanks

Therapeutic Procedures—a manner of effecting changes through the application of clinical skills and/or services that attempt to improve FUNCTION.

       97110 Therapeutic Exercises

       97112 Neuromuscular Re-education

       97113 Aquatic Therapy

       97116 Gait Training

       97124 Massage

       97140 Manual Therapy

       97530 Therapeutic Activities

       97535 ADL (home)

       97537 ADL (work)

The insurance industry is moving toward a more active model of healthcare where the policy holder/patient is becoming more responsible for his/her own healthcare, meaning the doctor should place a patient in a treatment plan that allows a patient to move from a passive care model to an active care model. In this way, the patient takes ownership of his/her health, which allows the patient to do most of the work rather than the doctor (see Table 1).

The case management strategy in Table 1 is not set in stone. You still must think as a doctor. If the patient is ahead of the set schedule and you believe that the patient can tolerate some of the therapeutic procedures, stop the modalities and start the procedures.

An important tool in determining medical necessity of the therapeutic procedures and determining whether or not the patient can tolerate the therapeutic procedures revolves around functional diagnostic tests, such as computerized ROM testing, computerized muscle testing, and pain pressure threshold testing (algometry). Theses functional diagnostic tests can be found in Table 1 as well. The patient should be re-examined using these diagnostic tests to check whether or not the patient is getting better, staying the same, or getting worse.

Again, you still must think as a doctor and decide if what you are performing on the patient is getting adequate results. The patients, in most cases, will be able to tell you either verbally or non-verbally, in the form of their body movements, as to whether or not they are able to begin the therapeutic procedures.

If you want to modernize your clinic and/or provide more services, consider the higher paying therapeutic procedure codes. The increased income from these codes is well worth the effort. The only price it costs you is in terms of documenting the medical necessity; but that can be taken care of with the use of functional diagnostic tests that are payable by the insurance companies as well.

I urge you to take a look at getting your practice ahead of the curve so that you can stay in line with the changes in the healthcare reimbursement world.

1. Jan Lucas Hoving, PT, PhD; Bart W. Koes, PhD; Henrica C.W. de Vet, PhD; Danielle A. W.M. van der Windt, PhD; Willem J.J. Assendelft, MD, PhD; Henk van Mameren, MD, PhD; Walter L.J.M. Deville, MD, PhD; Jan J.M. Pool, PT; Rob J.P.M Scholten, MD, PhD; and Lex M. Bouiter, PhD. Manual Therapy, Physical Therapy, or Continued Care by a General Practiioner for Patients with neck Pain A Randomized, Controlled Trial. Annals of Internal Medicine, Vol.136 No. 10, Pgs 713-722 May 21, 2002.

2. Ongeborg BC Korthals-de Bos, Jan L Hoving, Maurits W van Tulder, Maureen PMH Rutten-van Mölken, Hermann J Adèr, Henrica CW de Vet, Bart W Koes, Hindrik Vondeling, Lex M Bouter. Cost Effectiveness of Physiotherapy, manual therapy, and General Practitioner Care for Neck Pain: Economic Evaluation Alongside a Randomised Controlled Trial. British Medical Journal; 326:911; April 26, 2003.

Dr. Dwight Whynot is a successful full-time private practitioner in Johnson City, Tennessee and a graduate of Logan College with a bachelor’s degree from Dalhousie University, Nova Scotia, Canada. Dr. Whynot gives license-renewal lectures on Evidence-Based Chiropractic Practices which are promoted by the EBC Seminars and sponsored by Myo-Logic and Spinal Logic Diagnostics. Dr. Whynot also gives license-renewal lectures to the medical community in Tennessee. For questions regarding evidence-based practice procedures, email This e-mail address is being protected from spambots. You need JavaScript enabled to view it . For 6 and 12 hours CCE license renewal lecture dates and locations call Karl Parker Seminars at 1-888-437-5275 or visit www.EBCSeminars.com.

It’s happened to all of us many times. a patient comes into our office barely able to move and in excruciating pain. They have difficulty lying on the table, let alone moving through any range of motion and we want to get them into a side posture position. RIGHT!!!!!

So, in lieu of any type of chiropractic manipulative therapy, we apply a hot pack, maybe some ultra sound or motor nerve stimulation in order to reduce the muscle spasms.

That has been the traditional approach and, eventually, it has the desired result—or at least some level of the desired result. BUT….

What if we could use the body’s own neurologic and physiologic mechanisms to reduce those muscle spasms instead of using outside interventions? After all, isn’t that what we continually profess; use the body’s own healing powers? Yet, when it comes to muscle spasms, we ignore the physiologic processes that could reduce those muscle spasms. The question that comes to mind is: Why? Perhaps the answer lies in that we clinicians, to date, have not found any type of technique or equipment that could assist with these same neurological and physiological mechanisms—not until the Active Therapeutic Movements (ATM Concept) came along. But more on this unique treatment concept a little later.

Let’s look at the purpose of a muscle spasm. First of all, we know it is a protective mechanism, often elicited by the muscle spindle fibers as the stretch reflex. The stretch reflex protects the muscles and tendons against either too much of a stretch or too quick of a stretch. So, therefore, the stretch reflex is sensitive to the amount or speed of a muscle stretch. Located in the musculotendonis junction, the muscle spindle fibers protect this most vulnerable area of the muscle, the weak link of the chain, so to speak. If this area is protected, then the rest of the muscle will surely be. Unfortunately, the muscle spindle fiber is subjected to the same environmental factors as the rest of the muscles, the worst of which is inactivity.

As we have learned, when a muscle stays in a shortened state for any prolonged period of time, it becomes shorter. The same fate is assured for the muscle spindle fiber. If the muscle spindle fiber becomes shorter, then it will also become more active. This will elicit the stretch reflex when there is no need. The result is an increase in the excitation potential of a muscle, often resulting in muscles firing before they are supposed to or even when they are not supposed to fire. Because this is a protective mechanism, it often takes priority over other factors like, for example, reciprocal inhibition.

Reciprocal inhibition is the signal of relaxation that the antagonistic muscle receives when the agonist muscle contracts. This is necessary in order to allow movement to occur. This signal of reciprocal inhibition not only tells the antagonist muscle to relax, it tells it to relax at the same speed and intensity that the agonist is contracting, which helps to keep a smooth, fluid movement that can be controlled through the entire range of motion.

If these two mechanisms are functioning properly, we should get a smooth, controlled movement, as well as the protection the muscle needs if it is lengthened too far or too fast. When the muscle is injured or in a chronic shortened state, the muscle spindle fiber is in a hyper-reactive state and, thus, will activate, causing the muscle to contract or even spasm when almost any movement occurs. Again, since the stretch reflex of the muscle spindle fiber is a protective mechanism, it takes priority. So, even when the muscle is receiving the reciprocal inhibition telling it to relax, the stretch reflex overrides it. This causes the antagonistic muscle to contract when it should be relaxing. (See Figure 1) Consider, then, what happens to the path of motion of the joint when this is happening. Not Good!!!!

Figure1. is a graph of muscle activity with a symptomatic patient experiencing low back pain. These graphs were developed using sEMG technology whereby patients were asked to perform rotations showing left and right side back muscle contractions and documeting muscle spasm.

What if we could eliminate or at least dampen the stretch reflex? Only for a limited period of time of course, while the body’s own healing processes were underway, but what if we could actually do that? Medications could relax the muscles, obviously; but we are chiropractors, so we resort to the aforementioned modalities that mainly help to increase the blood supply to the muscle, which is certainly not a bad thing; but it still doesn’t address the neurological factors of the stretch reflex and the hyperactive muscle spindle fibers.

If we could just use the reciprocal inhibition to relax the muscle but somehow prevent the tight or spasmodic muscle from moving, we could get our patient’s own body to tell those muscles to relax. But, to do this, we would have to use an isometric contraction of the muscles that are opposing the tight or spasmodic muscles. By contracting these opposing muscles without movement, we could avoid activating the hyperactive muscle spindle fibers and receive the full benefit of the reciprocal inhibition, resulting in the body’s own mechanisms giving us the results that we want instead of using medications. This is a perfect example and illustration of how the ATM Concept works and works so wonderfully within this same interesting, dynamic and very complex neurological mechanism.

The ATM2 system is a vertical treatment table that can immobilize, support and stabilize the patient all at the same time. The ATM2 uses a series of adjustable stabilization straps against a positional pad to create a safe and stabilized environment for the patient, who can then perform isometric contractions in the opposite direction of the muscle spasms. The straps allow a forceful contraction, giving a strong message of reciprocal inhibition and, since there is no movement, it overrides the stretch reflex and helps the muscle to relax. (See Figure 2) Furthermore, the straps can be tightened in any configuration to isolate almost any of the spinal stabilizer muscles, to reduce muscle spasms. It can be used for movements in the frontal, sagital, or horizontal planes or any combination thereof, making it infinitely versatile for any movement pattern that you could imagine.

 Figure 2. shows the muscle activity after 1 treatment on the ATM2 system. Notice the distinct left side and right side muscle contractions showing their increased strength and their distinct muscle separations. This is reciprocal inhibition. Notice muscles, even in the neutralor resting position and after one 6-minute treatment intervention. Notice these same muscles contracting in a much lower intensity and in unison and at rest.

The question then becomes, how do we know the process is having the desired effect?

Actually, a very simple protocol of tightening the straps to make the patient feel safe, supported and comfortable lets you know you are isolating the proper areas. A series of short, yet forceful contractions (Active Therapeutic Movements or isometric exercises) that the patient is now able to perform, yet without discomfort or pain, also tells you that you are on the right track. The patient will be very surprised to be able to perform isometric exercises (a very conservative number of ten isometric repetitions is always recommended on the first visit) with that much force without feeling any pain. Then, after performing the contractions and being unstrapped, the patient will be amazed at the increased, pain free range of motion. (See Figure 3) You, also, will be amazed at how quickly they are able to move pain free, easily perform isometric exercises, and the increased flexibility, ROM and significant decrease in pain they exhibit on that first visit.

Figure 3. This patient is being treated for lumbar flexion movement impairments. We see the patient doing the Active Therapeutic Movements or Isometric flexion exercises.

Just like most other conditions that we face as chiropractors, the cause of the muscle spasm will most likely not disappear after the first treatment. Although, I have heard and read instances of patients that, on their very first visit, using the ATM2 system, the muscle spasm condition was changed or rectified completely. It can obviously vary from patient to patient. I also know that many of these spasm problems are deep rooted and so, just like the manufacturer recommends, continuing along the treatment path with further ATM’s can provide the correct stimulus to change these deep rooted muscle spasm conditions. The environmental factors that cause the tight or spasmodic muscle are probably still present, whether it is from an injury or from prolonged positioning and/or poor posture. Thus, these factors also need to be addressed and can easily be identified and corrected when the right assessment and treatment protocol is in place.

Most of us, as chiropractors, now deal with patients who are very inactive, both at their jobs and at home. This has created an epidemic of spinal instability. We see more and more patients everyday that possess low back injuries as a result of some ridiculously simple task or movement.

As a developer and instructor of the personal training program for the largest fitness chain in the country, I believe I have found an easy to implement a Core Stabilization program for chiropractors that can overcome these factors and restore spinal strength and stability to our patients who suffer from the effects of prolonged sitting and poor posture. The ATM2 can greatly enhance this Core Stabilization protocol and help us, as chiropractors, completely overcome the common muscle spasm, an all too familiar nemesis in our practices—thus, making us more effective as health care providers in obtaining faster, longer lasting results for our patients.

For more information on Dr. Meier’s Core Stabilization program, visit www.drkirkmdc.com or call 1-510- 713-7117. For more information on the ATM Concept, visit www.BackProject.com or call 1- 888-470-8100.