1. Introduction to Active Care
Program 1 – AC100

2. Active Care Certification Program
The Active Care Certification Program is a four-part series of classroom and online instruction. Participation in all four parts is required for certification.

3. The Changing Health Care Landscape
Health care in the United States is changing, especially as it relates to patient care. Passive care alone is no longer enough. Patients need to take ownership in their own treatment, and studies are confirming active care as an emerging new best practice for health care providers, including chiropractors.

4. The Changing Health Care Landscape – cont.
As doctors, chiropractors must teach and assist their patients in appropriate self-care/active care by developing patient’s coping skills and motivating them to resume activities.
Studies over the past several years show that active care is helpful in returning a patient to pre-morbid functional capacity.
The new model no longer focuses on pathology or symptomology. Pain is being used less as an indicator of patient progress; function is the measure of patient recovery.

5. Studies Referencing Benefits of Active Care
The New Zealand Guidelines and the British Guidelines recommended increased activities progressively based on time rather than pain.
Denmark Guidelines also reflect the need for earliest return to activities of daily living including modified work as opposed to rest.
Kirkaldy-Willis espoused early activity for back pain patients.1

6. Rest vs. Active Care
A comparison of patient progress using rest vs. active care shows the following:
Rest
Slower healing, as inactivity slows imbibition or diffusion of nutrients and fluids in a disc, therefore limiting repair. Pain and tissue healing are affected by metabolism.2
Demineralization of bone
Decreased physical fitness with a daily loss of muscle tone estimated at greater than 1 percent per day of inactivity
Increased psychological stress, depression and increased difficulty in starting a rehab program
Active Care
Promotion of bone density and muscle strength
Improved disc and cartilage nutrition
Improved joint stability
Avoidance of psychological issues
Less apt to develop chronic pain

7. Best Practices for Active Care
Adopting active care best practices requires a new philosophy of care that is patient-centric. The new care model measures patient progress by improvement in patient function, as opposed to pain.

8. 2 Elements of Active Care Best Practices
Diagnostic triage (Watch for red flag and yellow flag considerations):
Cancer red flags: history of cancer, unexplained weight loss, age over 50 and/or failure to respond to care in 4-6 weeks. Low back pain greater than 4 weeks.
Infection red flags: prolonged use of corticosteroid, IV drug use, current urinary tract, respiratory or other infection and or immunosuppression therapy.
Spinal Fracture red flag: history of significant trauma, minor trauma in a person older than 50 or osteoporotic or over age 70 and/or prolonged use of corticosteroids.
Cauda Equina red flags: acute onset or urinary retention or overflow incontinence, loss of anal sphincter tone or fecal incontinence, saddle distribution anesthesia, global or progressive motor weakness in lower extremity.

9. 2 Elements of Active Care Best Practices – cont.
There are three distinct groups for low back pain:
The red flag group - those patients with serious disease, tumors, fractures that make up less than 2 percent of low back pain cases.
Patients whose low back pain is caused by nerve root compression - these make up less than 10 percent of back pain patients.
Patients whose low back pain is caused by non-specific mechanical factors and make up 85 to 90 percent of all back pain patients

10. 2
Approach To Care
Chiropractic treatment, posture assessment, appropriate modalities, active care, McKenzie therapy and referral for appropriate care or to co-manage when necessary.
Prevention of deconditioning is a fundamental goal of the new model for treating back pain.
Active care is training motor control patterns that protect the spine. Spinal instability results from lack of endurance and poor coordination of the trunk flexors and extensors. Agonist-antagonist muscles co-activation is disturbed in low back pain patients thus compromising the stability mechanism involved in reacting to sudden perturbations

11. 2
Re-Activation
Level 1: Active care advice for a patient as they begin to return to normal function starting with ADL’s by reassuring patient that it is safe and beneficial to gradually resume activity.
Level 2: Exercise to retrain the weak links that led to patient’s condition.

12. 2 Cognitive Considerations
Low back pain has a strong link with psychosocial illness traits, such as fear avoidance behaviors and anxiety as noted in yellow flags.
With a behavioral approach to care, send non-responders with preponderance of yellow flags (see upcoming slide for more information on yellow flags) to a behavioral specialist. These are patients that are more prone to chronic pain and disability.
There is evidence that psychosocial illness behavior can improve with active care alone.11
Encourage patients to be independent.
Be mindful of old considerations that may contribute to deconditioning (e.g., “Let pain be your guide,” self-image of having a “bad back,” “learning to live with the pain,” etc.)

13. 2 Developing An Active Care Program is Unique to the Individual
When using an active care treatment program, the program must be appropriate to the individual. This will be addressed more in second phase of this program when the nature of a patient’s instability is evaluated through testing the individual’s muscle function, movement patterns, balance and stability.
Research indicates the effectiveness of different treatments that are matched to appropriate sub classifications of non-specific back pain is superior to unmatched treatment
The evaluation of low back pain is based on a thorough history, disability questionnaires and thorough examination using low-tech yet reliable tests. 14

14. 2 Developing An Active Care Program – cont.
Patients should be advised on how to exercise without aggravating their condition. It should be stressed that this process takes time to achieve their goals. Help the patient set realistic goals.
Assure the patient that pain will be part of their recovery, that pain isn’t always bad. Doctors must recognize that there are some non-responders (with yellow flags) that may need referral to a specialist that can deal with yellow flag issues.

15. 2 Additional Advice for Patient Healthy Lifestyles Smoking cessation
Good nutritional habits
Encourage weight loss when appropriate
Appropriate sleep
Ergonomic work stations and ergonomic home settings
Encourage non-reliance with active healthy lifestyles

16. 2
Considerations for Establishing a Physical Rehabilitation / Active Care Plan
Psychosocial Considerations (yellow flags)
Anxiety
A history of prior episodes, past or present disability
Duration of symptoms greater than one month
Sleep is affected by pain
Depression
Sciatica
Catastrophizing
Job dissatisfaction
Activity intolerance
Duration of symptoms before the first visit
Multiple sites of pain
Tolerance for light work
Physical activity makes pain worse
Belief that shouldn’t work with current pain

17. 2
Considerations for Establishing a Physical Rehabilitation / Active Care Plan
Other Risk Factors:
Abnormal illness behavior
Tobacco user
Pre-existing structural pathology / skeletal anomalies
Poor self-rated health

18. 2 Considerations for Establishing a Physical
Rehabilitation/Active Care Plan (cont.)
Phases of Physical Rehabilitation
Improving stability and neuromuscular control
Advanced stabilization exercises
Advanced work; activity conditioning (working towards end goal)
Rehabilitation Treatment Plan Should Indicate:
Agreed-upon goals
Reflect Activity Intolerance
Be progressive with program

19. Craig Liebenson, D.C., of Los Angeles Sports and Spine, Los Angeles, California, has written two editions of Rehabilitation of the Spine and is due to release a third edition in fall In 1999, Dr. Liebenson outlined in the Journal of Body Work the following regarding active care:
Active care is:
Motivating patients to share responsibility for their recovery.
Specific activity modification advice to reduce exposure to repetitive strain.
Exercise to stabilize a frequently painful area.
Helping patients to regain control over their symptoms, those that don’t regain control are more prone to develop chronic pain
Helping patients to see the doctor as their helper rather than healer in their case.
Discouraging a disabling attitude in the patient. 15
Helping patients understand that activating a joint may be uncomfortable, but not harmful (if examination was thorough). This also applies when re-activating the healing process.
Helping patients establish goals that help re-establish function.

20. 2 Tools For a Successful Active Care Program 360 Degrees of Support:
This is the proper balance of abdominal, spinal erectors and lateral spinal musculature. If one area is weak, this dictates the actual strength and stamina of that subject. The human body is primarily fluid with the musculoskeletal system being the container creating a hydrostatic cylinder. The weak area is where the strength of the cylinder will fail.

21. Bruegger’s Relief Posture:2
Tools For a Successful Active Care Program
Bruegger’s Relief Posture:
This is a posture that puts the spine in a neutral position, where the muscles that support the spine are at their lowest activity level. This posture has the patient doing abdominal hollowing, with palms of hands rotated externally, both scapula retracted inferiorly and the head centered over the shoulders. This position is held for 20 seconds several times per day. Teaching varies regarding length of hold times.
This reinforces neutral spine and correct posture. Bruegger’s posture is essential in all exercises and for optimal respiration. This can be measured with EMG or surface EMG.
Bogduc did considerable research on the mechanics of the human spine and on the Neutral A-P spinal curve or posture rather than a specific measurement of an optimal A-P spinal curvature.

22. Never Reinforce or Continue a Bad Exercise:2
Tools For a Successful Active Care Program
Never Reinforce or Continue a Bad Exercise:
Only continue a correct exercise; if correct form is lost, stop the exercise immediately. Reassess the amount of weight being used, the number or repetitions or the patient’s readiness for that level of exercise.

23. 2 Tools For a Successful Active Care Program Perfect Fit Pro System
This is the System that ChiroCare will use for this certification program to assist ChiroCare providers in establishing an exercise program for their patients. The Perfect Fit Pro System includes stretching, floor exercises, ball exercises, and strengthening all by area and type of exercise. Part 4 of this program will offer you an opportunity to use the Perfect Fit Pro System.

24. 2
Examples of tests that will be used to evaluate patient stability, disability and function:
One leg standing
Sorenson’s test for spinal extensor endurance and strength
Squat test for strength, coordination and proper spinal flexibility
Trunk flexion test
Postural analysis
Gait analysis
Hip abduction test
Hip extension test
Static back extension test
Centralization (McKenzie)
The tests above will help the doctor narrow down the weak links and establish the severity and helps to establish a starting point for active care. These tests will be discussed in greater detail during Part 2 of the program.

25. References
Dr. Craig Liebenson’s Rehabilitation of the Spine: A Practitioner's Manual (Lippincott, Williams and Wilkins, 2006) was the primary source for the material given in this article. NWCC’s physical rehabilitation diplomat program was also a great source of material as well.
1Chapman-Smith, David. The Chiropractic Report Jan; 14(1).
2Holm S, Machemson A. Nutritional changes in the canine intervertebral disc after spinal fusion. Clin Orthop 1982 Sept; 169:
3AHCPR Clinical Practice Guideline #
4Mannich C. et al. Danish Health Technology Assessment
5Royal College of General Practice Clinical Guidelines for the management of low back pain
6Cholewicki J., McGill S.M. Mechanical stability of the in vivo lumbar spine. Implications for injury and chronic low back pain. Clin Biomech Jan; 11(1):1-15.
7Cholewicki J., Punjabi M. M., Khachatryan A. Stabilizing function of the trunk flexors-extensor muscles around a neutral spine posture. Spine Oct; 22(19):
8Gardner-Morse M.G., Stokes IAF. The effects of abdominal muscle coactivation on lumbar spine stability. Spine Jan; 23(1):86-91.
9Granata K.P., Marras W.S. Cost-benefit of muscle co contraction in protecting against spinal instability. Spine June; 25(11):
10Parnianpour M., Nordin M., Kahanovitz N., Frankel V. The triaxial coupling of torque generation of trunk muscles during isometric exertins and the effect of fatiguing isoinsertial movements on the motor output and movement patterns. Spine Sept; 13(9):
11Royal College of General Practice Clinical Guidelines for the management of low back pain
12Mannion A.F., Junge A., Taimela S., Müntener M., Lorenzo K., Dvorak J. Active therapy for chronic low back pain. Part 3 Factor influencing self-rated disability and its change following therapy. Spine Apr; 26(8):
13Erhard R.E., Delitto A., Cibulka M. Relative effectiveness of an extension program and a combined program of manipulation and flexion and extension
exercises in patients with acute low back pain syndrome. Phy. Ther Dec; 74(12):
14Fritz J.M., George S. The use of a classification approach to identify subgroups of patients with acute low back pain: interrater reliability and
short-term treatment outcomes. Spine 2000 Jan; 25(1):
15Burton K., Waddell G., Tillotson K.M., Summerton N., Information and advice to patients with back pain can have a positive effect: a randomized
controlled trial of a novel educational booklet in primary care. Spine 1999 Dec; 24(23):

26. Active Care Certification Program
To complete Program 1 of the Active Care Certification Program, download and print the associated exam from ChiroCare’s website. Submit your completed exam as instructed. You will not receive credit for this portion of the program until you have successfully passed the exam.