2Active 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.
3The 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.
4The 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.
5Studies 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
6Rest vs. Active CareA comparison of patient progress using rest vs. active care shows the following:RestSlower 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.2Demineralization of boneDecreased physical fitness with a daily loss of muscle tone estimated at greater than 1 percent per day of inactivityIncreased psychological stress, depression and increased difficulty in starting a rehab programActive CarePromotion of bone density and muscle strengthImproved disc and cartilage nutritionImproved joint stabilityAvoidance of psychological issuesLess apt to develop chronic pain
7Best 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.
82 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.
92 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
102Approach To CareChiropractic 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
112Re-ActivationLevel 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.
122 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.11Encourage 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.)
132 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 treatmentThe evaluation of low back pain is based on a thorough history, disability questionnaires and thorough examination using low-tech yet reliable tests. 14
142 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.
152 Additional Advice for Patient Healthy Lifestyles Smoking cessation Good nutritional habitsEncourage weight loss when appropriateAppropriate sleepErgonomic work stations and ergonomic home settingsEncourage non-reliance with active healthy lifestyles
162Considerations for Establishing a Physical Rehabilitation / Active Care PlanPsychosocial Considerations (yellow flags)AnxietyA history of prior episodes, past or present disabilityDuration of symptoms greater than one monthSleep is affected by painDepressionSciaticaCatastrophizingJob dissatisfactionActivity intoleranceDuration of symptoms before the first visitMultiple sites of painTolerance for light workPhysical activity makes pain worseBelief that shouldn’t work with current pain
172Considerations for Establishing a Physical Rehabilitation / Active Care PlanOther Risk Factors:Abnormal illness behaviorTobacco userPre-existing structural pathology / skeletal anomaliesPoor self-rated health
182 Considerations for Establishing a Physical Rehabilitation/Active Care Plan (cont.)Phases of Physical RehabilitationImproving stability and neuromuscular controlAdvanced stabilization exercisesAdvanced work; activity conditioning (working towards end goal)Rehabilitation Treatment Plan Should Indicate:Agreed-upon goalsReflect Activity IntoleranceBe progressive with program
19Craig 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 painHelping patients to see the doctor as their helper rather than healer in their case.Discouraging a disabling attitude in the patient. 15Helping 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.
202 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.
21Bruegger’s Relief Posture: 2Tools For a Successful Active Care ProgramBruegger’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.
22Never Reinforce or Continue a Bad Exercise: 2Tools For a Successful Active Care ProgramNever 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.
232 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.
242Examples of tests that will be used to evaluate patient stability, disability and function:One leg standingSorenson’s test for spinal extensor endurance and strengthSquat test for strength, coordination and proper spinal flexibilityTrunk flexion testPostural analysisGait analysisHip abduction testHip extension testStatic back extension testCentralization (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.
25ReferencesDr. 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 Assessment5Royal College of General Practice Clinical Guidelines for the management of low back pain6Cholewicki 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 pain12Mannion 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 extensionexercises 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 andshort-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 randomizedcontrolled trial of a novel educational booklet in primary care. Spine 1999 Dec; 24(23):
26Active 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.