Introduction to Active Care

Program 1 – AC100

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.

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.

The Changing Health Care Landscape – cont.

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.

Studies Referencing Benefits of Active Care

Rest vs. Active Care

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

Best Practices for Active Care

2Elements of Active Care Best Practices

• 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.

2Elements of Active Care Best Practices – cont.

1. The red flag group - those patients with serious disease, tumors, fractures that make up less than 2 percent of low back pain cases.

2. Patients whose low back pain is caused by nerve root compression - these make up less than 10 percent of back pain patients.

3. Patients whose low back pain is caused by non-specific mechanical factors and make up 85 to 90 percent of all back pain patients. 3 4 5

2Approach 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. 6 7 8 9 10

2Re-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.

2Cognitive 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.)

2Developing 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. 12 13

The evaluation of low back pain is based on a thorough history, disability questionnaires and thorough examination using low-tech yet reliable tests. 14

2Developing 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.

2Additional 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

2Considerations 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

2Considerations 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

2Considerations for Establishing a Physical Rehabilitation/Active Care Plan (cont.)

Phases of Physical Rehabilitation

1. Improving stability and neuromuscular control

2. Advanced stabilization exercises

3. Advanced work; activity conditioning (working towards end goal)

Rehabilitation Treatment Plan Should Indicate:

1. Agreed-upon goals

2. Reflect Activity Intolerance

3. Be progressive with program

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.

2Tools For a Successful Active Care Program

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.

360 Degrees of Support:

2Tools For a Successful Active Care Program

Bruegger’s Relief Posture:

o 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.

o 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.

o 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.

2Tools 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.

2Tools 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.

2Examples 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.

ReferencesDr. 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. 2000 Jan; 14(1). 2Holm S, Machemson A. Nutritional changes in the canine intervertebral disc after spinal fusion. Clin Orthop 1982 Sept; 169:243-258. 3AHCPR Clinical Practice Guideline #14 1994. 4Mannich C. et al. Danish Health Technology Assessment. 1999. 5Royal College of General Practice Clinical Guidelines for the management of low back pain. 1999.  6Cholewicki J., McGill S.M. Mechanical stability of the in vivo lumbar spine. Implications for injury and chronic low back pain. Clin Biomech. 1996 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. 1997 Oct; 22(19):2207-2212. 8Gardner-Morse M.G., Stokes IAF. The effects of abdominal muscle coactivation on lumbar spine stability. Spine. 1998 Jan; 23(1):86-91. 9Granata K.P., Marras W.S. Cost-benefit of muscle co contraction in protecting against spinal instability. Spine. 2000 June; 25(11):1398-1404. 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. 1998 Sept; 13(9):982-992. 11Royal College of General Practice Clinical Guidelines for the management of low back pain. 1999.  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. 2001 Apr; 26(8):920-929. 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 .1994 Dec; 74(12): 1093-1100. 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):106-114. 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):2484-2491.

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.