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
Studies Referencing Benefits of Active Care
Rest vs. Active Care
Active Care
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
Demineralization of bone
Decreased physical fitness with a
daily loss of muscle tone estimated
at greater than 1 percent per day of
Increased psychological stress,
depression and increased difficulty
in starting a rehab program
Promotion of bone density and
muscle strength
Improved disc and cartilage
Improved joint stability
Avoidance of psychological issues
Less apt to develop chronic pain
Best Practices for Active Care
Elements 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
Elements 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
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. Agonistantagonist 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
• 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
• Level 2: Exercise to retrain the
weak links that led to patient’s
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.)
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. 12 13
 The evaluation of low back pain is based on a thorough history,
disability questionnaires and thorough examination using lowtech yet reliable tests. 14
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.
Additional Advice for Patient Healthy Lifestyles
 Smoking cessation
 Good nutritional habits
 Encourage weight loss when appropriate
 Appropriate sleep
 Ergonomic work stations and ergonomic home
 Encourage non-reliance with active healthy lifestyles
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
 Belief that shouldn’t work
with current pain
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
Considerations for Establishing a Physical
Rehabilitation/Active Care Plan (cont.)
Phases of Physical
Rehabilitation Treatment
Plan Should Indicate:
1. Improving stability and
neuromuscular control
1. Agreed-upon goals
2. Advanced stabilization
2. Reflect Activity
3. Advanced work; activity
conditioning (working
towards end goal)
3. Be progressive with
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
• 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 reactivating the healing process.
• Helping patients establish goals that help re-establish function.
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.
Tools 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.
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.
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
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.
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.
S, Machemson A. Nutritional changes in the canine intervertebral disc after spinal fusion. Clin Orthop 1982 Sept; 169:243-258.
David. The Chiropractic Report. 2000 Jan; 14(1).
Clinical Practice Guideline #14 1994.
C. et al. Danish Health Technology Assessment. 1999.
College of General Practice Clinical Guidelines for the management of low back pain. 1999.
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.
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-
M.G., Stokes IAF. The effects of abdominal muscle coactivation on lumbar spine stability. Spine. 1998 Jan; 23(1):86-91.
K.P., Marras W.S. Cost-benefit of muscle co contraction in protecting against spinal instability. Spine. 2000 June; 25(11):1398-1404.
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.
College of General Practice Clinical Guidelines for the management of low back pain. 1999.
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.
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.
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.
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.

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