Why, when and how to progress patients through active care
Patients want to progress to meet their health goals. Doctors document progress to justify care and increase compliance. Since active care is integral in the current chiropractic paradigm, incorporating the appropriate exercises at the relevant stage of care and the proper intensity becomes the cornerstone of evidence-based exercise management.
Exercise programming is commonplace for personal trainers, PTs, ATCs and the YouTube exercise guru DuJour. However, an exercise program focused on the correction of abnormal movement patterns, with a full-body postural kinetic chain approach while incorporating soft tissue management, lifestyle intervention and chiropractic manipulative therapy (CMT), is a chiro-centric approach that achieves exceptional outcomes and reinforces in-office care.
Tip: Make all exercise progressions chiro-centric. As movement patterns are restored, bring every exercise back to spinal and joint alignment. Perform every exercise with good alignment “from nose to toes” in every stage of care and exercise progression.
Acute and subacute phases of care
Exercise selection must complement the patient’s phase of care. In the acute and subacute phases of care, when the patient is still symptomatic, restoring ROM and arthrokinematics (segmental joint play) must be addressed, as well as symptom management. During these phases of care, working up to, but not through, the point of pain is the mantra since increasing symptoms would slow down recovery. Passive and assisted stretches, contract-relax and hold muscle energy techniques, CMT as tolerated and low-intensity cardio are good choices during these phases of care.
Tip: Post-exercise soreness lasting a few minutes to 24 hours is acceptable and a good goal for rehab intensity. Pain lasting 24-48 hours after exercise indicates that too much was done, and the exercise needs to be reduced by 50%. Pain lasting more than 48 hours indicates the prescribed exercises should be discontinued with a re-evaluation once symptoms reduce.
Corrective and performance enhancement phases of care
Once the patient begins to “feel pretty good,” they will enter the corrective phase of care. The primary goal of exercise selection is the complete restoration of ROM with the integration of stability exercises. Cardio is continued and can be increased to a moderate level. CMT, as needed, will continue, and postural correction will start.
After the corrective stage of care, the patient enters the performance enhancement phase. In sports, this is called the return to play phase; in industry, it is termed work hardening. This optimizes the patient’s performance for ADLs, work or recreation. Exercise selection must include core stability, balance, agility, power and speed. Change of direction and deceleration needs to be considered, too.
Tip: In performance enhancement, the caveat is speed kills. Adding speed training (i.e., intervals, jumping, hopping, sprints, etc.) without a stable foundation, good arthrokinematics and neuromuscular control will lead to injury.
Functional movement
Beyond exercise selection based on the phase of care, functional movement assessments can also be used to create a corrective exercise program. Corrective because it is designed to address static postural imbalances and abnormal movement patterns. The goal is to isolate underlying imbalances dynamically in joint motion and muscle length/tension relationships under load. After all, motion is life, and to move better is to live better. The corrective exercise paradigm has four components: inhibit, lengthen, activate and integrate and when stacked with CMT, it translates directly into the chiro-centric model.
Tip: Begin postural correction in the corrective phase of care. Regardless of your style of practice, all patients understand posture. Shift the patient’s attention from how they feel to how they look with a progression of rehabilitative exercises for postural correction.
Overactive, shortened muscles often demonstrate myofascial restrictions that need to be released; hence, the muscle must be inhibited from overactivity before it can be lengthened with stretching techniques.2 Foam roller, vibration, massage, ischemic compression and myofascial release all work well to restore compliance to the soft tissues.
Once myofascial densifications are released, static and dynamic stretching is beneficial to lengthening tight muscles and increasing ROM. Techniques to lengthen soft tissues and increase ROM include proprioceptive neuromuscular facilitation (PNF), instrument-assisted soft tissue manipulation (IASTM) with motion and active myofascial release.3,4
Lengthened muscles are inherently weak; therefore, strength must be regained once ROM is increased. This starts with isolated strengthening of the target muscle to restore neuromuscular control and prev
ent the already strong muscles from creating abnormal movement patterns.
This compensatory movement pattern is often the underlying cause of functional deficits. Isolated strengthening is critical before multiplanar and multi-joint exercises are performed.
Integrative exercises
The final phase of the corrective exercise paradigm is integrative exercises, which include multi-joint and multiplanar activities designed to groove the desired corrective movement prescription. Progressing to integrative exercises too quickly will perpetuate imbalances. The underlying dysfunction needs to be corrected first before advanced exercises can begin.
The chiro-centric approach to rehab is from the ground up since humans are bi-pedal. Therefore, the long-term goal for patients is to perform corrective exercises properly, standing with good static and dynamic posture under full weight bearing. Progress the patient from supine to standing activities, maintaining good mechanics and motor control. See Table 1.
Tip: Strong feet are essential for returning to ADLs and full weight-bearing activities. Flexible full-foot orthotics that maintain all three arches of the feet enhance this correction.
Exercise selection is the intersection of the phase of care, target tissue and appropriate base of support to ensure the exercises can be performed using the optimal technique. Proper execution is essential. Once successful movement and motor control are achieved, the patient can progress by increasing sets, repetitions and load/resistance and reducing the base of support.
Final thoughts
In acute and sub-acute care, ROM, light cardio, and CMT should be addressed as tolerated. Once pain-free, introduce postural and functional movement correction. In corrective care, the continuum is inhibited, lengthened, activated and integrated. Ultimately, the patient will progress to standing exercises in full weight-bearing. Introduce power and speed training once mechanics and neuromuscular control are restored. Keep it chiro-centric; bring all exercises back to alignment.
Donald DeFabio, DC, is a chiropractic influencer and motivational speaker who teaches relevant rehab seminars throughout the US. His e-book, “The Six Keys to In-Office Rehab,” is free on his website, defabiodifference.com, and his exercise protocols can be found on YouTube/DrDeFabio, which has more than 42,000 subscribers.
References
1. Izraelski J. Assessment and Treatment of Muscular Imbalance: The Janda Approach. J Can Chiropr Assoc. 2012;56(2):158. https://pmc.ncbi.nlm.nih.gov/articles/PMC3364069/. Accessed February 21, 2025.
2. Clark M, et al. NASM essentials of corrective exercise training. National Academy of Sports Medicine. 2014. Jones and Bartlett Learning: Burlington, MA. https://www.ncbi.nlm.nih.gov/nlmcatalog/101618368/. Accessed February 21, 2025.
3. Liebenson C. Rehabilitation of the Spine: A Practitioner’s Manual. 2nd ed. J Can Chiropr Assoc. 2007;51(1):62. https://pmc.ncbi.nlm.nih.gov/articles/PMC1924653/. Accessed February 21, 2025.
4. Therapeutic Exercise, Foundations and Techniques. 6th ed 2012. FA Kisner C, Kolby LA. Davis: Philadelphia, PA. Accessed February 21, 2025. https://fadavispt.mhmedical.com/content.aspx?bookid=1883§ionid=136735505/.
