Treatment of Low Back Pain

Question 1

O que é Non-Specific Low Back Pain? E sua patogénese?

Answer 1

Symptom of an unknown cause. It happens more than 85 percent in patients who are seen in primary care.
A variety of bio-psychosocial factors contribute to the problem, including changes in the nociceptive interpretation, (A dor é mais facilmente despertada). It does not mean that something anatomically isn’t wrong, It does involve maladaptive coping behaviors and deconditioning.

Question 2

Quais as principais classificações da lombalgia?

Answer 2

Mechanical Diagnosis and Treatment (MDT); Treatment Based Classification (TBC); Pathoanatomic Based Classification (PBC); Movement System Impairment Syndromes (MSI); O’Sullivan Classification System (OSC).

Question 3

Quais as quatro grandes categorias do treatment based classification (TBC)? E a que técnicas podem estar associadas?

Answer 3

1) Specific exercise (Exercise that centralizes, reduces symptoms or addresses the patient’s condition specifically. Ex: McKenzie approach);
2) Mobilization (Clinical prediction rule Concordancy - Thrust or Non-thrust manipulation, Mobilizations with movement, Muscle energy techniques);
3) Immobilization (active examination with no decrease with any movements - Strengthening (stabilization), Local and non-specific strengthening exercises, General activation exercises);
4) Traction (Radiculopathy - Decompression oriented procedures that are designed to reduce radicular symptoms).

Question 4

Qual a clinical prediction rule (CPR) que aumenta a probabilidade de uma resposta positiva após manipulação?

Answer 4

1) Duration of symptoms inferior to 16 days; 2) Hip internal rotation of at least 35 degrees; 3) Lumbar segmental hypomobility tested with a spring test; 4) No symptoms distal to the knee; 5) Score inferior to 19 on the work subscale of the Fear Avoidance Beliefs Questionnaire.
Four of 5 of these findings increases the odds of a
short term positive response from manipulation by
25 fold and demonstrated better outcomes than
exercises.

Question 5

Qual a CPR para beneficiar de estabilização?

Answer 5

Does the patient have at least 3 of the following:
1) Average SLR ROM superior 91 degrees;
2) Positive prone instability test;
3) Positive aberrant movements;
4) Age inferior 40 years.
(Não é muito precisa, intervalos de confiança muito largos, utilidade questionável)

Question 6

Qual o racioncínio subjacente ao motor control approach (specific spine stabilization)?

Answer 6

Um indivíduo com LBP tende a perder a sequência do controlo motor (sequência da ativação muscular), pelo que esta abordagem foca-se no controlo dos músculos profundos com progressão por três etapas. Procuram-se adquirir competências até atingir um nível mais elevado de movimento. São body-specific, requerendo mais atenção e precisão por parte do utente. O alvo é o sinal concordante.

Question 7

Como deve o terapeuta corrigir o shift em postura?

Answer 7

Attempt to correct the shift by pulling the pelvis (using a shear force) toward the displaced thoracic region. Block with your shoulder and consider moving the trunk into flexion and extension.

Question 8

Como se deve autocorrigir o shift da postura?

Answer 8

Have the patient stand next to a wall with the thoracic shift side closest to the wall. Using their arm, block the wall to place distance between the trunk and the wall. Then, using the other arm press the pelvis toward the wall in an attempt to ‘correct the shift’.

Question 9

Como se realiza a autocentralização?

Answer 9

Have the patient move repeatedly into end range, toward the movement that helped centralize (move toward the central spine or abolish pain peripherally) and re-assess their condition.

Question 10

Como se aplica a rotation thrust manipulation?

Answer 10

Place the individual in sidelying. Add side flexion to gap the upper facets and place the patient is slight flexion. Rotate the pelvis toward you and rotate the spine away. Use your fingers to identify the appropriate segment for a thrust manipulation. Apply a downward thrust.

Question 11

Qual o instrumento que nos pode ajudar a ensinar a contrair o abdominal transverso? Fase 1

Answer 11

Uma blood pressure cuff em baixo da coluna (com a pressão de 20 mmHg, por exemplo).

Question 12

Como ensinar uma contração do pavimento pélvico?

Answer 12

To appropriately perform the activity ask the patient to pull up in the pelvic floor in an attempt to stop the flow of urine. Palpate the transverse abdominus to feel for a shallowing of the muscles.

Question 13

Como estimular a contração do transverso do abdomen com a thera-band em resistência externa?

Answer 13

First, set the spine and then perform forward movements with resistance against the band. A transverse abdominus contraction will be performed prior to this.

Question 14

Que exercícios podem ser atribuídos para contração do abdomen transverso na fase 2?

Answer 14

Transversus abdominus with t-band external weight;
Side Plank;
Side Plank on Ball (under the feet);
Side Plank and Hip Abduction;
Reverse Plank (plank supine with chin retraction);
Prone Plank with Hip Extension;
Unilateral Bridging (levantar o rabo, membro extensão);

Question 15

Como se aplica Specific Sidelying Traction?

Answer 15

Side lying, perform a simultaneous activity of rotating the trunk toward the clinician (behind) while pushing the pelvis away. A gapping should occur at the top side of the spine and a specific tension is applied by pushing the pelvis anteriorly at the final step.

Question 16

Como aplicar Supine Traction?

Answer 16

In prone, the traction activity is performed by pulling the knees of the subject inferiorly while they maintain a hooklying position.
In supine, The activity is a combined movement of knees to chest and pulling the knees toward the chin.

Question 17

Qual é a fase 3 do tratamento por controlo motor e estabilização?

Answer 17

Return to Activity in the Clinic.

Question 18

O que são Adjunctive Specific Exercises?

Answer 18

Exercises designed to compliment, as a home exercise program, the manual interventions you have applied.

Question 19

Quais os diferentes tipos de abordagens para os exercícios de estabilização?

Answer 19

There is debate on which type of exercises are needed:
– Motor approach (local muscle stabilization);
– Graded exposure approach (targeted activities to increase tolerance and reduce fear);
– Cognitive Behavioral interventions (based on learning and cognitive changes);
– General approach (general activation).

Question 20

Quais os indicadores para escolher a motor approach para a estabilização?

Answer 20

Younger, very active, low FABQ, no yellow flags, acute and chronic.

Question 21

Quais os indicadores que sugerem a utilização da graded response approach e/ou cognitive behavoral approach para a estabilização?

Answer 21

Younger, not active, high FABQ, yellow flags, chronic.

Question 22

Quais os indicadores que sugerem um General Approach (activation) para a estabilização?

Answer 22

Older, either active or not active, low FABQ, no yellow flags, acute or chronic.

Question 23

Qual é o foco da Cognitive Behavoral Treatment (CBT) approach?

Answer 23

CBT is seen when it is used together with physical exercise as part of a multimodal treatment program; treat physical, psychosocial, and occupational elements; focus on future rather than symptoms of “here and now”.

Question 24

Quais as considerações acerca da Graded Exposure Approach?

Answer 24

A method that adjusts for patient tolerance of activity; FABQ drives the application; Involves positive reinforcement and focus on completion of activity and symptom confrontation; Exposure is increased through duration, frequency, and intensity modification.

Question 25

Qual o aumento atribuído a cada sessão em Graded Exposure Approach?

Answer 25

If the patient have less fear of the activities, we should do positive reinforcement and 10% increase dosage by duration, frequency or intensity (in each session).
If the patient have the same fear of the activities, the therapist reinforces the importance of completing activity and symptom confrontation; and no change in activity level.
Repeat the process.

Question 26

Explica o conceito Exercise Overload and Specificity na Graded Exposure Approach.

Answer 26

“The type of demand that is placed on the body dictates the type of adaptation that might occur”. If Physical stress exceeds the maintenance range of the biological tissue, increased tolerance will result.

Question 27

Quais são os elementos e objetivos da General Approach?

Answer 27

Active exercise (low load, high repetition endurance based) muscle activity; Aerobic exercise (Walking, Cycling, or Swimming); Advise to remain active; Reduction of passive approaches.

The main objective of the training is to restore not the pain, but the daily functioning of participants for the longer term; The training program is partly based on physical training and partly on behavioral cognitive training. The physical training is performed according the “graded activity” principle and involves intensive therapy involving 30 hours of training a week or more.

Question 28

Quais são os elementos da Graded Exposure Approach?

Answer 28

Treadmill Walking (activation - may substitute cycling);
Education (Icludes a list activities the individual is fearful of; develop a program of exposure to those
activities);
Body Section Exercises (involves large body groups);
Functional Lifting (adaptation).

Question 29

Qual a evidência na utilização da Graded Exposure Approach?

Answer 29

The best-evidence synthesis revealed that there was no or insufficient evidence for a positive effect of GA on pain, disabilities and return to work in patients with non-specific LBP. Ten articles were included in this systematic review; these articles described five RCTs (680 patients).

Van der Giessen et al. The effectiveness of graded activity in patients with non-specific
low-back pain: a systematic review. Disabil Rehabil. 2012;34(13):1070-6.

Question 30

Quais são os princípios da General Approach?

Answer 30

Improve physical adaptation (same concept as graded approach); Multidisciplinary (Physical Therapy, Medical, Occupational Therapy, Psychology); Change behavior (Knowledge, Expectancy, Avoidance behavior, Coping, Encouragement).

Question 31

Qual a influência das expectativas na CBT?

Answer 31

Recovery expectations when measured using a specific, time-based measure within the first 3 weeks of NSLBP can identify people at risk of poor outcome; Poor expectations = poor recovery.
Focus is on expecting return of function and not obliteration of pain.

Question 32

What presupposes a psychologically informed intervention?

Answer 32

A psychologically informed intervention presupposes that a clinician not only accepts the notion that the treatment is not directed solely at back pain and possible musculoskeletal contributors but also considers the person who has the back pain, contextual factors, and their combined contribution to the problem before developing an intervention plan.

Question 33

What involves a formulation of the fear-avoidance model of pain-related disability?

Answer 33

Interventions based on this formulation typically involve encouraging patients to confront and overcome their fears and unhelpful beliefs by performing the previously avoided activities.

Question 34

The goals of treatment and the roles and responsibilities of both clinicians and patients need to be agreed upon before commencement of interventions in which patients play an active role. What is imperative to do that?

Answer 34

Patients must understand how the treatment activities will lead to the achievement of their desired goals or outcomes. Without that linkage being accepted by patients, it should come as no surprise if patients do not adhere to a self-management program, such as home exercises.

Question 35

Dá um exemplo de ligação entre o objetivo terapêutico e o desejo do paciente de forma a se comprometer ativamente.

Answer 35

Improving range of movement in a limb will have relevance to patients only if they can understand how that will enable them to do something they value, such as lifting a child out of a car.

Question 36

What we can say about abnormal imaging findings?

Answer 36

Abnormal imaging findings:
• Very rarely a sign of serious disease
• Commonly found in people without low back pain.

Question 37

What implicate having low back pain?

Answer 37

Implications of low back pain:
• No suggestion of permanent damage
• The spine is strong, even when it is painful
• Pain does not mean your back has serious damage.

Question 38

Note the principles we should give, on treatment of low back pain.

Answer 38

• A number of treatments can help to control the pain
• Lasting relief depends on your effort
• Concentrate on mantaining anda improving activity to restore normal function and fitness
• Utilize positive attitude and adaptive coping skills.

Question 39

What we do in the first session of graded exposure process in chronic low back pain?

Answer 39

First session: determine fearful activities
• Patient completes FDAQ (Fear
• Therapist records most fearful activities (based on NRS from FDAQ)
• Patient reports level of activity he/she is willing to perform with increase in fear.

Question 40

After we determine fearful activities in the first session of graded exposure, what should we do next?

Answer 40

Subsequent sessions: patient performs fearful activities
• Level of activity determined from results of previous session
• Completion monitored by physical therapist and staf
• Patient completes FDAQ for reassessment.

Question 41

With the graded exposure process, if the patient have less fear of activities, what should we do?

Answer 41

Positive reinforcement:
• Completing activity
• Symptom confrontation

Increase activity level by at least 10%:
• Duration
• requency
• Intensity.

Question 42

In the case of a patient who doesn’t have less fear with graded exposure (the fear remains), what we do?

Answer 42

The therapist reinforces importance of:
• Completing activity
• Symptom confrontation

No change in activity level:
• Duration
• Frequency
• Intensity.

Question 43

In graded exposure, when should we increase the exposure?

Answer 43

At the conclusion of one session of exposure, the patient rate the postactivity fear and physical therapist plan to increase exposure for the next treatment session.