Functional Rehabilitation Of Non-Specific Chronic Low Back Pain
Dr. Yusef Sarhan,FACRM Amman, 2013
Definition of Pain “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage�
Epidemiology
Life time prevalence is up to 84% Relapses of pain 44-78% Relapses of work absenteeism 23-37% Prevalence of chronic non-specific LBP of 23% (best estimate) Disability by LBP 11-12% population
WHO and EU guidelines
Classifications (Diagnostic Triage)
Specific pathology Radiculopathy Non-specific (85%)
Duration
Acute up to (4)6 weeks Sub-acute (4)6-12 weeks Chronic >12 weeks
Non-Surgical Management Of Chronic Non-Specific Low Back Pain
Evidence Based Medicine
Recommended
Stay active Exercise therapy (Individualized, supervised, Stretching and strengthening) Cognitive Behavioral Therapy Functional Restoration Multidisciplinary Treatments (Bio-psycho-social)
applying the
biopsychosocial model
Facts About People Being Out Of Work
Has the equivalent impact to smoking 10 packs of cigarettes per day (Rose 1995) Suicide in young men who have been out of work for more than 6 months is increased 40 times (Wissey, 2004) Suicide rate in general is increased by 6 times in longer-term worklessness (Bartley etal, 2005)
The Risk of being out of work in the longer term is greater than the risk of other killer diseases such as coronary heart disease (Wassell & Aylward, 2005) Being out of work puts health at greater risk than most dangerous jobs such as the construction industry.
Getting Back to Work
No need to wait until pain free to return to work The longer the patient off work the harder it is to return to work The longer off work with back pain, the greater the risk of developing chronic pain and disability and the less likely to ever return to work After six week off work there is a 10 – 40 % chance that the patient will still be off work at one year After six to twelve months off work there is a 90 % chance that he/she will never return to any form of work in the foreseeable future.
Risk and Harm of being Out Of Work
Loss of fitness Physical and mental deterioration Psychological distress and depression Loss of work-related habits Increased social exclusion Poverty.
Why Work
Promote recovery and aids rehabilitation Leads to better health outcomes Minimizes the harmful physical, Mental and Social effects of long-term sickness absence Improves quality of life and well-being Reduces social exclusion and poverty.
Successful Rehabilitation Program
Exercise Therapy - Individually designed - Supervised - Including Stretching and Strengthening
Cognitive-Behavioral Approach Mechanisms of adherence Aerobic Component
Functional Rehabilitation ď‚Ą ď‚Ą
The inpatient approach The outpatient approach
Objectives
Restoring function in activities of ADL and returning to work Decreasing pain and medication use Avoid recurrent injury Limit future healthcare utilization
Treatment Components 1. 2. 3.
4. 5. 6.
Formal, repeated quantification of physical deficits Psychosocial assessment Multimodal disability management programs using CBT approaches Detoxification and psychosocial management Ongoing outcome assessment Interdisciplinary, medically directed team approach
Inpatient Approach
Outpatient preparatory period Intensive inpatient treatment
3-6 weeks Daily 5-6 hours daily Interdisciplinary team - Physical - Occupational - Theory lessons - Recreational activity
- Psychological group therapy - Socialization activities.
Outpatient Approach
Physical Psychological 2-3 sessions/week 1-3 hours each session 5-15 week
Documentation Based Care (DBC) DBC Treatment Concept Treatment Device
Patient
Assessment
Individualized Treatment Plan
Support Function
Outcome Monitoring
Baseline Assessment (Standardized) 1. Questionnaires
Medical background Pain intensity, duration and drawing Psychological questionnaires - Fear-Avoidance - Rimon Brief Depression Scale - Recovery Locus of Control
Physical Impairment Index Job description and working status Physical activity Stress VAS Personal Goals
2. Examination Range of motion Fatigue and EMG activity in Low back muscles Isometric strengthening Balance
Individualized Treatment Program
Pattern of the disorder Duration of treatment Exercises - Setting ROM - Setting load and progression Cognitive and Behavioral support Supporting elements - Relaxation and functional exercises - Psychological and work place intervention Maintaining Results
Monitoring Outcome
Progress check and outcome evaluation Follow up Reports
Why Current Treatments Are Not Very Effective?
Sub grouping ? Misdirected? Neuro- degeneration and Cortical Reorganization
Neuro degeneration
Dorsolateral prefrontal cortex (DLPFC) Brain stem Thalamus Sensory cortex
Cortical Reorganization
Reduced Cortico-cortical and descending inhibition Reactivation of implicit pain memories Centrally generated pain in response to sensori-motor incongruence when the patient moves the back
IS Chronic Non-Specific low Back Pain A Central Sensitivity Syndrome?
Hyperalgesia Allodynia
It is more important to add life to years, rather than add years to life