Rehabilitasi Masalah Tulang Belakang

Dengan DBC (Documentation Based Care)

Dr. Peni Kusumastuti, Sp.RM

RAMSAY Spine Center
RS. Internasional Bintaro
(Hotel Gumaya Semarang, 16 Mei 2009)

RS. Internasional Bintaro

THE PROBLEM OF LBP
 Optimal management depends on accurate diagnosis
 3 distinct groups of LBP caused by :
 Red Flags ( < 2%) :
tumor, infections, fractures, serious medical disease
 Nerve Root Compression (<10%)
 Non Specific / Mechanical (85-90%)
 Psychosocial factors (yellow flags)
Fear Avoidance Behaviour & anxiety

Chronic Symptom & Disability

 Mekanikal (97%) Non - mekanikal Penyakit organ
(1%) viseral (2%)
Strain, sprain lumbal Neoplasia (0,7%) Penyakit organ-organ
(70%) Infeksi (0,01%) pelvis (prostatitis,
Proses degeneratif diskus -Osteomyelitis endometriosis)
dan facet (10%) -Abses epidural Penyakit ginjal
Herniasi diskus (4%) (neprolitiasis,
-Abses paraspinal
Stenosis spinal (3%) pyelonepritis, abses
-Penyakit Pott perineprik)
Fraktur kompresi Artritis inflamatori (0,3%)
osteoporotik (4%) Aneurisma aorta
-Ankylosing Penyakit
Spondilolistesis (2%)
-spondylitis gastrointestinal
Fraktur traumatik (<1%)
-Psoriatic spondylitis (pankreatitis,
Penyakit kongenital (<1%) kolelitiasis)
-Sindroma Reiter
Penyakit Paget tulang

(Indonesian Study Group on LBP, 2004)

 Otot-otot penting pada punggung
Longissimus
capitis

Iliocostalis Longissimus
cervicis cervicis

Intertransversarii Spinalis
cervicis
Multifidus

Iliocostalis
thoracis
Spinalis
Iliocostalis thoracis
lumborum
Longissimus
 Ligamen - ligamen pada Pandangan Lateral
tulang belakang struktur tulang belakang

Ligamentum Flavum
Diskus Intervertebra
Ligamen
Intertransversa Korpus
Vertebra
Ligamen
Facet
Capsulary Ligamen
Longitudinal
Posterior Sendi
Ligamen Facet
Interspinous

Pedikel

Ligamen Ligamen
Supraspinous Longitudinal
Anterior
 Lumbopelvic Stability

a. Control of whole-body equilibrium Lack of intersegmental control

b. Control of lumbopelvic orientation
c. Intervertebral control

Therapeutic Exercise for Lumbopelvic Stabilization, Richardson, 2005

 The System of Lumbopelvic Stability

The three systems that contribute a. Local muscles

to lumbopelvic stability. b. Global muscles

Therapeutic Exercise for Lumbopelvic Stabilization, Richardson, 2005

The Specific Joint Protection: Abdominal
MS

 Abdominal : Tr. Abd., rectus Abd., obliqus

Abd., Pelvic floor m., psoas maj.
 The Specific Joint
Protection: Paraspinal
Muscles
 Intersegmental muscles:
- intertransversari
- interspinales
 Lumbar muscles:
- lumbar multifidus
- longissimus thoracis pars lumborum
- iliocostalis lumborum pars lumborum
 Quadratus lumborum (medial fibres)
 Deep muscle of the lumbar spine
Correlation Specific Performance & LBP

1. Isokenetic Strength reduced ratio of

extenson - flexor strength & endurance
2. Balance : Poor balance control
3. Spinal Motion ROM-Pain-Disability?
The quality of motion is more important
4. Fatigueability (EMG) of back muscles decline
inchronic LBP
Correlation Specific Performance & LBP

5. Delayed reaction time: when exposed to

unexpected pertubations, voluntary upper limb
movement, & external visual stimuli
6. Control of trunk movement : decrease
7. Endurance : Decrease of trunk extensor
8. Muscles : Atrophy
Decrease cross sectional analysis
of the multifidus muscles.
What Is The Best Current Management ?
 Conventional rehabilitation?

 Active care ??
The Current Management of LBP:

The main goal has shifted from

Treatment of pain to treatment of activity
intolerance, and the patient goal is to resume
activity with less pain.

(The Agency for Health Care Policy and Research/ AH CPR, 1994)

Active Care or Patient Reactivation

Active Care To Restore Function

 Active therapy for subacute & Chronic LBP

 Cognitive & Behavioral Approach
 Stabilization exercise
 Strengthening
 Motivation : to gradually resume normal activity
 Patient Reactivation :
Start from the acute to chronic phase is a fundamental
role
Active Care Adheres To :

1. Biomechanical principles :
Stress/muscle tension & pain are related
When & how to stabilize the back
2. Neurophysiological principles :
Poor endurance & coordination of trunk flexors &
extensors caused spinal instability.
Training motor control pattern
that are protective of the spine
Active Care Adheres To :

3.Biochemical principles
 Pain & tissue healing are related to metabolic &
nutritional status
 Macrophages are in high concentration with disc
herniation

The recovery is dependent on diffusion for

its nutrition.
Inactivity slows the recovery progress
Active Care Adheres To :

4.Psychological principles
• Patients who worry & fear of their pain will have
chronic problem
• Fear/ stress increase muscle tension
exacerbate pain

Enhance coping ability & motivate

to resume normal activities
Management Of The Acute Phase
(1 – 4 weeks)
 Passive modalities :
Higher level of patient satisfaction but has not
demonstrated to improved outcome & recovery.
(Hurwitz E.L,et al. J Manip. Phsyiol. Ther. 2000)
 Advice to stay active
Early exercise increase satisfaction and function while
reducing pain.
(Little P. et al, Spine. 2001)
Management Of The Acute Phase
(1 – 4 weeks)

 Exercise : the role is controversial, Mc Kenzie

exercise is recommended for acute LBP.
(Danish Health Technologi Assessment, 1999)
 Evaluation of behavioral strategies
Early Behavioral Modification
Management Of The Subacute Phase
(4-12 weeks)

 The ideal time for both active & aggressive

treatment.
Exercise therapy is recommended for LBP more
than 6 weeks.
(Danish Health Technologi Assessment, 1999)
 Multidiciplinary Rehabilitation is effective for subacute
LBP.
(Cochrane Back Review Group, Spine 2001)
 Manipulation + exercise most effective
(Uk Beam Trial Tem, BMJ, 2004)
Management Of The Chronic Phase
(>12 weeks)
 Reactivation exercise & fear avoidance
 Exercise therapy is more effective than usual care for
chronic LBP.
(The Cochrane Collaroration Back Review Group, Spine , 2000)
 Spine Stabilization exercise achieved superior outcomes to
isotonic exercise.
(O’suzlivan P. et al, Spine, 1997)
 Isotonic exc. emphasizing endurance & improving outcome.
(Manniche G. et al, Pain, 1991)
 The Mc Kenzie at least 8 weeks. as effective as isotonic exc.
(Petersen T. et al, Spine, 2002)
BACK EXERCISE
BACK EXERCISE
 Benar Salah
Mengemudi
Benar Salah
Berdiri

Benar Salah
Memasukkan/mengeluarkan
Benar Salah barang dalam mobil
Duduk

Salah Benar Bekerja Salah

Benar Tidur
Pengaturan Postur Saat Membawa Barang

Mengangkat barang

Benar Salah

Membawa barang
didepan tubuh

Benar Salah

Membawa barang
di punggung
Benar Salah
Sit-up parsial untuk memperkuat Latihan untuk mengurangi
otot-otot abdomen peregangan otot punggung

Latihan untuk memperkuat Latihan untuk memperkuat

otot punggung dan panggul otot perut dan panggul

Beberapa variasi latihan ekstensi, mulai dari yang paling ringan ditingkatkan
disesuaikan dengan kekuatan otot-otot ekstensor lumbal
 DBC
(Documentation Based Care)
Is a functional rehabilitation progam
→ To restore lumbar function & movement
→ To influence the behavioral pattern

Based on :
→ The severity of pain & deconditioning
→ Psychological profile
→ Social needs
 Stabilization Training

• Addressed to the motor control problems

• Improving the mechanical supports
 deep muscle contraction exercises
To relieve Pain
 Reconditioning Program

 Coordination
 Mobility
 Muscle endurance exercise
 Stretching
 Relaxation
 Individualized Treatment Program
 Exercise :
→ The DBC device guide patients movement:
• Plane
• Targeted
• Controlled & physiologically correct patterns
 Cognitive & behavioral support
 Supporting elements : - relaxation & functional exercise
- psychological & work place intervention
 DBC Program
One course: 12 sessions
 1st session: baseline evaluation

 2nd –11th session: - individual treatment

- progress check
- treatment in group
 12th session: outcome evaluation

 Follow up / maintenance
 Indications

 Back
 Inflammatory
 Post-traumatic

 Post-operative

 Nerve root compression

 Narrowing of spinal canal

 Pelvic and low back pain

 Spondylolisthesis/ -lysis

 Non-specific pain
 Indications
 Neck
 Inflammatory
 Post-traumatic

 Whiplash-Associated-Disorder

 Post-operative

 Narrowing of spinal canal

 Nerve root compression

 Non-specific neck pain

 Indications
 Shoulder
 Shoulder dislocation
 Shoulder instability

 Impingement and rotator cuff

tear
 AC separation

 Shoulder arthritis

 Frozen shoulder
 QA 2007, Back
Pattern % N
I=Inflammatory 1,4 % 805
II=Post-traumatic 5,2 % 2 990
III=Postoperative 7,3 % 4 198
IV=Nerve root compression 12,4 % 7 130
V= Stenosis 2,5 % 1 438
VI=Pelvic and LBP 7,8 % 4 485
VII= Spondylolisthesis and –lysis 4,3 % 2 473
VIII=Non-specific pain 59,0 % 33 926
DBC Internasional
 QA 2007, Back

I=Inflammatory, II=Post-traumatic, III=Postoperative,

IV=Nerve root compression, V=Stenosis, VI=Pelvic and LBP,
VII=Spondylolisthesis and -lysis, VIII=Non-specific pain.

DBC Internasional
 QA 2007, Back

I=Inflammatory, II=Post-traumatic, III=Postoperative,

IV=Nerve root compression, V=Stenosis, VI=Pelvic and LBP,
VII=Spondylolisthesis and -lysis, VIII=Non-specific pain.

DBC Internasional
 DBC Clinic RS Internasional Bintaro

Distribusi Kasus

4,34%
20,65%
Back
Neck
Shoulder

82,50%

N = 229 Umur rata-rata: 44, 8

52,40 % mengikuti > 1 sessi terapi
DBC RS Internasional Bintaro 2007-2008
 Perubahan Intensitas Nyeri pada LBP

50,00
45,00 42,88
40,00
34,26
35,00
30,00
Sebelum Treatment
VAS

25,00 22,33
Sesudah Treatment
20,00 18,06

15,00
10,00
5,00
0,00
2007 2008
TAHUN

DBC Clinic RS. Internasional Bintaro

 Treatment Results
PAIN
18,5 %

Pain decreased

No change or
pain increased

81,5%
DBC RSIB 2007-2008
 Treatment Results
TROUBLE
21,9 %

Trouble decreased

No change or
trouble increased

78,1 %
DBC RSIB 2007-2008
 Treatment Results
ROTATION MOBILITY

4,1 %

Mobility increase

No change or mobility
decreased

95,9 %

DBC RSIB 2007-2008

 Treatment Results
SAGITTAL MOBILITY

6,0 %

Mobility increase

No change or
mobility decreased

94,0 %
DBC RSIB 2007-2008
 Treatment Results
LATERAL FLEXION MOBILITY

3,6 %

Mobility increase

No change or
mobility decreased

96,4 %
DBC RSIB 2007-2008
 PAIN AND TROUBLE

Clinic Country World

Average Average Average
Pain (VAS, 0-100)
-Baseline (pain during last 6 wks) 55,2 52,6 54,2

-Outcome (pain during last 6 wks) 27,9 27,2 30,7

-Outcome (pain on outcome day) 20,8 21,0 22,2

-Change (outcome pain 6 wks) -26,8 -25,2 -23,5

-Change (outcome pain on outcome day) -34,0 -31,3 -32,0

DBC Clinic RSIB & DBC Internasional

2007
 Clinic Country World
Average Average Average
Trouble (VAS, 0-100 mm)

-Baseline (trouble during last 6 wks) 53,3 49,7 52,8

-Outcome (trouble during last 6 wks) 27,1 26,8 30,0

-Outcome (trouble on outcome day) 19,6 20,6 21,9

-Change (outcome trouble 6 wks) -25,9 -22,7 -22,8

-Change (outcome trouble on outcome day) -33,3 -28,9 -30,9

DBC Clinic RSIB & DBC Internasional

2007
Conclusion :

 LBP  Chronic Symptoms & Disability.

 Correlation specific performance of LBP patients. Reduced iso-
kinetic strength, spinal motion, back muscle fatigueability,
decrease endurance, delayed reaction time & poor balance
control.
 The main goal of treatment has shifted from treatment of pain to
treatment at activity intolerance to restore function.
 Active therapy involving such exercise, cognitive-behavioral
approach, stabilization & strengthening effective for sub-acute &
chronic LBP.
 With DBC treatment, pain & trouble/impairment are
significantly reduced in back, neck & shoulder problems