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( 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(85--90%)
( Psychosocial factors (yellow flags)
Fear Avoidance Behaviour & anxiety

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


Abd., Pelvic floor m., psoas maj.
 
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( ðntersegmental 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
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1. +  , reduced


reduced ratio of
extenson - flexor strength & endurance
2.  : Poor balance control
3. 
  ROM--Pain-
ROM Pain-Disability?
The quality of motion is more important
4.  ,  (EMG) of back muscles decline
inchronic LBP
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unexpected pertubations, voluntary upper limb
movement, & external visual stimuli
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7.  : Decrease of trunk extensor
8.  : Atrophy
Decrease cross sectional analysis
of the multifidus muscles.
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( Conventional rehabilitation?

( Active care ??
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The main goal has shifted from


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activity with less pain.

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( 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
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Stress/muscle tension & pain are related
When & how to stabilize the back
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Poor endurance & coordination of trunk flexors &
extensors caused 
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Training motor control pattern
that are protective of the spine
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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.
nutrition.
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4.Psychological principles
‡ Patients who worry & fear of their pain will have
chronic problem
‡ Fear/ stress increase muscle tension
exacerbate pain

 
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ý Passive modalities :
Higher level of patient satisfaction but has not
demonstrated to improved outcome & recovery.
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ý Advice to stay active
Early exercise increase satisfaction and function while
reducing pain.
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ý Exercise : the role is controversial,


controversial, Mc Kenzie
exercise is recommended for acute LBP.
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ý Evaluation of behavioral strategies
Early Behavioral Modification
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ý Multidiciplinary Rehabilitation is effective for subacute
LBP.
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ý Manipulation + exercise most effective
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 ðsotonic exc. emphasizing endurance & improving outcome.
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 The Mc Kenzie at least 8 weeks. as effective as isotonic exc.
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ðs 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
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ã Addressed to the motor control problems


ã ðmproving the mechanical supports
ý deep muscle contraction exercises
To relieve Pain
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( Coordination
( Mobility
( Muscle endurance exercise
( Stretching
( Relaxation
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ù Exercise :
 The DBC device guide patients movement:
‡ Plane
‡ Targeted
‡ Controlled & physiologically correct patterns
ù Cognitive & behavioral support
ù Supporting elements : - relaxation & functional exercise
- psychological & work place intervention
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One course: 12 sessions
( 1st session: baseline evaluation

( 2nd ²11th session: - individual treatment

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

( Follow up / maintenance
 

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( ðnflammatory
( Post
Post--traumatic
( Post
Post--operative
( Nerve root compression

( Narrowing of spinal canal

( Pelvic and low back pain

( Spondylolisthesis/ -lysis

( Non
Non--specific pain
 
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( ðnflammatory
( Post
Post--traumatic
( Whiplash
Whiplash--Associated
Associated--Disorder
( Post
Post--operative
( Narrowing of spinal canal

( Nerve root compression

( Non
Non--specific neck pain
 
(  
( Shoulder dislocation
( Shoulder instability

( ðmpingement and rotator cuff


tear
( AC separation

( Shoulder arthritis

( Frozen shoulder
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ðð " 0 5,2 % 2 990
ððð "  7,3 % 4 198
ð     12,4 % 7 130
   2,5 % 1 438
ð "  ," 7,8 % 4 485
ðð      1  4,3 % 2 473
ððð 0    59,0 % 33 926
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Pain decreased

No change or
pain increased

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Trouble decreased

No change or
trouble increased

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Mobility increase

No change or mobility

decreased

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Mobility increase

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Average Average Average
R/ ")2""$
-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

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Average Average Average
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-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

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( LBP ý Chronic Symptoms & Disability.
( Correlation specific performance of LBP patients. Reduced iso- iso-
kinetic strength, spinal motion, back musc
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-
cognitive-behavioral
approach, stabilization & strengthening effective for sub-
sub-acute &
chronic LBP.
( With DBC treatment, pain & trouble/impairment are
significantly reduced in back, neck & shoulder problems