rehabilitasi masalah tulang belakang dengan dbc (makalah)dr. peni k, sprm
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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
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Optimal management depends on accurate diagnosisOptimal management depends on accurate diagnosis
3 distinct groups of LBP caused by :3 distinct groups of LBP caused by : Red Flags ( < 2%) :Red Flags ( < 2%) :
tumor, infections, fractures, serious medical diseasetumor, infections, fractures, serious medical disease
Nerve Root Compression (
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Mekanikal (97%) Non - mekanikal(1%)
Penyakit organviseral (2%)
Strain, sprain lumbal
(70%)
Proses degeneratif diskus
dan facet (10%)
Herniasi diskus (4%)
Stenosis spinal (3%)
Fraktur kompresi
osteoporotik (4%)
Spondilolistesis (2%)
Fraktur traumatik (
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Longissimus
capitis
Spinalisthoracis
Longissimus
Longissimus
cervicis
Spinalis
cervicis
Iliocostalis
lumborum
Iliocostalis
thoracis
Multifidus
Intertransversarii
Iliocostalis
cervicis
Otot-otot penting pada punggung
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Ligamen - ligamen pada
tulang belakang
LigamenLongitudinal
Anterior
LigamenLongitudinal
Posterior
LigamenIntertransversa
Ligamentum Flavum
LigamenFacet
Capsulary
LigamenInterspinous
LigamenSupraspinous
Pandangan Lateral
struktur tulang belakang
Pedikel
SendiFacet
KorpusVertebra
Diskus Intervertebra
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Lumbopelvic Stability
a. Control of whole-body equilibrium
b. Control of lumbopelvic orientationc. Intervertebral control
Lack of intersegmental control
Therapeutic Exercise for Lumbopelvic Stabilization, Richardson, 2005
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The System of Lumbopelvic Stability
a. Local muscles
b. Global muscles
The three systems that contribute
to lumbopelvic stability.
Therapeutic Exercise for Lumbopelvic Stabilization, Richardson, 2005
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The Specific Joint Protection: AbdominalThe Specific Joint Protection: Abdominal
MSMS
Abdominal : Tr. Abd., rectus Abd., obliqus
Abd., Pelvic floor m., psoas maj.
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The Specific JointThe Specific Joint
Protection: ParaspinalProtection: Paraspinal
MusclesMuscles
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
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Correlation Specific Performance & LBPCorrelation Specific Performance & LBP
1.1. Isokenetic StrengthIsokenetic Strength reduced ratio ofreduced ratio of
extensonextenson -- flexor strength & enduranceflexor strength & endurance
2.2. BalanceBalance : Poor balance control: Poor balance control3.3. Spinal MotionSpinal Motion ROMROM--PainPain--Disability?Disability?
The quality of motion is more importantThe quality of motion is more important
4.4. FatigueabilityFatigueability (EMG) of back muscles decline(EMG) of back muscles decline
inchronic LBPinchronic LBP
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5.5. Delayed reaction timeDelayed reaction time: when exposed to: when exposed tounexpectedunexpected pertubations, voluntary upper limbpertubations, voluntary upper limb
movement,movement, && external visual stimuliexternal visual stimuli6. Control of trunk movement6. Control of trunk movement :: decreasedecrease
7.7. EnduranceEndurance : Decrease of trunk extensor: Decrease of trunk extensor
8.8. MusclesMuscles : Atrophy: Atrophy
Decrease cross sectional analysisDecrease cross sectional analysisof the multifidus muscles.of the multifidus muscles.
Correlation Specific Performance & LBPCorrelation Specific Performance & LBP
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What Is The Best Current Management ?What Is The Best Current Management ?
Conventional rehabilitation?Conventional rehabilitation?
Active care ??Active care ??
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The Current ManagementThe Current Management ooff LBP:LBP:
The main goal has shifted fromThe main goal has shifted from
TTreatmentreatment ofof painpain toto treatment of activitytreatment of activityintoleranceintolerance, and the patient goal is to resume, and the patient goal is to resumeactivity with less pain.activity with less pain.
((The Agency for Health Care Policy and Research/ AH CPR, 1994)The Agency for Health Care Policy and Research/ AH CPR, 1994)
Active Care or Patient ReactivationActive Care or Patient Reactivation
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Active Care To Restore Function Active Care To Restore Function
Active therapy for subacute & Chronic LBPActive therapy for subacute & Chronic LBP
Cognitive & Behavioral ApproachCognitive & Behavioral Approach
StabilizationStabilization exerciseexercise
StrengtheningStrengthening
Motivation : to gradually resume normal activityMotivation : to gradually resume normal activity
Patient Reactivation :Patient Reactivation :
Start from the acute to chronic phase is a fundamentalStart from the acute to chronic phase is a fundamentalrolerole
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Active Care Adheres To :Active Care Adheres To :
1.1. Biomechanical principles :Biomechanical principles :
Stress/muscle tension & pain are relatedStress/muscle tension & pain are related
When & how to stabilize the backWhen & how to stabilize the back2.2. NeurophysiologicalNeurophysiological principles :principles :
Poor endurance & coordination of trunk flexors &Poor endurance & coordination of trunk flexors &extensors causedextensors caused spinal instability.spinal instability.
Training motor control patternTraining motor control patternthat are protective of the spinethat are protective of the spine
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3.Biochemical principles3.Biochemical principles
Pain & tissue healing are related to metabolic &Pain & tissue healing are related to metabolic &nutritionalnutritional statusstatus
Macrophages are in high concentration with discMacrophages are in high concentration with discherniationherniation
The recovery is dependent on diffusion forThe recovery is dependent on diffusion forits nutritionits nutrition..
Inactivity slows the recoveryInactivity slows the recovery progressprogress
Active Care Adheres ToActive Care Adheres To ::
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4.Psychological principles4.Psychological principles
Patients who worryPatients who worry && fearfear of theirof their painpain willwill havehavechronic problemchronic problem
Fear/ stress increase muscle tensionFear/ stress increase muscle tension
exacerbate painexacerbate pain
Enhance coping ability & motivateEnhance coping ability & motivate
to resume normal activitiesto resume normal activities
Active Care Adheres To :Active Care Adheres To :
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Management Of The Acute PhaseManagement Of The Acute Phase
(1(1 4 weeks)4 weeks)
Passive modalities :Passive modalities :
Higher level of patient satisfaction but has notHigher level of patient satisfaction but has not
demonstrated to improved outcome & recovery.demonstrated to improved outcome & recovery.(Hurwitz E.L,et al. J Manip. Phsyiol. Ther. 2000(Hurwitz E.L,et al. J Manip. Phsyiol. Ther. 2000))
Advice to stay activeAdvice to stay active
Early exercise increase satisfaction and function whileEarly exercise increase satisfaction and function while
reducing pain.reducing pain.(Little P. et al, Spine. 2001(Little P. et al, Spine. 2001))
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Exercise : the role is controversialExercise : the role is controversial,, MMcc KenzieKenzie
exercise is recommended for acute LBP.exercise is recommended for acute LBP.
(Danish Health Technologi Assessment, 1999)(Danish Health Technologi Assessment, 1999)
Evaluation of behavioral strategiesEvaluation of behavioral strategies
Early Behavioral ModificationEarly Behavioral Modification
Management Of The Acute PhaseManagement Of The Acute Phase
(1(1 4 weeks)4 weeks)
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Management Of The Subacute PhaseManagement Of The Subacute Phase
(4(4--12 weeks)12 weeks)
The ideal time for both active & aggressiveThe ideal time for both active & aggressivetreatment.treatment.
Exercise therapy is recommended for LBP moreExercise therapy is recommended for LBP morethan 6 weeks.than 6 weeks.((Danish Health Technologi Assessment, 1999Danish Health Technologi Assessment, 1999))
Multidiciplinary Rehabilitation is effective for subacuteMultidiciplinary Rehabilitation is effective for subacuteLBP.LBP.
(Cochrane Back Review Group, Spine 2001)(Cochrane Back Review Group, Spine 2001) Manipulation + exercise most effectiveManipulation + exercise most effective
(Uk Beam Trial Tem, BMJ, 2004)(Uk Beam Trial Tem, BMJ, 2004)
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Management Of The Chronic PhaseManagement Of The Chronic Phase
(>12 weeks)(>12 weeks)
Reactivation exercise & fearReactivation exercise & fear avoidanceavoidance
Exercise therapy is more effective than usual care forExercise therapy is more effective than usual care forchronic LBP.chronic LBP.
((The Cochrane Collaroration Back Review Group, Spine , 2000)The Cochrane Collaroration Back Review Group, Spine , 2000) Spine Stabilization exercise achieved superior outcomes toSpine Stabilization exercise achieved superior outcomes to
isotonic eisotonic exercisexercise..
((Osuzlivan P. et al, Spine, 1997Osuzlivan P. et al, Spine, 1997))
Isotonic exc. emphasizing endurance & improving outcome.Isotonic exc. emphasizing endurance & improving outcome.
(Manniche G. et al, Pain, 1991(Manniche G. et al, Pain, 1991))
The Mc Kenzie at least 8 weeks. as effective as isotonic exc.The Mc Kenzie at least 8 weeks. as effective as isotonic exc.
(Petersen T. et al, Spine, 2002(Petersen T. et al, Spine, 2002))
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BACK EXERCISE
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BACK EXERCISE
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Berdiri
Benar Salah
Duduk
Benar Salah
TidurBenar
Salah
Mengemudi
Benar Salah
Memasukkan/mengeluarkan
barang dalam mobil
Benar Salah
BekerjaBenar Salah
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Pengaturan Postur Saat Membawa Barang
Benar
Mengangkat barang
Salah
Benar
Membawa barang
didepan tubuh
Salah
Benar
Membawa barang
di punggungSalah
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Sit-up parsial untuk memperkuat
otot-otot abdomen
Latihan untuk mengurangi
peregangan otot punggung
Latihan untuk memperkuat
otot punggung dan panggul
Latihan untuk memperkuat
otot perut dan panggul
Beberapa variasi latihan ekstensi, mulai dari yang paling ringan ditingkatkan
disesuaikan dengan kekuatan otot-otot ekstensor lumbal
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DBCDBC
(Documentation Based Care)(Documentation Based Care)Is a functional rehabilitationIs a functional rehabilitation progamprogam
To restore lumbar functionTo restore lumbar function && movementmovement
To influence the behavioral patternTo influence the behavioral pattern
Based on :Based on :
The severity of pain &The severity of pain & deconditioningdeconditioning
Psychological profilePsychological profile
SocialSocial needsneeds
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Stabilization TrainingStabilization Training
Addressed to the motor control problemsAddressed to the motor control problems
Improving the mechanical supportsImproving the mechanical supports
deep muscle contraction exercisesdeep muscle contraction exercises
To relieve PainTo relieve Pain
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Reconditioning ProgramReconditioning Program
CoordinationCoordination
MobilityMobility
Muscle endurance exerciseMuscle endurance exercise
StretchingStretching
RelaxationRelaxation
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Individualized Treatment ProgramIndividualized Treatment Program
Exercise :Exercise :The DBC deviceThe DBC device guideguide patients movement:patients movement:
PlanePlane
TargetedTargeted
Controlled & physiologically correct patternsControlled & physiologically correct patterns
Cognitive & behavioral supportCognitive & behavioral support Supporting elements :Supporting elements : -- relaxation & functional exerciserelaxation & functional exercise
-- psychological & work place interventionpsychological & work place intervention
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DBC ProgramDBC Program
One course: 12 sessionsOne course: 12 sessions
11stst session:session: baseline evaluationbaseline evaluation
22ndnd
1111thth
session:session: -- individual treatmentindividual treatment-- progress checkprogress check
-- treatment in grouptreatment in group
1212thth session:session: outcome evaluationoutcome evaluation Follow up / maintenanceFollow up / maintenance
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IndicationsIndications
BackBack
InflammatoryInflammatory
PostPost--traumatictraumatic PostPost--operativeoperative
Nerve root compressionNerve root compression
Narrowing of spinal canalNarrowing of spinal canal
Pelvic and low back painPelvic and low back pain
Spondylolisthesis/Spondylolisthesis/ --lysislysis
NonNon--specific painspecific pain
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IndicationsIndications
NeckNeck
InflammatoryInflammatory
PostPost--traumatictraumaticWhiplashWhiplash--AssociatedAssociated--DisorderDisorder
PostPost--operativeoperative
Narrowing of spinal canalNarrowing of spinal canal
Nerve root compressionNerve root compression
NonNon--specific neck painspecific neck pain
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IndicationsIndications
ShoulderShoulder
Shoulder dislocationShoulder dislocation
Shoulder instabilityShoulder instability Impingement and rotator cuffImpingement and rotator cuff
teartear
AC separationAC separation
Shoulder arthritisShoulder arthritis
Frozen shoulderFrozen shoulder
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DBC Internasional
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
QA 2007, Back
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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
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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
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DBC Clinic RS Internasional Bintaro
D K
82,50%
20,65%
4,34%
B c
N c
S
52,40 % mengikuti > 1 sessi terapiN = 229
DBC RS Internasional Bintaro 2007-2008
Umur rata-rata: 44, 8
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Perubahan Intensitas Nyeri pada LBP
,88
, 6
,
8, 6
0,00
5,00
10,00
15,00
20,00
25,00
30,00
35,00
40,00
45,00
50,00
2007 2008
TA U
Al Treat ent
esudahTreat ent
DBC Clinic RS. Internasional Bintaro
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Treatment ResultsPAIN
18,5 %
Pain decreased
81,5%
No change or
pain increased
DBC RSIB 2007-2008
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Treatment Results
TROUBLE
21,9 %
No change or
trouble increased
78,1 %
Trouble decreased
DBC RSIB 2007-2008
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Treatment ResultsROTATION MOBILITY
Mobility increase
No change or mobility
decreased
4,1 %
95,9 %
DBC RSIB 2007-2008
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Treatment Results
SAGITTAL MOBILITY
6,0 %
94,0 %
Mobility increase
No change ormobility decreased
DBC RSIB 2007-2008
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Treatment Results
LATERAL FLEXION MOBILITY
Mobility increase
No change ormobility decreased
3,6 %
96,4 %DBC RSIB 2007-2008
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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
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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
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Conclusion :Conclusion :
LBPLBP Chronic Symptoms & Disability.Chronic Symptoms & Disability.
Correlation specific performance of LBP patients.Correlation specific performance of LBP patients. ReducedReduced isoiso--kinetickinetic strength, spinal motion, back musstrength, spinal motion, back musccle fatigueability,le fatigueability,decrease endurance, delayed reaction time & poor balancedecrease endurance, delayed reaction time & poor balance
control.control. The main goal of treatment has shifted from treatment of pain toThe main goal of treatment has shifted from treatment of pain to
treatment at activity intolerance to restore function.treatment at activity intolerance to restore function.
Active therapy involving such exercise, cognitiveActive therapy involving such exercise, cognitive--behavioralbehavioralapproach, stabilization & strengthening effective for subapproach, stabilization & strengthening effective for sub--acute ´ &chronic LBP.chronic LBP.
With DBC treatment, pain & trouble/impairment areWith DBC treatment, pain & trouble/impairment aresignificantly reduced in back, neck & shoulder problemssignificantly reduced in back, neck & shoulder problems
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