Associação Brasileira de Medicina Física e Reabilitação. Chronic nonspecific low back pain: rehabilitation

A critical review of the role of manual therapy in the treatment of individuals with low back pain

The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients' expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients' beliefs, addressing illness behaviors, and seeking to understand each patient's journey.

Diagnostic codes for low back pain, nomenclature or noise? A descriptive study of disease classification system coding of low back pain

AIM

To compare and contrast the diagnostic codes for spinal causes of low back pain (LBP) in 3 disease classification systems (International Classification of Diseases [ICD]-10, International Classification of Primary Care [ICPC]-2 PLUS and Systematized Nomenclature of Medicine Clinical Terms - Australia [SNOMED CT-AU]) and consider how well they are aligned with the diagnostic approach recommended in contemporary clinical practice guidelines for LBP.

METHOD

This was a descriptive study which included 3 disease classification systems: ICD-10, ICPC-2 PLUS and SNOMED CT-AU. Two independent authors extracted relevant LBP codes from each system and mapped the codes to 3 guideline-endorsed categories of spine-related diagnoses for LBP (specific spinal pathology, radicular syndromes, and non-specific LBP) and the various clinical conditions (sub-categories) within each of the 3 categories.

RESULTS

ICD-10, ICPC-2 PLUS, and SNOMED CT-AU had 126, 118 and 100 codes for LBP, respectively. All systems provided codes that would cover the 3 guideline-endorsed categories of spine-related diagnoses for LBP. On the basis of contemporary guidelines, the authors developed lists of discrete sub-categories of specific spinal pathology (56 sub-categories), radicular syndromes (7 sub-categories), and non-specific LBP (10 sub-categories). Each of the classification systems was then mapped against these sub-categories to tally redundancy and determine exhaustiveness. However, no system covered all 73 sub-categories of LBP, and within each system, there was substantial redundancy with up to 22 codes for the same clinical condition.

CONCLUSION

LBP diagnostic codes used in popular disease classification systems are out of touch with current approaches to diagnosis, as reflected in contemporary LBP guidelines. Our findings suggest these disease classification systems need revision, but precisely how they should be revised is unclear.

Self-Healing: A Concept for Musculoskeletal Body Pain Management - Scientific Evidence and Mode of Action

Traditionally, musculoskeletal pain management has focused on the use of conventional treatments to relieve pain. However, multi-modal integrative medicine including alternative/complementary treatments is becoming more widely used and integrated into treatment guidelines around the world. The uptake of this approach varies according to country, with generally a higher uptake in developed countries and in females aged more than 40 years. Integral to the concept described here, is that the body has an innate ability to self-heal, which can be optimized by the use of integrative medical strategies. Stress triggers for acute or recurring musculoskeletal pain are diverse and can range from physical to psychological. The mechanism by which the body responds to triggers and initiates the self-healing processes is complex, but five body networks or processes are thought to be integral: the nervous system, microcirculation/vasodilation, immune modulation, muscular relaxation/contraction and psychological balance. Multi-modal integrative medicine approaches include nutritional/dietary modification, postural/muscular training exercises, and cognitive behavioral mind/body techniques. This article will review the self-healing concept and provide plausible scientific evidence where available.

Sex and gender considerations in low back pain clinical practice guidelines: a scoping review

Objective

The purpose of this scoping review is to determine if and how sex and gender have been incorporated into low back pain (LBP) clinical practice guidelines (CPG), and if sex and gender terms have been used properly.

Methods

CPGs were searched on MEDLINE, Embase, NICE, TRIP and PEDro from 2010 to 2020. The inclusion criteria were English language, CGPs within physiotherapy scope of practice and for adult population with LBP of any type or duration. Three pairs of independent reviewers screened titles, abstracts and full texts. Guidelines were searched for sex/gender-related terms and recommendations were extracted. The AGREE II (Appraisal of Guidelines for Research and Evaluation II) was used to evaluate the quality of the CPGs.

Results

Thirty-six CPGs were included, of which 15 were test-positive for sex or gender terms. Only 33% (n=5) of CPGs incorporated sex or gender into diagnostic or management recommendations. Sixty percent of guidelines (n=9) only referenced sex or gender in relation to epidemiology, risk factors or prognostic data, and made no specific recommendations. Overall, there was no observable relationship between guideline quality and likeliness of integrating sex or gender terms. The majority of guidelines used sex and gender terms interchangeably, and no guidelines defined sex or gender.

Conclusion

CPGs did not consistently consider sex and gender differences in assessment, diagnosis or treatment of LBP. When it was considered, sex and gender terms were used interchangeably, and considerations were primarily regarding pregnancy. Researchers should consider the importance of including sex-based and/or gender-based recommendations into future LBP CPGs.

Função, atividade e participação na percepção do paciente com dor lombar crônica: estudo em um grupo focal

Objetivo: Identificar a percepção da dor lombar (DL) crônica em usuários de uma unidade de reabilitação fisioterapêutica de um município de Minas Gerais, Brasil. Métodos: Trata-se de uma pesquisa exploratória descritiva e qualitativa. Realizaram-se grupos focais com usuários do serviço de saúde de ambos os sexos com idade superior a 18 anos, diagnóstico médico de DL crônica, e em reabilitação física. As unidades norteadoras foram: conversando sobre dor e tratamentos prévios para alívio da dor, programadas por roteiro semiestruturado. Emergiram as unidades: fala dos profissionais de saúde e a fala dos colegas de trabalho e familiares. As falas foram gravadas, transcritas e analisadas utilizando a Técnica de Elaboração e Análise de Unidades de Significado. Utilizou-se o escore de dor do Índice de Incapacidade de Oswestry (IIO) e o IIO completo para avaliação da dor e da funcionalidade. Resultados: 14 pacientes (média de idade 52 ± 3 anos), na maioria mulheres, relataram DL crônica em média há 5 ± 5 anos. O valor médio do escore de dor foi de 1,37 ± 1,72 e média de incapacidade de 21,96% (IC95% 15,43 – 28,50%).  Os relatos sobre a dor foram: ‘um incômodo’, ‘uma doença’, ‘incapacidade’, tratada com remédios e Fisioterapia; profissionais da saúde demonstram ‘negligência’, ‘agressão’ ou ‘proibição’; enquanto família e colegas de trabalho demonstram ‘desprezo’, ‘represália’ ou ‘apoio’. Conclusão: A percepção da DL crônica equivale a incômodo, desconforto, doença, restrições, agressão, negligência, desprezo, represália ou apoio a um misto de sensações físicas e psicológicas.

Tackling low back pain in Brazil: a wake-up call

BACKGROUND

Low back pain is the leading cause of years lived with disability in Brazil based upon Global Burden of Disease estimates. Since 1990, the number of years lived with disability has increased by 79.7%, and this number is expected to continue to rise due to population growth and ageing. Yet, similarly to other countries, little attention has been given to it in both the public and private health systems, arguably making it an overlooked epidemic in Brazil. There is evidence that Brazil has adopted unwarranted practices in the management of low back pain in a similar manner to what has been observed in high-income countries. To tackle the burden of low back pain in Brazil, we need highly coordinated efforts from government, the private sector, universities, health workers and civil society.

OBJECTIVE

This masterclass intends to provide an overview of the challenges faced by Brazil in relation to low back pain management and propose potential solutions that could potentially be implemented based on experiences reported in the literature.

Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview

OBJECTIVE

The aim of this study was to provide an overview of the recommendations regarding the diagnosis and treatment contained in current clinical practice guidelines for patients with non-specific low back pain in primary care. We also aimed to examine how recommendations have changed since our last overview in 2010.

METHOD

The searches for clinical practice guidelines were performed for the period from 2008 to 2017 in electronic databases. Guidelines including information regarding either the diagnosis or treatment of non-specific low back pain, and targeted at a multidisciplinary audience in the primary care setting, were considered eligible. We extracted data regarding recommendations for diagnosis and treatment, and methods for development of guidelines.

RESULTS

We identified 15 clinical practice guidelines for the management of low back pain in primary care. For diagnosis of patients with non-specific low back pain, the clinical practice guidelines recommend history taking and physical examination to identify red flags, neurological testing to identify radicular syndrome, use of imaging if serious pathology is suspected (but discourage routine use), and assessment of psychosocial factors. For treatment of patients with acute low back pain, the guidelines recommend reassurance on the favourable prognosis and advice on returning to normal activities, avoiding bed rest, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and weak opioids for short periods. For treatment of patients with chronic low back pain, the guidelines recommend the use of NSAIDs and antidepressants, exercise therapy, and psychosocial interventions. In addition, referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks. While there were a few discrepancies across the current clinical practice guidelines, a substantial proportion of recommendations was consistently endorsed. In the current review, we identified some differences compared to the previous overview regarding the recommendations for assessment of psychosocial factors, the use of some medications (e.g., paracetamol) as well as an increasing amount of information regarding the types of exercise, mode of delivery, acupuncture, herbal medicines, and invasive treatments. These slides can be retrieved under Electronic Supplementary Material.