Tratamiento de la Lumbalgia, dolor lumbar, dolor espalda baja.

1. CONSERVATIVECONSERVATIVE
TREATMENTTREATMENT
OF LOW BACK PAINOF LOW BACK PAIN
AOSLA FELLOWSHIPAOSLA FELLOWSHIP
CURITIBA BRAZILCURITIBA BRAZIL

2. INTRODUCTIONINTRODUCTION
Low back painLow back pain
 ““ Integral part of most human livesIntegral part of most human lives ”” (( 60% to60% to
80% )80% )
• Degrees of sufferingDegrees of suffering
• DisabilityDisability
 The exact cause ??The exact cause ??
 Diagnosis = Patient's history (Location /Diagnosis = Patient's history (Location /
Duration)Duration)
Low back pain: diagnosis, treatment, and prognosis. Autor:Low back pain: diagnosis, treatment, and prognosis. Autor: Indahl, Hospital forIndahl, Hospital for
Rehabilitation, Stavern, NorwayRehabilitation, Stavern, Norway Publicação:Publicação: Scandinavian Journal of Rheumatology. 33(4):199-Scandinavian Journal of Rheumatology. 33(4):199-
209, July 2004.209, July 2004.

3. Problems management of patients withProblems management of patients with
chronic low back painchronic low back pain
 Psychosocial factorsPsychosocial factors
 Ambiguous diagnoses (Ambiguous diagnoses ( Definitive 15%Definitive 15% ))
 Lack of a clearly superior treatmentLack of a clearly superior treatment
Effective conservative treatments - inconclusiveEffective conservative treatments - inconclusive
Conflicting studies (Conflicting studies (Differing types of patients / MethodologicDiffering types of patients / Methodologic
problemsproblems ))
Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal ManipulationChronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation
Volume 28(14), 15Volume 28(14), 15
July 2003, pp 1490-1502 SPINEJuly 2003, pp 1490-1502 SPINE

4. Factors that influence chronicFactors that influence chronic
disabilitydisability

5. Acute Low Back PainAcute Low Back Pain
 Defined acute as a 1-14 day episodeDefined acute as a 1-14 day episode
 CareyCarey et al : Aet al : Acute to episodes of “less thancute to episodes of “less than
10 weeks10 weeks durationduration
 SkouenSkouen et al.et al. ::
 Acute (<28 days duration)Acute (<28 days duration)
 Subacute (4–12 weeks duration)Subacute (4–12 weeks duration)
 Chronic (>12 weeks duration)Chronic (>12 weeks duration)
Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal ManipulationChronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation Volume 28(14), 15 JulyVolume 28(14), 15 July
2003, pp 1490-1502 SPINE2003, pp 1490-1502 SPINE

6. FATIGUE
SLEEP PROBLEMS
HEADACHE
MEMORY / CONCENTRATION PROBLEMS
SEXUAL DYSFUNCION
MEDICALLY UNESPLAINED SYMPTOMS
SOMATIC COMORBIDITIES IN CHRONIC PAIN
“EAR IRRADIATION OF LOW BACK PAIN ”

7. FACTORS PATIENT’SFACTORS PATIENT’S
Pain (Grade)Pain (Grade)
DisabilityDisability
Quality of lifeQuality of life
Work statusWork status
Health care contactsHealth care contacts
RecurrenceRecurrence
Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation
Volume 28(14), 15 July 2003, pp 1490-1502 SPINE
[

8. Cognitive-Behavioral Therapy andCognitive-Behavioral Therapy and
Psychosocial Factors in Low Back Pain:Psychosocial Factors in Low Back Pain:
Directions for the FutureDirections for the Future
 Psychosocial factorsPsychosocial factors
 Attitudes (e.g., catasrophizing)Attitudes (e.g., catasrophizing)
 Beliefs (e.g., fear avoidance)Beliefs (e.g., fear avoidance)
 Mood state (e.g., anxiety and depression)Mood state (e.g., anxiety and depression)
 Social factors, (family, job satisfaction)Social factors, (family, job satisfaction)
SPINE Volume 27(5), 1 March 2002, pp E133-E138 Pincus, Tamar PhD*;SPINE Volume 27(5), 1 March 2002, pp E133-E138 Pincus, Tamar PhD*;

9. Three major groups of psyco-Three major groups of psyco-
comorbidities in chronic paincomorbidities in chronic pain

Behavioral comorbidities (psychiatricBehavioral comorbidities (psychiatric))
 Behavioral comorbiditiesBehavioral comorbidities
(psychological) not diagnosable(psychological) not diagnosable
by theby the PsychiatricPsychiatric 58%58%
 Somatic comorbiditiesSomatic comorbidities

11. CONSERVATIVE OPTIONSCONSERVATIVE OPTIONS
 Educational bookletEducational booklet
 Back massage and back care adviceBack massage and back care advice
 Strength trainingStrength training
 Spinal mobilisationSpinal mobilisation
 General exercisesGeneral exercises
 MedicationMedication

12. Adjunctive therapyAdjunctive therapy
Nonpharmacologic therapiesNonpharmacologic therapies
ExerciseExercise
Physical therapyPhysical therapy
Psychologic counselingPsychologic counseling
YogaYoga
AcupunctureAcupuncture
BiofeedbackBiofeedback
MassageMassage
Relaxation techniques,Relaxation techniques,
Other alternative therapies.Other alternative therapies.
Treating the Patient in Pain. Autor: Katz, Warren A. MD * : Journal on Clinical Rheumatology. 11(2) Supplement:S16-
S28, April 2005.

13. Information and Low Back PainInformation and Low Back Pain
Management: A SystematicManagement: A Systematic
Volume 31(11), 15 May 2006, pp E326-E334 SPINEVolume 31(11), 15 May 2006, pp E326-E334 SPINE
 Booklets :Booklets : Increase knowledgeIncrease knowledge
Positively modify patients'Positively modify patients'
beliefsbeliefs
 ““ AA psychosocial bookletpsychosocial booklet is moreis more
efficient than biomedical booklet.efficient than biomedical booklet.

14. Effectiveness of :Effectiveness of :
MedicationMedication
AcupunctureAcupuncture
SpinalSpinal
manipulationmanipulation
Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, andChronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and
Spinal ManipulationSpinal Manipulation Volume 28(14), 15 July 2003, pp 1490-1502 SPINEVolume 28(14), 15 July 2003, pp 1490-1502 SPINE

15. MEDICATIONMEDICATION
With out other Therapy:With out other Therapy:
 Not achieve a marked improvementNot achieve a marked improvement
in chronic spinal painin chronic spinal pain
 Adverse reactions : 6.1%Adverse reactions : 6.1%

16. SELECTIVE CYCLOOXYGENASE-2SELECTIVE CYCLOOXYGENASE-2
INHIBITORSINHIBITORS
SulfonamidesSulfonamides
CelecoxibCelecoxib
ValdecoxibValdecoxib
ParecoxibParecoxib
(prodrug of valdecoxib)(prodrug of valdecoxib)
MethylsulfonesMethylsulfones
RofecoxibRofecoxib
EtoricoxibEtoricoxib

17. TRADITIONAL NONSTEROIDAL ANTI-TRADITIONAL NONSTEROIDAL ANTI-
INFLAMMATORY DRUGSINFLAMMATORY DRUGS
ACETAMINOPHENACETAMINOPHEN
 Remains first-line therapy because ofRemains first-line therapy because of
its cost, efficacy, and safety profilesits cost, efficacy, and safety profiles
 Recently – acetaminophen - inhibit aRecently – acetaminophen - inhibit a
COX isoform - same gene as COX-1COX isoform - same gene as COX-1
= COX-3= COX-3
American College of Rheumatology guidelinesAmerican College of Rheumatology guidelines

18. Opioid Use by Patients in an OrthopedicsOpioid Use by Patients in an Orthopedics
Spine ClinicSpine Clinic..
Mahowald, Maren MDMahowald, Maren MD Arthritis & Rheumatism. 52(1):312-321, January 2005Arthritis & Rheumatism. 52(1):312-321, January 2005
 Codeine, oxycodone, propoxyphene, tramadol,Codeine, oxycodone, propoxyphene, tramadol,
morphine, meperidine, fentanyl, hydroxycodonemorphine, meperidine, fentanyl, hydroxycodone
 Reduced the back pain severity score from 8.3 -Reduced the back pain severity score from 8.3 -
4.5 (mean +/- SD)4.5 (mean +/- SD)
 Mild side effects 58% (constipation /Mild side effects 58% (constipation /
sedation)sedation)
 Abuse behaviorsAbuse behaviors

19. MEDICATIONMEDICATION
Muscle RelaxantsMuscle Relaxants
 Study : Low BP patients (2,000)Study : Low BP patients (2,000)
 1th1th herniated nucleus pulposusherniated nucleus pulposus
 2th2th Myofascial pain 20%Myofascial pain 20%
 Volume 101(2), August 2004, pp 495-526Volume 101(2), August 2004, pp 495-526 The Pharmacologic Treatment of Muscle PainThe Pharmacologic Treatment of Muscle Pain

20. Clinical and Pharmacologic Review of Skeletal MuscleClinical and Pharmacologic Review of Skeletal Muscle
Relaxants for Musculoskeletal Conditions.Relaxants for Musculoskeletal Conditions.
Beebe, Frank A 1*Beebe, Frank A 1*
American Journal of Therapeutics.American Journal of Therapeutics. 12(2):151-171, 200512(2):151-171, 2005
CONTROVERSIAL SUBJETCONTROVERSIAL SUBJET
Muscle painMuscle pain ::
SpasmSpasm
SwellingSwelling
InflammationInflammation
}
P
R
O
T
E
C
T
IO
N

21. Clinical and Pharmacologic Review of Skeletal MuscleClinical and Pharmacologic Review of Skeletal Muscle
Relaxants for Musculoskeletal Conditions.Relaxants for Musculoskeletal Conditions.
Beebe, Frank A 1*Beebe, Frank A 1*
American Journal of Therapeutics.American Journal of Therapeutics. 12(2):151-171, 200512(2):151-171, 2005
 Muscle Relaxants + NSAID or COX-2Muscle Relaxants + NSAID or COX-2
inhibitorinhibitor
 Muscle Relaxants + Tramadol /Muscle Relaxants + Tramadol /
acetaminophenacetaminophen
““Superior to single agents alone”Superior to single agents alone”

22. INDICATIONS FOR POLYPHARMACY
Minimize treatment intolerance
Analgesic efficacy for different
parts of the day
Lower dose – second medication
Different pathogenes or different
locations of pain

23. SpinalSpinal
ManipulationManipulation

24. Spinal ManipulationSpinal Manipulation
 Insufficient data are available concerning efficacyInsufficient data are available concerning efficacy
 Cervical spine manipulation :Short-term benefits forCervical spine manipulation :Short-term benefits for
neckneck painpain
 Low back manipulation Favorably in long-termLow back manipulation Favorably in long-term
outcomesoutcomes
 Improvement and satisfaction at 1 monthImprovement and satisfaction at 1 month
Giles and MullerGiles and Muller ::
 Spinal manipulation - Greater improvement v/sSpinal manipulation - Greater improvement v/s
acupuncture or medicineacupuncture or medicine
Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal ManipulationChronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation VolumeVolume
28(14), 15 July 2003, pp 1490-1502 SPINE28(14), 15 July 2003, pp 1490-1502 SPINE

25. Repeated massage-like stimulation inducesRepeated massage-like stimulation induces
long-term effects on nociception: contributionlong-term effects on nociception: contribution
of oxytocinergic mechanisms.of oxytocinergic mechanisms.
Lund, Irene 1 Karolinska Institutet, ELund, Irene 1 Karolinska Institutet, European Journal of Neuroscience. 16(2):330-338,.uropean Journal of Neuroscience. 16(2):330-338,.
July 2002July 2002
 Long-term antinociceptive effects ofLong-term antinociceptive effects of
massage-likemassage-like
 Oxytocinergic system interactionOxytocinergic system interaction
opioid system ( Brain ):opioid system ( Brain ):
Receptors[mu]- and [kappa]Receptors[mu]- and [kappa]

26. AcupunctureAcupuncture

27. AcupunctureAcupuncture
 Vickers et al.Vickers et al.
Current levels of evidence ofCurrent levels of evidence of
acupuncture for chronic spinalacupuncture for chronic spinal
pain “pain “ probably are sufficient toprobably are sufficient to
justify this practicjustify this practic ””
Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, andChronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and
Spinal ManipulationSpinal Manipulation Volume 28(14), 15 July 2003, pp 1490-1502 SPINEVolume 28(14), 15 July 2003, pp 1490-1502 SPINE

28. Acupuncture and Dry-Needling for Low Back Pain: An UpdatedAcupuncture and Dry-Needling for Low Back Pain: An Updated
Systematic Review Within the Framework of the CochraneSystematic Review Within the Framework of the Cochrane
CollaborationCollaboration Volume 30(8), 15 April 2005, pp 944-963Volume 30(8), 15 April 2005, pp 944-963

2861 patients - systematic review.2861 patients - systematic review.
 Insufficient evidenceInsufficient evidence to make any recommendationsto make any recommendations
about acupuncture or dry-needling for acute low back pain.about acupuncture or dry-needling for acute low back pain.
 Chronic low back pain = More effective for pain relief thanChronic low back pain = More effective for pain relief than
no treatmentno treatment
 Acupuncture + Conventional therapies : Relieves painAcupuncture + Conventional therapies : Relieves pain
Improves functionImproves function
““ lower methodologic quality”lower methodologic quality”

29. 52% 32%

31. Asymptomatic status maximum treatmentAsymptomatic status maximum treatment
of 9 weeksof 9 weeks
 Spinal manipulationSpinal manipulation (27%)(27%)
 AcupunctureAcupuncture (9.4%)(9.4%)
 MedicationMedication (5%)(5%)
ImprovementImprovement general health statusgeneral health status
 MedicationMedication 18 %18 %
 AcupunctureAcupuncture 15%15%
 Spinal manipulationSpinal manipulation 47%47%
Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and SpinalChronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal
ManipulationManipulationVolume 28(14), 15 July 2003, pp 1490-1502 SPINEVolume 28(14), 15 July 2003, pp 1490-1502 SPINE

32. A Focused Review of the Use of BotulinumA Focused Review of the Use of Botulinum
Toxins for Low Back PainToxins for Low Back Pain.. Difazio, Mark M.D.Difazio, Mark M.D. Clinical Journal ofClinical Journal of
Pain. 18(6) Supplement:S155-S162,November/December2002Pain. 18(6) Supplement:S155-S162,November/December2002
Botulinum toxinBotulinum toxin
Effective in selected patientsEffective in selected patients
Sensitivity to pain stimuliSensitivity to pain stimuli
Blocking cycle of reactivityBlocking cycle of reactivity ::
-Biochemical processes-Biochemical processes
-Inflammation-Inflammation
-Nerve sensitization-Nerve sensitization

33. CONCLUSIONSCONCLUSIONS
 What are psychosocial riskWhat are psychosocial risk
factors in back pain?factors in back pain?
 How can we identify them?How can we identify them?
 What can we do about them?What can we do about them?

34. Patient ExpectationsPatient Expectations
 Patients have explicit expectations :Patients have explicit expectations :
- Diagnosis- Diagnosis
- Instructions- Instructions
- Interpersonal management- Interpersonal management
 Practice guidelinesPractice guidelines
- Discussing causes- Discussing causes
-Diagnosis with the-Diagnosis with the
-Involve them in the decision-Involve them in the decision
treatmenttreatment
Patient Expectations of Treatment for Back Pain: A Systematic Review of QualitativePatient Expectations of Treatment for Back Pain: A Systematic Review of Qualitative
and Quantitative Studies. Autor:and Quantitative Studies. Autor: Verbeek, Jos MD, PhD *Verbeek, Jos MD, PhD * Spine. 29(20):2309-2318,Spine. 29(20):2309-2318,
October 15, 2004.October 15, 2004.

35. The Association Between PsychopathologyThe Association Between Psychopathology
and Placebo Analgesia in Patients withand Placebo Analgesia in Patients with
Discogenic Low Back PainDiscogenic Low Back Pain..
Pain Medicine. 7(3):217-228, May/June 2006.Pain Medicine. 7(3):217-228, May/June 2006.
““ High and moderate levels of PsychoHigh and moderate levels of Psycho
pathology are associated with placebopathology are associated with placebo
analgesia in chronic low back painanalgesia in chronic low back pain
patientspatients ””