INSTABILITA VERTEBRALE LOMBARE. Trattamenti riabilitativi: evidence-based medicine

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1 INSTABILITA VERTEBRALE LOMBARE Trattamenti riabilitativi: evidence-based medicine Marco Paoloni, Valter Santilli Physical Medicine and Rehabilitation «Sapienza» University, Rome

2 Evidence best practice EBP is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

3 Acquiring the Evidences.

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6 Lumbar stabilization exercises May not give you abs like Michael Phelps But they may help you avoid looking like this

7 Lumbar stabilization exercises Sensorimotor re-programmation of spine stabilizer muscles intended to improve their motor control skill and delay of response and consequently to compensate for weakness of the passive stabilization system. A simultaneous isometric cocontraction of transversus abdominis and multifidus. This cocontraction is progressively integrated in positions and exercises that are more and more functional and of increasing complexity. Demoulin et al. Annales de réadaptation et de médecine physique 50 (2007)

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9 In order to establish the efficacy of motor control exercise for chronic low back pain, we conducted the first placebo-controlled trial of this intervention The motor control exercise program involved 2 stages Stage 1. Train coordinated activity of the trunk muscles, including independent activation of the deeper muscles (including transversus abdominis and multifidus). Stage 2. Implement precision of the desired coordination and train these skills in static tasks and incorporate them into dynamic tasks and functional positions The placebo intervention consisted of 20 minutes of detuned shortwave diathermy and 5 minutes of detuned ultrasound for 12 sessions over an 8-week period

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14 Segmental stabilization and strengthening exercises effectively reduce pain and functional disability in individuals with chronic low back pain. Efficacy demonstrated for BOTH treatments Segmental stabilization but not strengthening improves TrA muscle activation capacity. General strengthening was NOT focused on TrA activation Improvement in all variables was superior in the segmental stabilization group opposed to the strengthening group. No between groups comparison performed

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19 Interventions Participants attended for up to 12 treatment sessions over an 8 week period General exercise The main aims of the program were to improve physical function and confidence in using the spine, and to teach participants how to cope with their back problems. The class included strengthening and stretching exercises for the main muscle groups of the body as well as exercises for cardiovascular fitness. Motor control exercise Exercises aimed at improving function of specific trunk muscles thought to control inter-segmental movement of the spine, including transversus abdominis, multifidus, the diaphragm and pelvic floor muscles. Spinal manipulative therapy Joint mobilization or manipulation techniques applied to the spine or pelvis (Maitland).

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25 Do all patients with LBP may benefit from spinal stabilization exercise retraining on the premise that deconditioning of trunk muscles leads to instability symptoms?

26 55 patients with recurrent, nonspecific back pain and no clinical signs suggesting spinal instability were recruited

27 our findings tend to suggest that general trunk muscle exercises alone, without the addition of stabilization exercises, reduce patient self-reported disability more effectively immediately after the end of a 2-month exercise period

28 Objective. To determine the efficacy of a specific exercise intervention in the treatment of patients with chronic low back pain and a radiologic diagnosis of spondylolysis or spondylolisthesis. 2

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30 A "specific exercise" treatment approach appears more effective than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis or spondylolisthesis

31 Can lumbar stabilization exercises prevent from LBP?

32 Hypothesis: Soldiers receiving core stabilization and psychosocial education would have lower incidence of LBP in comparison to those receiving only traditional lumbar exercise

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34 Exercise programs that target core lumbar musculature may offer no additional preventative benefit when compared to traditional lumbar exercise programs. Also, brief psychosocial education may be an important adjunct to exercise programs as they may prevent the seeking of health care when experiencing LBP

35 Conclusions With no clear definition of lumbar instability it s hard to clearly define the effectiveness of any proposed treatment Data about effectiveness of treatments derive from RCTs on non-specific LBP, in which sub-population of patients with instability may be included

36 Conclusions Lumbar stabilization exercises appear to be superior than placebo in relieving symptoms in LBP patients Lumbar stabilization exercises are not always superior than general exercises in LBP patients

37 Conclusions Studies are needed to determine which categories of patients could benefit from lumbar stabilization exercises Lumbar stabilization exercises should not be used for LBP prevention

38 Thank you for your attention