Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

download Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

of 48

Transcript of Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    1/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    2/48

    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 (

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    3/48

    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 (

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    4/48

    Longissimus

    capitis

    Spinalisthoracis

    Longissimus

    Longissimus

    cervicis

    Spinalis

    cervicis

    Iliocostalis

    lumborum

    Iliocostalis

    thoracis

    Multifidus

    Intertransversarii

    Iliocostalis

    cervicis

    Otot-otot penting pada punggung

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    5/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    6/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    7/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    8/48

    The Specific Joint Protection: AbdominalThe Specific Joint Protection: Abdominal

    MSMS

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

    Abd., Pelvic floor m., psoas maj.

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    9/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    10/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    11/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    12/48

    What Is The Best Current Management ?What Is The Best Current Management ?

    Conventional rehabilitation?Conventional rehabilitation?

    Active care ??Active care ??

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    13/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    14/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    15/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    16/48

    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 ::

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    17/48

    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 :

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    18/48

    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))

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    19/48

    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)

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    20/48

    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)

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    21/48

    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))

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    22/48

    BACK EXERCISE

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    23/48

    BACK EXERCISE

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    24/48

    Berdiri

    Benar Salah

    Duduk

    Benar Salah

    TidurBenar

    Salah

    Mengemudi

    Benar Salah

    Memasukkan/mengeluarkan

    barang dalam mobil

    Benar Salah

    BekerjaBenar Salah

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    25/48

    Pengaturan Postur Saat Membawa Barang

    Benar

    Mengangkat barang

    Salah

    Benar

    Membawa barang

    didepan tubuh

    Salah

    Benar

    Membawa barang

    di punggungSalah

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    26/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    27/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    28/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    29/48

    Reconditioning ProgramReconditioning Program

    CoordinationCoordination

    MobilityMobility

    Muscle endurance exerciseMuscle endurance exercise

    StretchingStretching

    RelaxationRelaxation

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    30/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    31/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    32/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    33/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    34/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    35/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    36/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    37/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    38/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    39/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    40/48

    Treatment ResultsPAIN

    18,5 %

    Pain decreased

    81,5%

    No change or

    pain increased

    DBC RSIB 2007-2008

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    41/48

    Treatment Results

    TROUBLE

    21,9 %

    No change or

    trouble increased

    78,1 %

    Trouble decreased

    DBC RSIB 2007-2008

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    42/48

    Treatment ResultsROTATION MOBILITY

    Mobility increase

    No change or mobility

    decreased

    4,1 %

    95,9 %

    DBC RSIB 2007-2008

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    43/48

    Treatment Results

    SAGITTAL MOBILITY

    6,0 %

    94,0 %

    Mobility increase

    No change ormobility decreased

    DBC RSIB 2007-2008

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    44/48

    Treatment Results

    LATERAL FLEXION MOBILITY

    Mobility increase

    No change ormobility decreased

    3,6 %

    96,4 %DBC RSIB 2007-2008

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    45/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    46/48

    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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    47/48

    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 &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

  • 8/7/2019 Rehabilitasi Masalah Tulang Belakang Dengan DBC (Makalah)Dr. Peni K, SpRM

    48/48