Intervenções para LBP

Intervenções para LBP

by with No Comment Uncategorized

Education

Most guidelines suggest education and advice as a key intervention strategy[1][2][3][4][5][6][7].  The common message is that patients should be reassured that they do not have a serious disease, that they should stay as active as possible, progressively increase their activity levels and return to work as soon as possible.  This is particularly relevant for patients with acute back pain who are low risk of disbaility.

The NICE Guidelines[1] summarise many of the available guidelines and state the following:

  • Provide people with advice and information to promote self-management of their low back pain.
  • Offer educational advice that includes information on the nature of non-specific low back pain and encourages the person to be physically active and continue with normal activities as far as possible.
  • Include an educational component consistent with this guideline as part of other interventions, but do not offer stand-alone formal education programmes.
  • Take into account the person’s expectations and preferences when considering recommended treatments, but do not use their expectations and preferences to predict their response to treatments.
  • Advise people with low back pain that staying physically active is likely to be beneficial.
  • Advise people with low back pain to exercise.

The STarT Back Approach also has some advice for us when educating individuals with LBP:

Language and labels

  • Use functional explanations for pain (sprained back, non-serious back pain). Example: “Many people have back pain from time to time but it is rare for this to be caused by a specific problem. Mostly all that is needed is to get your back moving again and things will settle down.
  • ”Avoid “spondylitis, degeneration, crumbling” etc.
  • Can be more specific sometimes, for example sciatica, if this leads to specific management.
  • Avoid investigating in the first place unless it is specifically indicated. However if you do so be aware that the technical terms used in reports often alarm patients. Translate appropriately, examples: “normal for your age ”, “ the changes seen on your scan are like getting grey hair or wrinkles as you get older”

Dealing with distress

  • Suspend pre-judgment
  • Listen carefully / summarize points
  • Plan to address points
  • Care with language and labels
  • Be honest and realistic
  • Do not criticize the opinions of other clinicians who have seen the patient.
  • Provide information

Activity promotion

  • Activity promotion: beneficial, hurt doesn’t equal harm, minimise bed rest
  • Pacing: short, frequent bouts of activity rather than overdoing things and then regretting it the next day, rests between activity, do less than maximal capabilities and increase as tolerated.
  • Return to work as soon as possible, prolonged absence likely to lead to loss of employment. Use fit notes to support return to work and communicate suggestions to the employer. Help the patient negotiate an early return to work if at all possible.

Exercise Therapy

There is now relatively large consensus across the various guidelines that specific back exercises (as opposed to the advice to stay active, including for example walking, cycling) are not recommended for patients with acute low back pain[3].  There are now also more firm recommendations in favour of exercise therapy in patients with subacute and chronic low back pain[3] but there is no evidence that one form of exercise is superior to another[8].  

NICE Guidelines[1] recommend offering a structured exercise programme tailored to the person. Exercise programmes may include aerobic activity, movement instruction, muscle strengthening, postural control and& stretching.  They should comprise up to a maximum of eight sessions over a period of up to 12 weeks, a group supervised exercise programme in a group of up to 10 people or one-to-one supervised exercise programme may be offered if a group programme is not suitable for a particular person.

Delitto [4]et al suggest that clinicians should consider:

  • utilizing trunk coordination, strengthening, and endurance exercises to reduce low back pain and disability in patients with sub-acute and chronic low back pain with movement coordination impairments and in patients post lumbar microdiscectomy. 
  • utilizing repeated movements, exercises, or procedures to promote centralization to reduce symptoms in patients with acute low back pain with related (referred) lower extremity pain. Clinicians should consider using repeated exercises in a specific direction determined by treatment response to improve mobility and reduce symptoms in patients with acute, subacute, or chronic low back pain with mobility deficits. 
  • flexion exercises, combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking, for reducing pain and disability in older patients with chronic low back pain with radiating pain.
  • utilizing lower-quarter nerve mobilization procedures to reduce pain and disability in patients with subacute and chronic low back pain and radiating pain.
  • moderate- to high-intensity exercise for patients with chronic low back pain without generalized pain
  • incorporating progressive, low-intensity, submaximal fitness and endurance activities into the pain management and health promotion strategies for patients with chronic low back pain with generalized pain.

Manual Therapy

Manual Therapy refers to spinal manipulation (a low-amplitude, high-velocity movement at the limit of joint range that takes the joint beyond the passive range of movement), spinal mobilisation (joint movement within the normal range of motion) and massage (manual manipulation or mobilisation of soft tissues).

The recommendations regarding spinal manipulation continue to show some variation and systematic reviews have demonstrated marginal treatment effects across heterogeneous groups of patients with low back pain[9][10]. In some guidelines manipulation is recommended, or presented as a therapeutic option, usually for short-term benefit, but others do not recommend it[3].  The reason for these differences is probably that the underlying evidence is not strong enough to result in similar recommendations regarding manipulation across all guidelines, leaving more room for interpretation.  There may also be local and political reasons involved.  Recent research has demonstrated that spinal manipulative therapy is effective for subgroups of patients and as a component of a comprehensive treatment plan, rather than in isolation[4]. Clinical prediction rules can be used to identify patients that will benefit form thrust manipulation[11][12][13][14].

The NICE guidelines recommend offering a course of manual therapy, including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks in early management of non-specific LBP[1].  

Delitto et al[4] suggest that clinicians should consider utilising thrust manipulative procedures to reduce pain and disability in patients with mobility deficits and acute low back and back-related buttock or thigh pain.  Thrust manipulative and nonthrust mobilization procedures can also be used to improve spine and hip mobility and reduce pain and disability in patients with subacute and chronic low back and back-related lower extremity pain.

Traction

There is conflicting evidence for the efficacy of intermittent lumbar traction for patients with low back pain. There is preliminary evidence that a subgroup of patients with signs of nerve root compression along with peripheralization of symptoms or a positive crossed straight leg raise will benefit from intermittent lumbar traction in the prone position. There is moderate evidence that clinicians should not utilize intermittent or static lumbar traction for reducing symptoms in patients with acute or subacute, nonradicular low back pain or patients with chronic low back pain[4][15] and recent guidelines advise against traction as a treatment option[8].

Electrotherapy

Evidence for efficacy of most electrotherapy modalities in the managment of low back pain is weak or lacking[16][17].  Guidelines suggest that electrotherapy modalities (laser, interferrential, ultrasound, TENS) are not appropriate for non-specific low back pain[3][1]  Passive treatment modalities (for example bed rest, massage, ultrasound, electrotherapy, laser and traction) should be avoided as mono-therapy and not routinely be used, because they may increase the risk of illness behaviour and chronicity[18].

Cognitive Behavioural Therapy

Behavioral education, also known as cognitive behavioral theory, encompasses many aspects of patient education and counseling for patients with low back pain, including:

  • Activity pacing
  • Attention diversion
  • Cognitive restructuring
  • Goal setting
  • Graded exposure
  • Motivational enhancement therapy
  • Maintenance strategies
  • Problem-solving strategies

Henschke et al[19] in a recent Cochrane review, concluded there is moderate-quality evidence that operant therapy and behavioral therapy are more effective than waiting-list or usual care for short-term pain relief in patients with chronic low back pain, but no specific type of behavioral therapy is superior to another. In the intermediate to long term, there is no established difference between behavioral therapy and group exercise for management of pain or depressive symptoms in patients with chronic low back pain.

The NICE guidelines[1] suggest referral for a combined physical and psychological treatment programme that includes a cognitive behavioural approach and exercise, comprising around 100 hours over a maximum of 8 weeks, for people who have received at least one less intensive treatment and have high disability and/or significant psychological distress.

References

  1. ↑ 1.01.11.21.31.41.5 National Institute for Health and Care Excellence. ↑ Hill J, D Whitehurst, Lewis M, Bryan S, Dunn K, Foster N, Konstantinou, Main C, Mason E, Somerville S, Sowden G, Vohora K, Hay E. A randomised controlled trial and economic evaluation of stratified primary care management for low back pain compared with current best practice: The STarT Back trial.The Lancet, Volume 378, Issue 9802, Pages 1560 – 1571, 29 October 2011
  2. ↑ 3.03.13.23.33.4 Koes BW, van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C. ↑ 4.04.14.24.34.4 Anthony Delitto, Steven Z. George, Linda Van Dillen, Julie M. Whitman, Gwendolyn Sowa, Paul Shekelle, Thomas R. Denninger, Joseph J. Godges. Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic and Sports Physical Therapy, 2012, 42(4)
  3. ↑ Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 2018; 27: 60-75.
  4. ↑ Van Wambeke P, Desomer A, Ailliet L, et al. Summary: ↑ Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017; 166: 514-530.
  5. ↑ 8.08.1 Almeida M, Saragiotto B, Richards B, Maher C. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018; 208 (6): 272-275
  6. ↑ Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, hekelle PG. Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev. 2004;CD000447.
  7. ↑ Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med. 2003;138:871-881
  8. ↑ Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila Pa 1976).
  9. ↑ Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004;141:920-928.
  10. ↑ Cleland JA, Fritz JM, Kulig K, et al. Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial. Spine (Phila Pa 1976).
  11. ↑ Hancock MJ, Maher CG, Latimer J, Herbert RD, McAuley JH. Independent evaluation of a clinical prediction rule for spinal manipulative therapy: a randomised controlled trial. Eur Spine J. 2008;17:936-943.
  12. ↑ Delitto A, Erhard RE, Bowling RW. ↑ Matthew S Thiese, Matthew Hughes and Jeremy Biggs. Electrical stimulation for chronic non-specific lowfckLRback pain in a working-age population: a 12-weekfckLRdouble blinded randomized controlled trial. BMC Musculoskeletal Disorders 2013, 14:117
  13. ↑ GE Bekkering, HJM Hendriks, BW Koes, RAB Oostendorp, RWJG Ostelo, JMC Thomassen, MW van Tulder. ↑ van Tulder M, Becker A, Bekkering T, Breen A, del Real MT, Hutchinson A, Koes B, Laerum E, Malmivaara A; COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care. Chapter 3. ↑ Henschke N, Ostelo RW, van Tulder MW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010;CD002014

Conteúdos relacionados

DPOC (Doença Pulmonar Obstrutiva Crônica)

DPOC (Doença Pulmonar Obstrutiva Crônica)

by with No Comment Uncategorized

Introduction

Chronic Obstructive Pulmonary Disease (COPD) is a non-reversible progressive disease that is characterised by symptoms such as shortness of breath, wheezing and a cough that produces a high volume of secretions. It may include Asthma, Emphysema and bronchitis,

Clinically Relevant Anatomy

See this page for information on the anatomy of the lungs

Causes

  • Smoking – The primary risk factor for COPD is chronic tobacco smoking. In the United States, 80 to 90% of cases of COPD are due to smoking.[1]
  • Occupational exposure – Intense and prolonged exposure to workplace dusts found in coal mining, gold mining, and the cotton textile industry and chemicals such as cadmium, isocyanates, and fumes from welding have been implicated in the development of airflow obstruction, even in nonsmokers.[2] Workers who smoke and are exposed to these particles and gases are even more likely to develop COPD. Intense silica dust exposure causes silicosis, a restrictive lung disease distinct from COPD; however, less intense silica dust exposures have been linked to a COPD-like condition.[3] The effect of occupational pollutants on the lungs appears to be substantially less important than the effect of cigarette smoking.[4]
  • Air pollution – Studies in many countries have found that people who live in large cities have a higher rate of COPD compared to people who live in rural areas.[[5] Urban air pollution may be a contributing factor for COPD as it is thought to slow the normal growth of the lungs although the long-term research needed to confirm the link has not been done. In many developing countries indoor air pollution from cooking fire smoke (often using biomass fuels such as wood and animal dung) is a common cause of COPD, especially in women.[6]
  • Genetics – Some factor in addition to heavy smoke exposure is required for a person to develop COPD. This factor is probably a genetic susceptibility. COPD is more common among relatives of COPD patients who smoke than unrelated smokers.[7]] The genetic differences that make some peoples’ lungs susceptible to the effects of tobacco smoke are mostly unknown
  • Autoimmune disease – There is mounting evidence that there may be an autoimmune component to COPD.[8] Many individuals with COPD who have stopped smoking have active inflammation in the lungs.[9]The disease may continue to get worse for many years after stopping smoking due to this ongoing inflammation.[9] This sustained inflammation is thought to be mediated by autoantibodies and autoreactive T cells.[10]

Mechanism of Injury / Pathological Process

It is not fully understood how tobacco smoke and other inhaled particles damage the lungs to cause COPD. The most important processes causing lung damage are:

  • Oxidative stress produced by the high concentrations of free radicals in tobacco smoke.
  • Cytokine release due to inflammation as the body responds to irritant particles such as tobacco smoke in the airway.
  • Tobacco smoke and free radicals impair the activity of antiprotease enzymes such as alpha 1-antitrypsin, allowing protease enzymes to damage the lung.

Clinical Presentation

COPD is a complex interaction between Chronic Bronchitis, Emphysema, and Asthma

Asthma

Asthma is a chronic lung disease which is a very common respiratory condition. It is also known as a reactive airway disease which is inconvenient most of the time but manageable. Asthma is caused by inflammation and constriction of bronchial walls which leads to a series of spasmodic attacks of wheezing and shortness of breath as a result of the hyper-reactivity of smooth muscle in the bronchial walls and in the absence of any other apparent cause. There are various factors such as exposure to cigarette smoke, climate change, physical exertion or emotional stress that causes asthma. It begins during childhood and the disease is commonly triggered by viral infection[11].

Asthma can be diagnosed by the presence of the signs and symptoms. The diagnosis is normally confirmed by presenting a response to a inhaled bronchodialator. Often pulmonary function tests, chest x-rays and blood tests can also be done in order to confirm the diagnosis.

Chronic bronchitis

Lung damage and inflammation in the large airways results in chronic bronchitis. Chronic bronchitis is defined in clinical terms as a cough with sputum production on most days for 3 months of a year, for 2 consecutive years.[12] In the airways of the lung, the hallmark of chronic bronchitis is an increased number (hyperplasia) and increased size (hypertrophy) of the goblet cells and mucous glands of the airway. As a result, there is more mucus than usual in the airways, contributing to the narrowing of the airways and causing a cough with sputum. Microscopically there is infiltration of the airway walls with inflammatory cells. Inflammation is followed by scarring and remodeling that thickens the walls and also results in narrowing of the airways. As chronic bronchitis progresses, there is squamous metaplasia (an abnormal change in the tissue lining the inside of the airway) and fibrosis (further thickening and scarring of the airway wall). The consequence of these changes is a limitation of airflow.[13]

Patients with advanced COPD that have primarily chronic bronchitis rather than emphysema were commonly referred to as “blue bloaters” because of the bluish color of the skin and lips (cyanosis) seen in them.[14] The hypoxia and fluid retention leads to them being called “Blue Bloaters.”

Emphysema

A lateral chest x-ray of a person with emphysema.
Note the barrow chest and flap diaphragm.

Lung damage and inflammation of the alveoli results in emphysema. Emphysema is defined as enlargement of the air spaces distal to the terminal bronchioles, with destruction of their walls.[12] The destruction of air space walls reduces the surface area available for the exchange of oxygen and carbon dioxide during breathing. It also reduces the elasticity of the lung itself, which results in a loss of support for the airways that are embedded in the lung. These airways are more likely to collapse causing further limitation to airflow. The effort made by patients suffering from emphysema during exhalation, causes a pink color in their faces, hence the term commonly used to refer to them, “pink puffers”.

Diagnostic Procedures

Unfortunately there is no single diagnostic test for COPD; diagnosis relies on the presence/absence of symptoms and clinical judgement. The best approach is to undertake a detailed subjective history and physical examination. As COPD is not curable the earlier that it is diagnosed, the earlier treatment can start and that may help to slow down the progression of the disease and the subsequent damage to the lungs.

  • Assessment – A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter ‘bronchitis’ or wheeze.
  • Spirometry – The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry. All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results
  • X-Ray – An x-ray of the chest may show an over-expanded lung (hyperinflation) and can be useful to help exclude other lung diseases.
  • Pulmonary function tests – Complete pulmonary function tests with measurements of lung volumes and gas transfer may also show hyperinflation and can discriminate between COPD with emphysema and COPD without emphysema.
  • Blood tests – A blood sample taken from an artery can be tested for blood gas levels which may show low oxygen levels (hypoxemia) and/or high carbon dioxide levels (respiratory acidosis). A blood sample taken from a vein may show a high blood count (reactive polycythemia), a reaction to long-term hypoxemia.

Outcome Measures

Follow the link Lung Function – Forces Expiratory Volume in 1 second (FEV1)

It is known that COPD lungs lose function quicker and more rapidly than non-COPD lungs. In recognition of this FEV1 is the most important marker to determine severity and treatment in COPD algorithms, with decline of FEV1 over-time as the marker for disease progression[15]. The ratio of FEV1/FVC (Forced vital capacity) as well as the percentage predicted FEV1 is a fixed ratio used in current guidelines to assess the function of lungs.

The strengths of using this measure is that:

  • FEV1 and FVC measurements are highly reproducible
  • Poor lung function if a risk factor for all cause of cardiovascular mortality and poorer health[16]

Limitations being:

  • FEV1 measurements are based on an artificial manoeuvre and do not always correlate with clinically relevant outcomes such as dyspnoea, health status, exercise capacity, or exacerbations[17][18]
  • Patients with similar FEV1 may represent different underlying phenotypes.
  • Reference equations for lung function by European Community for Coal and Steel are disputed and limited in predicting lung function in the general population [19]
  • No minimal important difference (MID) has been established yet. It was suggested that an appropriate range of values for the MID for FEV1 might be 100-140 mL but the MID for FEV1 remains poorly defined for COPD [20]

Lung Volumes

Changes in absolute lung volumes can occur in COPD patients even in the absence of FEV1 changes. Progressive hyperinflation due to airflow limitation and loss of lung elastic recoil not only increases the work required during inspiration but also profoundly decreases the ventilatory reserve and increases the sense of effort and dyspnoea[21]

In terms of measurement static lung hyperinflation and its increase during exercise (dynamic hyperinflation) are measured as elevations of total lung capacity (TLC), functional residual capacity (FRC), residual volume (RV) and as a decrease in inspiratory capacity (IC)[15].

Strengths of lung volumes include:

  • Indices of dynamic hyperinflation correlate better than FEV1 with activity limitation and exertional dyspnoeaand pharmacological and surgical lung volume reduction have been associated with improvements in exercise performance and dyspnoea[22][23]
  • A severely reduced IC/TLC ratio with a threshold value of 25% has been shown to predict mortality in COPD patients[24]

Weaknesses include:

  • Body plethysmography remains the gold standard for the measurement of lung volumes such as TLC, FRC and RV. Spirometrically derived assessments of lung hyperinflation are more difficult to interpret in the absence of simultaneous bodyplethysmographic volume measurements to rule out a concomitant restrictive ventilatory disorder[25]
  • The reproducibility of FRC, IC and RV in absolute values has yet to be demonstrated. Measurement of IC alone is not a reliable marker of lung hyperinflation and does not consistently reflect changes in FRC or TLC[25]
  • The natural course of dynamic hyperinflation in COPD is unknown and seems likely to be highly variable among COPD patients [25]

Exercise Capacity

Includes the Management / Interventions

As COPD is not curable the aim of treatment and interventions are directed at improving quality of life by managing symptoms and exacerbations and slowing down damage to the lungs.

Stopping Smoking

Encouraging patients with COPD to stop smoking is one of the most important components of their management. All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity.

Exercise

Exercise prescription is a key component of pulmonary rehabilitation programmes, which are part of the non-pharmacological approach to managing COPD. There is a high level of evidence for the benefits of pulmonary rehabilitation for people with COPD[27] Strength and endurance exercise are endorsed for people with COPD.[28]

Muscles that are required for arm exercise are also involved in movement of the chest wall during respiration and thus the need to breathe often compromises the individual’s ability to undertake daily activities, therefore exercise prescription involving arm exercise needs to be carefully prescribed.[29]

Promote Effective Inhaled Therapy

In people with stable COPD who remain breathless or have exacerbations despite use of short-acting bronchodilators as required, offer the following as maintenance therapy:

  • if forced expiratory volume in 1 second (FEV1)≥50% predicted: either long-acting beta2 agonist (LABA) or long-acting muscarinic antagonist (LAMA)
  • if FEV1

Offer LAMA in addition to LABA + ICS to people with COPD who remain breathless or have exacerbations despite taking LABA + ICS, irrespective of their FEV1.

Provide Pulmonary Rehabilitation

Pulmonary rehabilitation should be made available to all appropriate people with COPD including those who have had a recent hospitalisation for an acute exacerbation.

Use Non-Invasive Ventilation

Non-invasive ventilation (NIV) should be used as the treatment of choice for persistent hypercapnicventilatory failure during exacerbations not responding to medical therapy. It should be delivered by staff trained in its application, experienced in its use and aware of its limitations. When patients are started on NIV, there should be a clear plan covering what to do in the event of deterioration and ceilings of therapy should be agreed.

Manage Exacerbations

The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations.

The impact of exacerbations should be minimised by:

  • giving self-management advice on responding promptly to the symptoms of an exacerbation
  • starting appropriate treatment with oral steroids and/or antibiotics
  • use of non-invasive ventilation when indicated
  • use of hospital-at-home or assisted-discharge schemes

Ensure Multidisciplinary Working

COPD care should be delivered by a multidisciplinary team.

Managing Symptoms and Conditions in Stable COPD

Breathlessness and Exacerbations

  • Manage breathlessness and exercise limitation with inhaled therapy
  • For exacerbations or persistent breathlessness:
    • use long-acting bronchodilators or LABA + ICS
    • consider adding theophylline if still symptomatic
  • Offer pulmonary rehabilitation to all suitable people
  • Refer patients who are breathless, have a single large bulla on a CT scan and an FEV1 less than 50% predicted for consideration of bullectomy
  • Refer people with severe COPD for consideration of lung volume reduction surgery if they remain breathless with marked restrictions of their activities of daily living, despite maximal medical therapy (including rehabilitation), and meet all of the following:
    • FEV1 greater than 20% predicted
    • PaCO2 less than 7.3 kPa
    • upper lobe predominant emphysema
    • TLCO greater than 20% predicted
  • Consider referring people with severe COPD for assessment for lung transplantation if they remain breathless with marked restrictions of their activities of daily living despite maximal medical therapy. Considerations include:
    • age
    • FEV1
    • PaCO2
    • homogeneously distributed emphysema on CT scan
    • elevated pulmonary artery pressures with progressive deterioration
    • comorbidities
    • local surgical protocols

Frequent Exacerbations

  • Optimise inhaled therapy
  • Offer vaccinations and prophylaxis
  • Give self-management advice
  • Consider osteoporosis prophylaxis for people requiring frequent oral corticosteroids

Cor Pulmonale

  • Consider in people who have peripheral edema, a raised venous pressure, a systolic parasternal heave, a loud pulmonary second heart sound
  • Exclude other causes of peripheral edema
  • Perform pulse oximetry, ECG and echocardiogram if features of cor pulmonale
  • Assess need for LTOT
  • Treat edema with diuretic
  • Angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers are not recommended
  • Digoxin may be used where there is atrial fibrillation

Respiratory Failure

  • Assess for appropriate oxygen
  • Consider referral for assessment for long-term domiciliary NIV therapy

Abnormal BMI

  • Refer for dietetic advice
  • Offer nutritional supplements if the BMI is low
  • Pay attention to weight changes in older patients (especially>3 kg)

Chronic Productive Cough

  • Consider mucolytic therapy

Anxiety and Depression

Alpha-1 Antitrypsin Deficiency

  • Offer referral to a specialist centre to discuss the clinical management of this condition
  • Alpha-1 antitrypsin replacement therapy is not recommended

Palliative Setting

  • Opioids should be used when appropriate for the palliation of breathlessness in people with end-stage COPD unresponsive to other medical therapy
  • Use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen to treat breathlessness
  • Provide access to multidisciplinary palliative care teams and hospices

Resources

  • KNGF guidelines for physical therapy in patients with chronic obstructive pulmonary disease

Videos

References

  1. ↑ Young RP, Hopkins RJ, Christmas T, Black PN, Metcalf P, Gamble GD (August 2009). “COPD prevalence is increased in lung cancer, independent of age, sex and smoking history”. Eur. Respir. J. 34 (2): 380–6
  2. ↑ Devereux, Graham (May 2006). “ABC of chronic obstructive pulmonary disease. Definition, epidemiology, and risk factors”. BMJ 332 (7550): 1142–4
  3. ↑ Hnizdo E, Vallyathan V (April 2003). “Chronic obstructive pulmonary disease due to occupational exposure to silica dust: a review of epidemiological and pathological evidence”. Occup Environ Med 60 (4): 237–43
  4. ↑ Loscalzo, Joseph; Fauci, Anthony S.; Braunwald, Eugene; Dennis L. Kasper; Hauser, Stephen L; Longo, Dan L. (2008). Harrison’s Principles of Internal Medicine (17th ed.). McGraw-Hill Professional
  5. ↑ Halbert RJ, Natoli JL, Gano A, Badamgarav E, Buist AS, Mannino DM (September 2006). “Global burden of COPD: systematic review and meta-analysis”. Eur. Respir. J. 28 (3): 523–32
  6. ↑ Kennedy SM, Chambers R, Du W, Dimich-Ward H (December 2007). “Environmental and occupational exposures: do they affect chronic obstructive pulmonary disease differently in women and men?”. Proceedings of the American Thoracic Society 4 (8): 692–4.
  7. ↑ ilverman EK, Chapman HA, Drazen JM, et al. (June 1998). “Genetic epidemiology of severe, early-onset chronic obstructive pulmonary disease. Risk to relatives for airflow obstruction and chronic bronchitis”. Am. J. Respir. Crit. Care Med. 157 (6 Pt 1): 1770–8
  8. ↑ Agustí A, MacNee W, Donaldson K, Cosio M. (2003). “Hypothesis: does COPD have an autoimmune component?”. Thorax 58 (10): 832–4
  9. ↑ 9.09.1 Rutgers, Steven R.; Postma, Dirkje S.; Ten Hacken, Nick H. .T.; Kauffman, Henk F.;van der Mark,Thomas W; Koeter, Gerard H.; Timens, Wim (2000). “Ongoing airway inflammation in patients with COPD who do not currently smoke”. Thorax 55 (1): 12–18.
  10. ↑ Feghali-Bostwick CA, Gadgil AS, Otterbein LE, et al. (January 2008). “Autoantibodies in patients with chronic obstructive pulmonary disease”. Am. J. Respir. Crit. Care Med. 177 (2): 156–63. doi:10.1164/rccm.200701-014OC
  11. ↑ http://www.atsjournals.org/doi/abs/10.1164/rccm.200809-1512OC
  12. ↑ 12.012.1 Longmore, J. M.; Murray Longmore; Wilkinson, Ian; Supraj R. Rajagopalan (2004). Oxford handbook of clinical medicine. Oxford [Oxfordshire]: Oxford University Press. pp. 188–9. ISBN 0-19-852558-3
  13. ↑ Kumar P, Clark M (2005). Clinical Medicine (6th ed.). Elsevier Saunders. pp. 900–1. ISBN 0702027634
  14. ↑ Chung C, Delaney J, Hodgins R (2008). “Respirology”. in Somogyi, Ron; Colman, Rebecca. The Toronto notes 2008: a comprehensive medical reference and review for the Medical Council of Canada Qualifying Exam – Part 1 and the United States Medical Licensing Exam – Step 2. Toronto: Toronto Notes for Medical Students. p. R9. ISBN 0-9685928-8-0
  15. ↑ 15.015.1 Glaab T. Vogelmeier C and Buhl R. Outcome measures in chronic obstructive pulmonary disease (COPD): strengths and limitations. Respiratory Research. 2010:11:79
  16. ↑ Sin DD, Wu L, Man SF: The relationship between reduced lung function and cardiovascular mortality: a population-based study and a systematic review of the literature. Chest 2005, 127:1952-1959
  17. ↑ Cazzola M, MacNee W, Martinez FJ, Rabe KF, Franciosi LG, Barnes PJ, Brusasco V, Burge PS, Calverley PMA, Celli BR, Jones PW, Mahler DA, Make B, Miravitlles M, Page CP, Palange P, Parr D, Pistolesi M, Rennard SI, Rutten-van Mölken MP, Stockley R, Sullivan SD, Wedzicha JA, Wouters EF, American Thoracic Society/European Respiratory Society Task Force on outcomes of COPD: Outcomes for COPD pharmacological trials: from lung function to biomarkers. Eur Respir J 2008, 31:416-469
  18. ↑ 11.Wise RA: The value of forced expiratory volume in 1 second decline in the assessment of chronic obstructive pulmonary disease progression. Am J Med 2006, 119:4-11
  19. ↑ 12.Pellegrino R, Viegi G, Brusasco V, Crapo RO, Burgos F, Casaburi R, Coates A, van der Grinten CPM, Gustafsson P, Hankinson J, Jensen R, Johnson DC, MacIntyre N, McKay R, Miller MR, Navajas D, Pedersen OF, Wanger J: Interpretative strategies for lung function tests. Eur Respir J 2005, 26:948-968
  20. ↑ 4.Cazzola M, MacNee W, Martinez FJ, Rabe KF, Franciosi LG, Barnes PJ, Brusasco V, Burge PS, Calverley PMA, Celli BR, Jones PW, Mahler DA, Make B, Miravitlles M, Page CP, Palange P, Parr D, Pistolesi M, Rennard SI, Rutten-van Mölken MP, Stockley R, Sullivan SD, Wedzicha JA, Wouters EF, American Thoracic Society/European Respiratory Society Task Force on outcomes of COPD: Outcomes for COPD pharmacological trials: from lung function to biomarkers. Eur Respir J 2008, 31:416-469
  21. ↑ O’Donnell DE, Laveneziana P: Physiology and consequences of lung hyperinflation in COPD. Eur Respir Rev 2006, 15:61-67
  22. ↑ 17.O’Donnell DE: Is sustained pharmacologic lung volume reduction now possible in COPD? Chest 2006, 129:501-503
  23. ↑ 18.Criner GJ, Belt P, Sternberg AL, Mosenifar Z, Make BJ, Utz JP, Sciurba F: National Emphysema Treatment Trial Research Group. Effects of lung volume reduction surgery on gas exchange and breathing pattern during maximum exercise. Chest 2009, 135:1268-79
  24. ↑ 19.Casanova C, Cote C, de Torres JP, Aguirre-Jaime A, Marin JM, Pinto-Plata V, Celli BR: Inspiratory-to-total lung capacity predicts mortality in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2005, 171:591-597
  25. ↑ 25.025.125.2 O’Donnell DE, Laveneziana P: Physiology and consequences of lung hyperinflation in COPD. Eur Respir Rev 2006, 15:61-67
  26. ↑ Burke Rehabilitation. COPD Treatments & Rehab: Upper Body Exercises. Available from: http://www.youtube.com/watch?v=VR7QnSnHmBU[last accessed 13/02/15]
  27. ↑ Roisin RR, Rabe KF, Anzueto A, et al. Global strategy for the diagnosis management, and prevention of chronic obstructive pulmonary disease. Bethesda, MD: Global Initiative for Chronic Obstructive Lung Disease, 2008; 1–91.
  28. ↑ Skinner, Margot. Strength and endurance exercise endorsed for people with COPD. Physical Therapy Reviews, Volume 14, Number 6, December 2009 , pp. 418-418(1)
  29. ↑ Ennis S, Alison J, McKeough Z. The effects of arm endurance and strength training on arm exercise capacity in people with chronic obstructive pulmonary disease. Phys Ther Rev 2009;14(4):226–39.
  30. ↑ SMACC. Non-Invasive Ventilation. Available from: http://www.youtube.com/watch?v=QQZvhkBWBgQ [last accessed 13/02/15]
  31. ↑ National Institute for Health and Clinical Excellence. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Available from http://guidance.nice.org.uk/CG91 [last accessed 2/8/10]

Conteúdos relacionados

Adesão às diretrizes do NICE para dor lombar Ir para: navegação, pesquisa

Adesão às diretrizes do NICE para dor lombar

by with No Comment Fisioterapia Traumato-Ortopédica

A adesão às diretrizes do NICE para dor lombar é um tema central na prática clínica, pois essas recomendações orientam o manejo baseado em evidências na atenção primária. A dor lombar é uma condição comum que afeta pessoas de todas as idades, sendo a principal causa de limitação de atividades e ausência do trabalho em grande parte do mundo. No Reino Unido, mais de 100 milhões de dias de trabalho são perdidos anualmente devido a essa condição, que também é a causa mais comum de incapacidade em adultos, especialmente na faixa etária de 40 a 60 anos. Esse cenário impõe um alto ônus econômico aos indivíduos, famílias, comunidades, indústria e governos.

O custo da dor lombar para a economia do Reino Unido é estimado em cerca de £ 12 bilhões por ano, e a demanda crescente gera custos elevados para o NHS, aproximadamente £ 12,3 bilhões anuais. Com o envelhecimento populacional, esses números tendem a aumentar, pressionando ainda mais um sistema de saúde já sobrecarregado. A maioria dos casos de lombalgia aguda se recupera em 4 a 6 semanas, e a maior parte dos episódios é resolvida na atenção primária. Para apoiar os profissionais nesse contexto, as diretrizes do NICE (2016) foram desenvolvidas como um padrão de cuidado recomendado na Inglaterra e no País de Gales, destinadas a todos os clínicos da atenção primária que atendem pacientes com dor lombar.

Recomendações do NICE (2016) para o manejo da dor lombar

As diretrizes do NICE recomendam um pacote de tratamento que inclui exercício, aconselhamento e educação, podendo ser complementado com terapias manuais e psicológicas, se necessário. O tipo de exercício pode variar conforme as necessidades, preferências e capacidades do paciente. Essas recomendações refletem uma abordagem biopsicossocial, na qual fatores físicos, psicológicos e sociais influenciam o desfecho do paciente. Na avaliação inicial, deve-se realizar uma estratificação de risco, como a ferramenta Keele STarT Back, e a imagem não deve ser oferecida rotineiramente.

Intervenções não farmacológicas

Autogerenciamento: Fornecer conselhos e informações adaptados às necessidades e capacidades do paciente, incluindo informações sobre a natureza da dor lombar e ciática, e encorajamento para continuar com as atividades normais.

Exercício: Considerar um programa de exercícios em grupo (biomecânico, aeróbico, mente-corpo ou combinação) dentro do NHS para pessoas com um episódio ou surto de dor lombar com ou sem ciática, respeitando as preferências e capacidades individuais.

Terapias manuais: Não oferecer tração para controle da dor lombar. Considerar terapia manual (manipulação espinhal, mobilização ou técnicas de tecidos moles como massagem) apenas como parte de um pacote de tratamento incluindo exercícios, com ou sem terapia psicológica.

Terapia psicológica: Considerar terapias psicológicas com abordagem cognitivo-comportamental para manejo da dor lombar, mas apenas como parte de um pacote de tratamento incluindo exercícios, com ou sem terapia manual. Para pacientes com dor lombar persistente ou ciática e barreiras psicossociais significativas, considerar um programa físico e psicológico combinado, preferencialmente em grupo.

Adesão às diretrizes do NICE como medida de resultado

As diretrizes mais recentes não oferecem recomendações específicas sobre a prescrição do tratamento, o que gera incerteza sobre o que seria classificado como cuidado aderente. Com base em pesquisas e raciocínio clínico, uma medida razoável de adesão seria a realização de três ou mais sessões de fisioterapia do NHS, com a inclusão de exercício como parte do plano de tratamento. Pacientes que recebem menos sessões poderiam ser classificados como recebendo cuidados não aderentes. Esse número foi determinado a partir de estudos que investigaram os efeitos do exercício na lombalgia, com durações geralmente entre 8 e 12 semanas, o que equivaleria a aproximadamente 3 a 4 sessões de fisioterapia. No entanto, as limitações incluem a variação nos tipos, intensidade, duração e frequência da terapia com exercícios entre os estudos. Embora 1 a 2 sessões possam ser insuficientes para produzir mudanças positivas, mais de seis sessões podem ser inviáveis devido aos recursos limitados do NHS. A falta de evidências claras sobre a dose ideal de exercício dificulta o estabelecimento de padrões para classificar a adesão.

Estrutura do NHS e o papel da atenção primária

O NHS é estruturado em atenção primária e secundária, com os médicos da atenção primária atuando como “guardiões” que definem a necessidade de encaminhamento para cuidados especializados. Os clínicos gerais encaminham para especialistas por diversos motivos, como segunda opinião, procedimentos especializados ou aconselhamento diagnóstico. Contudo, o sistema de referência nem sempre é eficaz: alguns pacientes não recebem os cuidados necessários, enquanto muitos são encaminhados desnecessariamente, gerando demandas excessivas e custos elevados. Aderir às diretrizes e utilizar a prática baseada em evidências na atenção primária é, portanto, fundamental, e compreender as barreiras à adesão pode melhorar a prática futura.

Evidências sobre a adesão dos clínicos às diretrizes

Estudos que exploraram a adesão às diretrizes para dor lombar encontraram níveis variáveis, com considerável variação entre os clínicos. Uma revisão sistemática relatou que entre 69% e 90% dos pacientes recebiam prescrição de opioides em níveis mais elevados do que o recomendado, e havia pouca promoção de atividade física. O uso de raios-X para dor lombar na atenção primária variou entre países, com taxas de 4% a 7% no Reino Unido. Uma meta-análise para outros desfechos não foi possível devido à heterogeneidade dos estudos.

Em um estudo transversal no Canadá, medicamentos foram a modalidade mais comum, com opioides como segunda analgesia mais utilizada. Apenas 28% dos pacientes receberam modalidades adjuvantes, sendo a massagem a mais frequente, mas não ficou claro se foi prescrita como parte de um pacote ativo. Quarenta e três por cento dos pacientes não realizaram exercício antes do encaminhamento, e apenas 14% fizeram exercícios específicos para lombalgia. Somente 12% dos pacientes esgotaram todas as quatro categorias de intervenção (medicações, encaminhamento a profissional de saúde aliado, modalidades adjuntas e exercícios), enquanto 22% receberam apenas medicamentos. Mais de 40% não foram avaliados por um profissional de saúde aliado na atenção primária antes do encaminhamento.

Um estudo brasileiro com fisioterapeutas experientes mostrou taxas de adesão plena às diretrizes de prática clínica variando de 5% a 25%, adesão parcial de 42% a 75% e não adesão de 15% a 75%. A educação para manter um estilo de vida ativo foi selecionada em menos de 20% dos casos, apesar de ser um componente essencial. Correntes interferenciais e TENS foram escolhidas em menos de 40% dos casos, mesmo não sendo recomendadas.

Uma auditoria clínica na Holanda estabeleceu parâmetros de adesão baseados no número de sessões, prescrição de exercício ou aconselhamento e definição de pelo menos um objetivo de tratamento. Apenas 53% dos episódios de tratamento atenderam a esses parâmetros. Em 88% dos episódios, houve incorporação de terapia com exercícios ou aconselhamento, mas intervenções passivas foram usadas em 12% dos casos. O número mediano de sessões foi de oito para pacientes agudos e nove para crônicos.

Em resumo, é difícil avaliar o grau de adesão devido às variações entre profissionais e à heterogeneidade na definição de adesão como medida de resultado. As razões para os níveis submodestos de adesão incluem barreiras discutidas a seguir.

Resultados do cuidado aderente

Pesquisas indicam que o aumento da adesão está associado à redução da necessidade de consultas frequentes de fisioterapia, embora isso não tenha gerado economias substanciais. Evitar o uso inadequado de imagens radiológicas também foi associado à redução de tratamentos inadequados, como terapia com injeção e cirurgia. Um estudo de coorte mostrou que maior adesão melhorou o manejo do paciente e reduziu os escores de incapacidade (Quebec Back Pain Disability Scale), especialmente em pacientes com dor lombar crônica, mas não houve redução significativa nos escores médios de dor. As evidências sobre os resultados da adesão ainda são limitadas, com apenas quatro estudos incluídos em uma revisão sistemática, e mais pesquisas são necessárias para confirmar os benefícios em termos de desfechos clínicos, utilização e custos de saúde.

Barreiras à adesão dos clínicos

Na área de Nottingham, uma alta proporção de pacientes não recebe tratamento adequado para dor lombar na atenção primária. Uma revisão sistemática e metassíntese de estudos qualitativos explorou as percepções dos clínicos gerais sobre as diretrizes e as barreiras para implementá-las. Muitos clínicos, incluindo fisioterapeutas e médicos, acreditam que as diretrizes sufocam o julgamento clínico e a autonomia profissional, descrevendo-as como constrangedoras e prescritivas. No entanto, as recomendações do NICE são frequentemente vistas como pouco claras e abertas à interpretação, sem prescrição clara sobre o número de sessões ou o momento adequado para encaminhamento.

Alguns clínicos acreditam que as diretrizes não são apoiadas por evidências suficientes e que são produzidas para reduzir custos em vez de melhorar resultados. Embora muitos fisioterapeutas valorizem a prática baseada em evidências, consideram as recomendações atuais pouco práticas e irrealistas para implementação clínica, devido a limitações de tempo para ler e assimilar as diretrizes. Atitudes e crenças dos profissionais também influenciam os resultados: aqueles com abordagem mais biomédica têm menor probabilidade de aderir às diretrizes do que os que adotam uma visão psicossocial. Um estudo revelou que 28% dos profissionais recomendariam afastamento do trabalho se considerado necessário, o que conflita com as diretrizes e pode fortalecer crenças negativas e comportamentos de evitação por medo.

Em relação à imagem, as diretrizes do NICE recomendam não oferecer exames de imagem rotineiramente em ambientes não especializados e explicar aos pacientes que o encaminhamento para opinião especializada pode não exigir imagem. No entanto, muitos clínicos solicitam exames para obter um diagnóstico definitivo, por medo de perder uma patologia subjacente ou por preocupações com litígios por negligência. A imagem é frequentemente usada para aliviar a ansiedade do paciente, construir confiança ou como substituto do tempo de consulta, enquanto aguardam longas listas de espera para fisioterapia. Contudo, achados benignos como degeneração discal podem ser mal interpretados como causa da dor, levando a mais medo, incapacidade e intervenções inadequadas. Os pacientes muitas vezes esperam um diagnóstico por imagem para validar sua experiência de dor, e os clínicos temem que a não solicitação possa gerar dúvidas sobre sua competência.

Diante desse cenário, a formação continuada pode ser uma aliada para superar essas barreiras. Curso de RPG/RNP – Reeducação Postural Global

Conclusão

A adesão às diretrizes do NICE para dor lombar é baixa a modesta, com variação considerável entre clínicos e grupos profissionais, o que pode levar a desfechos desfavoráveis para os pacientes. Os profissionais frequentemente exercem sua autonomia para além das recomendações escritas, e alguns ainda buscam diagnósticos anatomopatológicos definitivos para manejar a condição. As altas demandas e a pressão de tempo na prática clínica tornam irrealista a aplicação plena das diretrizes no contexto atual dos serviços de saúde. A pesquisa sobre adesão ainda é escassa e de qualidade metodológica inadequada. Estratégias como educação e auditoria clínica podem ser usadas para monitorar e melhorar a adesão, mas a falta de uma medida de resultado padronizada e confiável para a adesão representa um desafio significativo para avaliação e quantificação.

Perguntas frequentes

Quais são as principais recomendações do NICE para o manejo da dor lombar?

As diretrizes do NICE (2016) recomendam um pacote de tratamento que inclui exercício, aconselhamento e educação, podendo ser complementado com terapias manuais e psicológicas, se necessário. A imagem não deve ser oferecida rotineiramente, e a estratificação de risco deve ser realizada na avaliação inicial.

Como a adesão às diretrizes do NICE pode ser medida?

Uma medida razoável de adesão é a realização de três ou mais sessões de fisioterapia do NHS, com a inclusão de exercício como parte do plano de tratamento. Pacientes com menos sessões podem ser classificados como recebendo cuidados não aderentes.

Quais são as barreiras para a adesão dos clínicos às diretrizes de dor lombar?

As barreiras incluem a percepção de que as diretrizes sufocam a autonomia profissional, a crença de que não são apoiadas por evidências suficientes, a falta de clareza nas recomendações, limitações de tempo para leitura e assimilação, e a tendência de solicitar exames de imagem para diagnóstico definitivo ou para aliviar a ansiedade do paciente.

Quais são os resultados do cuidado aderente às diretrizes?

Estudos sugerem que o aumento da adesão está associado à redução da necessidade de consultas frequentes de fisioterapia e à diminuição de tratamentos inadequados, como terapia com injeção e cirurgia. Em pacientes com dor lombar crônica, a maior adesão pode reduzir os escores de incapacidade.

Por que a imagem não é recomendada rotineiramente para dor lombar?

As diretrizes do NICE recomendam não oferecer exames de imagem rotineiramente porque achados benignos, como degeneração discal, podem ser mal interpretados como causa da dor, levando a mais medo, incapacidade e intervenções inadequadas. A imagem só deve ser considerada em ambientes especializados se o resultado puder mudar o manejo.