Active Multimodal Treatment, Lumbar Thoracic Extension, Proprioceptive Exercises, Horizontal Leg Press, Functional Restoration with Cognitive Behavioural Factors for Musculoskeletal Disorders
Documentation Based Care for Musculoskeletal Pain
DBC International, a company registered in Finland, was founded in 1991 to develop and make available therapies for musculoskeletal disorders. A principle which the company follows is that all therapies developed by the company should be validated scientific research and tested in fully documented clinical practice. DBC stands for Documentation Based Care. EVIDENCE BASED TREATMENT FOR MUSCULOSKELETAL DISORDERS Dr. Simo Taimela, M.D. is CEO and Medical Director of DBC International. The mission of DBC International is to develop and make available evidence based treatment and rehabilitation methods for musculoskeletal disorders. DBC treatments are currently available in dozens of clinics in 22 countries. High-quality clinics specialising in the treatment of musculoskeletal disorders are invited to join the DBC Network. Clinics joining the DBC Network obtain several benefits: Staff training by DBC International raises skills Outcomes of treatments improve Paying customers, employers and insurance companies express improved satisfaction with treatment results Higher skills as well as DBC management and marketing tools raise productivity. DBC PROGRAMMES FOR CHRONIC SHOULDER, BACK AND NECK PAIN Our main message is that almost all patients suffering from chronic back pain, chronic neck pain or chronic shoulder pain benefit from DBC treatment programmes. If DBC programmes are not available locally, some improvement in wellbeing can be achieved by developing a general understanding of the principles of these programmes and leading a physically active life. SYMPTOMS OF RECURRENT, MUSCULOSKELETAL PAIN The severity of acute musculoskeletal pain tends to diminish if you remain physically active. Recurrent pain episodes sometimes induce functional deficits associated with inactivity, and the deficits in turn may cause further discomfort. In this way episodes of acute pain can lead to a chronic problem. Especially in the presence of specific severe symptoms it is always advisable to see a doctor. You should visit a doctor if you have back or neck pain and any of the following holds true: You cannot manage your daily activities You have unexplained fever The pain was caused by an accident, such as a fall, and persists The pain is severe and worsens instead of improving over a period of weeks The pain recurs often You have been earlier diagnosed with or treated for cancer If you have back pain and suddenly develop any of the following rare symptoms, please see a doctor immediately: Numbness around crotch or genitals Difficulty in passing or controlling urine Numbness, pins and needles or weakness in both legs Unsteadiness while standing DBC Support Functions: DBC license and service agreement define the level of support each DBC clinic receives. Training: Initial training constitutes a part of every contract establishing a new DBC clinic. The duration of the initial training given to medical staff is three to seven days depending on the treatments provided in the clinic. Further training covers the latest research findings and their impacts on DBC treatments as well as topics related to individual clinics. Helpdesks: Online helpdesks are a service available to all DBC clinics. The service also comprises an extensive FAQ database. Clinical helpdesk is available for topics and problems related to DBC treatments. Software and technical helpdesks focus on software and DBC devices, respectively. Data Analysis and Quality Assurance: Twice a year DBC International analyses summaries of patient data submitted by DBC clinics. The analysis produces important feedback for the clinics on patient outcomes - pain, response rate, impairment, mobility, and work absenteeism. The feedback makes it possible for clinics to see if there is room for improvement in patient outcomes when compared with other clinics. The comparison helps clinics to keep their procedures up-to-date. As a result of the quality assurance system uniform results are obtained all over the world at DBC clinics. For instance, in pain reduction, response rates exceed 80% at DBC clinics in different countries. Device Maintenance: The Maintenance organisation of DBC International provides DBC clinics with after-sales services such as installation, regular maintenance and parts supplies. Trademark: The right to use the DBC trademark and related material, including guidelines for interior design, is granted to authorised DBC clinics. Similarly information sets comprising scientific and marketing material are made available to DBC clinics. MUSCULOSKELETAL PHYSIOTHERAPY UNDER DBC BRAND DBC License and Service Agreements: When a clinic purchases the DBC license, it obtains the right to operate under the DBC brand. In musculoskeletal physiotherapy and rehabilitation, the DBC brand signifies all-in-one centres of excellence. Every contract that establishes a new DBC clinic includes an agreement on ongoing license and support functions. The license agreement covers all immaterial rights to use the DBC treatments and to receive new treatment concept updates. New versions of the DBC software, DBC manuals and DBC patient assessments are included in the concept updates free of charge as well as an online helpdesk for clinical, software and technical questions. The customer has the right to attend initial and ongoing training seminars for the clinic staff. The license agreement grants rights to use all DBC trademark material, including, for example, scientific and marketing material, local branding and guidelines for interior design. The exclusivity granted through the license agreement ensures that each clinic can develop its business in its own region without facing competition from within the DBC network. SERVICE AGREEMENT COVERING PATIENT DATA ANALYSIS The service agreement may cover additional physical services to be provided on an ongoing basis. The typical service portfolio includes patient data analysis and consulting, initial and ongoing training, and device installation and maintenance. Additional services may be incorporated by local DBC representative on need basis.
DBC International, a company registered in Finland, was founded in 1991 to develop and make available therapies for musculoskeletal disorders. A principle which the company follows is that all therapies developed by the company should be validated scientific research and tested in fully documented clinical practice. DBC stands for Documentation Based Care.
Dr. Simo Taimela, M.D. is CEO and Medical Director of DBC International. The mission of DBC International is to develop and make available evidence based treatment and rehabilitation methods for musculoskeletal disorders.
DBC treatments are currently available in dozens of clinics in 22 countries. High-quality clinics specialising in the treatment of musculoskeletal disorders are invited to join the DBC Network. Clinics joining the DBC Network obtain several benefits:
Our main message is that almost all patients suffering from chronic back pain, chronic neck pain or chronic shoulder pain benefit from DBC treatment programmes. If DBC programmes are not available locally, some improvement in wellbeing can be achieved by developing a general understanding of the principles of these programmes and leading a physically active life.
The severity of acute musculoskeletal pain tends to diminish if you remain physically active. Recurrent pain episodes sometimes induce functional deficits associated with inactivity, and the deficits in turn may cause further discomfort. In this way episodes of acute pain can lead to a chronic problem. Especially in the presence of specific severe symptoms it is always advisable to see a doctor. You should visit a doctor if you have back or neck pain and any of the following holds true:
If you have back pain and suddenly develop any of the following rare symptoms, please see a doctor immediately:
DBC Support Functions: DBC license and service agreement define the level of support each DBC clinic receives.
Training: Initial training constitutes a part of every contract establishing a new DBC clinic. The duration of the initial training given to medical staff is three to seven days depending on the treatments provided in the clinic. Further training covers the latest research findings and their impacts on DBC treatments as well as topics related to individual clinics.
Helpdesks: Online helpdesks are a service available to all DBC clinics. The service also comprises an extensive FAQ database. Clinical helpdesk is available for topics and problems related to DBC treatments. Software and technical helpdesks focus on software and DBC devices, respectively.
Data Analysis and Quality Assurance: Twice a year DBC International analyses summaries of patient data submitted by DBC clinics. The analysis produces important feedback for the clinics on patient outcomes - pain, response rate, impairment, mobility, and work absenteeism.
The feedback makes it possible for clinics to see if there is room for improvement in patient outcomes when compared with other clinics. The comparison helps clinics to keep their procedures up-to-date. As a result of the quality assurance system uniform results are obtained all over the world at DBC clinics. For instance, in pain reduction, response rates exceed 80% at DBC clinics in different countries.
Device Maintenance: The Maintenance organisation of DBC International provides DBC clinics with after-sales services such as installation, regular maintenance and parts supplies.
Trademark: The right to use the DBC trademark and related material, including guidelines for interior design, is granted to authorised DBC clinics. Similarly information sets comprising scientific and marketing material are made available to DBC clinics.
DBC License and Service Agreements: When a clinic purchases the DBC license, it obtains the right to operate under the DBC brand. In musculoskeletal physiotherapy and rehabilitation, the DBC brand signifies all-in-one centres of excellence. Every contract that establishes a new DBC clinic includes an agreement on ongoing license and support functions.
The license agreement covers all immaterial rights to use the DBC treatments and to receive new treatment concept updates. New versions of the DBC software, DBC manuals and DBC patient assessments are included in the concept updates free of charge as well as an online helpdesk for clinical, software and technical questions. The customer has the right to attend initial and ongoing training seminars for the clinic staff. The license agreement grants rights to use all DBC trademark material, including, for example, scientific and marketing material, local branding and guidelines for interior design. The exclusivity granted through the license agreement ensures that each clinic can develop its business in its own region without facing competition from within the DBC network.
The service agreement may cover additional physical services to be provided on an ongoing basis. The typical service portfolio includes patient data analysis and consulting, initial and ongoing training, and device installation and maintenance. Additional services may be incorporated by local DBC representative on need basis.
DBC Programmes for Chronic Musculoskeletal Conditions
Functional restoration helps overcome pain and DBC treatment programmes are based on this principle. Reviews of medical studies have shown that this is the most effective approach in reducing pain and sick days among patients with chronic back pain. FUNCTIONAL RESTORATION AND COGNITIVE BEHAVIOURAL FACTORS TO TREAT CHRONIC NECK, BACK AND SHOULDER PAIN Evidence on the benefits of functional restoration in the treatment of chronic neck pain is convincing. The first results obtained at DBC clinics confirm the promise of the approach in the treatment of chronic shoulder pain too. What makes the functional restoration approach special is that it includes not only physical training but also addresses cognitive behavioural factors. After years of suffering from intense pain, every patient needs convincing information about the underlying safety and benefits of planned exercises. The functional restoration approach induces physiological changes and facilitates learning by doing. The DBC method enhances the benefits of this approach. Exercises used in the DBC programmes have been carefully designed so that their impacts are focussed on the most important areas of the musculoskeletal system. The exercises are individually tailored for each patient for maximum safety, benefit and comfort. The DBC method relies on the skills of doctors and physiotherapists, who have received special training so that they know exactly what is the target and function of each exercise. DBC devices are designed so that the correct patterns of movement come naturally to each patient. PROLONGED BED REST IS BAD FOR CHRONIC MUSCULOSKELETAL CONDITIONS AND PAIN Inactivity hampers recovery from chronic musculoskeletal pain. Physical exercises are an integral part of the functional restoration approach. It is important for patients having chronic musculoskeletal pain to understand the harmful effects of prolonged bed rest. It has been proven that prolonged bed rest is not only a bad option in the treatment of chronic back pain but that it also aggravates other medical conditions. Complete bed rest is ``a highly unphysiologic and definitely hazardous form of therapy, to be ordered only for specific indications and discontinued as early as possible.`` That was the conclusion of an article published in 1944 in the Journal of the American Medical Association. Nevertheless, only a decade ago, prolonged bed rest was in many countries the treatment method of choice for lower back pain. Similarly, various forms of rest or support were often recommended for recurrent pain in the neck or shoulder. Since then there has been a complete change in the way of thinking, and medical researchers associated with DBC International and DBC clinics have contributed to this change. Now it is widely recognized that rest and traditional physical therapies in which patients receive treatments passively are not very effective in chronic musculoskeletal conditions. Physical inactivity has several harmful effects: Muscles, ligaments and bones weaken The spine stiffens and loses control and coordination Overall physical fitness deteriorates Patients become prone to depression and sensitive to pain Resumption of normal activities and daily routines becomes more and more difficult as time passes The current consensus is that inactivity is the wrong response to acute and chronic back pain, chronic neck pain and chronic shoulder pain. In acute pain, it is advisable for patients to continue daily activities as much as possible. In chronic pain, physical exercises can bring about some relief gradually, and the best results are obtained when carefully designed functional restoration approaches are followed. Research is an integral part of the ongoing development of the DBC system. Results of DBC research collaboration have been published in medical journals such as Spine, Archives of Physical Medicine and Rehabilitation, and Journal of Spinal Disorders and Pathophysiology. The practical implications of research are taken into account in the development of DBC protocols and devices. Data on thousands of patients treated in DBC clinics are an important source of information. While medical information on individual patients is strictly confidential, information obtained from patient assessment yields important aggregate data on the efficacy of treatments given in DBC clinics. Acute pain is a warning signal of tissue damage. In chronic pain, discomfort continues even though the original tissue damage has been healed, and there is no clearly identifiable physical cause for pain. Instead, tissues and the central nervous system may have become overly sensitive so that ordinary stimuli are interpreted as pain by the central nervous system. Often back pain that has lasted for less than 6 weeks is classified as acute; subacute or prolonged when its duration has been between 6 and 9 weeks; and chronic if it has lasted more than 12 weeks. RANDOMISED CONTROLLED TRIAL, COCHRANE LIBRARY AND REVIEWS TO ASSESS THERAPY FOR MUSCULOSKELETAL PAIN Musculoskeletal pain is pain associated with muscles or joints. Evidence based medicine is healthcare applying therapies based on the best available information and scientific evidence on the effectiveness of each individual intervention. In medical research, the Cochrane Library has been designed to provide such information on a systematic basis and is therefore widely referred to in our research. The criteria for assessing therapies: Efficacy: does it work as expected in randomised clinical trials (RCTs)? Safety: does it have adverse effects? Effectiveness: does it work in normal clinical environment? Cost-effectiveness: is it an efficient use of resources? Randomised controlled trial (RCT) is an experiment in which investigators allocate eligible people randomly into intervention groups that receive or do not receive treatments that are being tested. The results are assessed by comparing outcomes in the treatment and control groups. A systematic review of RCTs is a review of a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant RCTs, and to collect and analyse data from the studies that are included in the review. Statistical methods (meta-analysis) may or may not be used to analyse and summarise the results of the included studies. Example: Cochrane Reviews.
Functional restoration helps overcome pain and DBC treatment programmes are based on this principle. Reviews of medical studies have shown that this is the most effective approach in reducing pain and sick days among patients with chronic back pain.
Evidence on the benefits of functional restoration in the treatment of chronic neck pain is convincing. The first results obtained at DBC clinics confirm the promise of the approach in the treatment of chronic shoulder pain too. What makes the functional restoration approach special is that it includes not only physical training but also addresses cognitive behavioural factors. After years of suffering from intense pain, every patient needs convincing information about the underlying safety and benefits of planned exercises. The functional restoration approach induces physiological changes and facilitates learning by doing.
The DBC method enhances the benefits of this approach. Exercises used in the DBC programmes have been carefully designed so that their impacts are focussed on the most important areas of the musculoskeletal system. The exercises are individually tailored for each patient for maximum safety, benefit and comfort.
The DBC method relies on the skills of doctors and physiotherapists, who have received special training so that they know exactly what is the target and function of each exercise. DBC devices are designed so that the correct patterns of movement come naturally to each patient.
Inactivity hampers recovery from chronic musculoskeletal pain. Physical exercises are an integral part of the functional restoration approach. It is important for patients having chronic musculoskeletal pain to understand the harmful effects of prolonged bed rest. It has been proven that prolonged bed rest is not only a bad option in the treatment of chronic back pain but that it also aggravates other medical conditions.
Complete bed rest is ``a highly unphysiologic and definitely hazardous form of therapy, to be ordered only for specific indications and discontinued as early as possible.`` That was the conclusion of an article published in 1944 in the Journal of the American Medical Association. Nevertheless, only a decade ago, prolonged bed rest was in many countries the treatment method of choice for lower back pain. Similarly, various forms of rest or support were often recommended for recurrent pain in the neck or shoulder. Since then there has been a complete change in the way of thinking, and medical researchers associated with DBC International and DBC clinics have contributed to this change.
Now it is widely recognized that rest and traditional physical therapies in which patients receive treatments passively are not very effective in chronic musculoskeletal conditions. Physical inactivity has several harmful effects:
The current consensus is that inactivity is the wrong response to acute and chronic back pain, chronic neck pain and chronic shoulder pain. In acute pain, it is advisable for patients to continue daily activities as much as possible. In chronic pain, physical exercises can bring about some relief gradually, and the best results are obtained when carefully designed functional restoration approaches are followed.
Research is an integral part of the ongoing development of the DBC system. Results of DBC research collaboration have been published in medical journals such as Spine, Archives of Physical Medicine and Rehabilitation, and Journal of Spinal Disorders and Pathophysiology. The practical implications of research are taken into account in the development of DBC protocols and devices. Data on thousands of patients treated in DBC clinics are an important source of information. While medical information on individual patients is strictly confidential, information obtained from patient assessment yields important aggregate data on the efficacy of treatments given in DBC clinics.
Acute pain is a warning signal of tissue damage. In chronic pain, discomfort continues even though the original tissue damage has been healed, and there is no clearly identifiable physical cause for pain. Instead, tissues and the central nervous system may have become overly sensitive so that ordinary stimuli are interpreted as pain by the central nervous system. Often back pain that has lasted for less than 6 weeks is classified as acute; subacute or prolonged when its duration has been between 6 and 9 weeks; and chronic if it has lasted more than 12 weeks.
Musculoskeletal pain is pain associated with muscles or joints. Evidence based medicine is healthcare applying therapies based on the best available information and scientific evidence on the effectiveness of each individual intervention. In medical research, the Cochrane Library has been designed to provide such information on a systematic basis and is therefore widely referred to in our research. The criteria for assessing therapies:
Randomised controlled trial (RCT) is an experiment in which investigators allocate eligible people randomly into intervention groups that receive or do not receive treatments that are being tested. The results are assessed by comparing outcomes in the treatment and control groups.
A systematic review of RCTs is a review of a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant RCTs, and to collect and analyse data from the studies that are included in the review. Statistical methods (meta-analysis) may or may not be used to analyse and summarise the results of the included studies. Example: Cochrane Reviews.
Functional Restoration and Cognitive Behavioural Approach for Chronic Musculoskeletal Pain
The DBC method is based on the principles of functional restoration and cognitive behavioural approach. Treatments based on the functional restoration principle combine the benefits of exercise therapies and the cognitive behavioural approach. That is why functional restoration treatments produce good results for instance in reducing work absenteeism, as was noted in a recent Cochrane Review: ``Physical conditioning programs that include a cognitive behavioral approach plus intensive physical training (specific to the job or not) that includes aerobic capacity, muscle strength and endurance, and coordination; are in some way work-related; and are given and supervised by a physiotherapist or a multidisciplinary team, seem to be effective in reducing the number of sick days for some workers with chronic back pain, when compared to usual care``. (Source: Schonstein et al. 2002) COGNITIVE BEHAVIOURAL APPROACH FOR CHRONIC MUSCULOSKELETAL PAIN, ACUTE LOW BACK PAIN AND SCIATA In the treatment of chronic musculoskeletal pain, the cognitive behavioural approach takes advantage of the fact that fears related to physical activities and exercises can be reduced by supplying the patient consistently with the correct information on the safety and benefits of exercise. In addition, the DBC system involves the principle of learning by doing. By starting with easy exercises patients are encouraged to do exercises and learn by experience how well-designed exercises can lead to functional benefits and reduce pain. DBC Treatment Concept: The DBC treatment concept comprises methods and devices used in the various phases of patient assessment, treatment and outcome monitoring. Musculoskeletal Pain: In acute back, neck or shoulder pain it is important to address the cause and ameliorate the distress by appropriate medication. The length of the pain episode may be reduced and the risk of chronicity reduced if the patient stays active, keeps spirits high and avoids fixing thoughts on pain. Staying active to the extent possible is important in all musculoskeletal conditions. For instance, in acute low back pain it has been shown that ``…it is reasonable to advise people with acute low back pain and sciatica to stay active``. RANDOMISED CLINICAL TRIALS DISCOURAGE ENFORCED BED REST This recommendation is based on a systematic review of randomised clinical trials in which advice to stay active was compared with advice to rest in bed. The recommendation is based on the potentially harmful effects of enforced bed rest. (Hilde et al. 2001.) If the treatment of acute pain is not successful, a chronic condition can gradually develop as recurrent pain can induce behavioural, postural and functional changes that increase the likelihood of further pain episodes. While acute pain often has specific causes, chronic pain is a multidimensional problem. Often there are no clear correlations between pain and specific diagnostic findings. In medicine, the usual approach is to diagnose what the exact causes of a condition are. Then these causes are rectified by means of surgery or other forms of treatment targeting these specific causes. In chronic musculoskeletal pain, the exact physical causes are in most cases not identifiable, and that is why surgery or other specialised treatments often do not produce lasting results. Chronic musculoskeletal pain involves subtle changes that have taken place in the affected tissues and the central nervous system. These are not identifiable by current clinical methods. Moreover there are changes in behaviour, such as tendency to avoid exertion. In consequence, the musculoskeletal system may develop deficits in control and reflex patterns, thus becoming increasingly susceptible to further problems. PHILADELPHIA PANEL SUPPORT EXERCISE THERAPIES FOR MUSCULOSKELETAL CONDITIONS A recent comparison of treatments for musculoskeletal pain showed that exercise therapies provide a good basis for treatment. In the DBC system, the benefits of exercise therapies are enhanced by the inclusion of the cognitive behavioural approach. The Philadelphia Panel, a group of eminent members of American medical societies, carried out comparisons of various treatments. The group has developed a method of its own for systematic and scientific assessment of such medical therapies. While not so popular as the approach of the Cochrane Reviews, the method of the Philadelphia Panel has yielded a methodologically consistent review of treatments of the most important musculoskeletal conditions. The aim of the Philadelphia Panel study was to formulate evidence based guidelines for the management of low back, knee, neck and shoulder pain (Harris and Susman 2002). The treatments reviewed in the study were therapeutic exercise, massage, transcutaneous electrical nerve stimulation (TENS), thermotherapy, ultrasound, electrical stimulation, and combinations of these therapies. Supporting evidence was found mainly for therapeutic exercise. According to the findings of the study, for acute low back pain there is strong evidence for the beneficial effects of continuing of normal activities in comparison to enforced bed rest. Continuation of normal activities seems to speed up return to work, while benefits related to pain or function were not clinically important. THERAPEUTIC AND PROPRIOCEPTIVE EXERCISES ALLEVIATE SUBACTUTE LOW BACK AND NECK PAIN In subactute low back pain, the study found therapeutic exercises producing clinically significant improvements in pain, function and overall recovery. Similarly, chronic low back pain therapeutic exercise, including stretching, strengthening and mobility exercises, resulted in clinically significant improvements in pain and function. However, there was no benefit in facilitating return to work. The Philadelphia Panel located only 8 studies on neck pain that met all the selection criteria. For chronic neck pain, only therapeutic and proprioceptive exercises showed benefits related to pain and function. There was a paucity of high-quality studies on shoulder pain as well. Consequently, the only recommendation that could be given was that ultrasound is beneficial for calcific tendonitis. The recommendations of the Philadelphia Panel show that for various musculoskeletal conditions there is significant evidence mainly for exercise-based approaches. The DBC system produces good results because in addition to carefully designed exercise treatments it covers the cognitive behavioural dimension.
The DBC method is based on the principles of functional restoration and cognitive behavioural approach. Treatments based on the functional restoration principle combine the benefits of exercise therapies and the cognitive behavioural approach. That is why functional restoration treatments produce good results for instance in reducing work absenteeism, as was noted in a recent Cochrane Review:
``Physical conditioning programs that include a cognitive behavioral approach plus intensive physical training (specific to the job or not) that includes aerobic capacity, muscle strength and endurance, and coordination; are in some way work-related; and are given and supervised by a physiotherapist or a multidisciplinary team, seem to be effective in reducing the number of sick days for some workers with chronic back pain, when compared to usual care``. (Source: Schonstein et al. 2002)
In the treatment of chronic musculoskeletal pain, the cognitive behavioural approach takes advantage of the fact that fears related to physical activities and exercises can be reduced by supplying the patient consistently with the correct information on the safety and benefits of exercise. In addition, the DBC system involves the principle of learning by doing. By starting with easy exercises patients are encouraged to do exercises and learn by experience how well-designed exercises can lead to functional benefits and reduce pain.
DBC Treatment Concept: The DBC treatment concept comprises methods and devices used in the various phases of patient assessment, treatment and outcome monitoring.
Musculoskeletal Pain: In acute back, neck or shoulder pain it is important to address the cause and ameliorate the distress by appropriate medication. The length of the pain episode may be reduced and the risk of chronicity reduced if the patient stays active, keeps spirits high and avoids fixing thoughts on pain.
Staying active to the extent possible is important in all musculoskeletal conditions. For instance, in acute low back pain it has been shown that ``…it is reasonable to advise people with acute low back pain and sciatica to stay active``.
This recommendation is based on a systematic review of randomised clinical trials in which advice to stay active was compared with advice to rest in bed. The recommendation is based on the potentially harmful effects of enforced bed rest. (Hilde et al. 2001.)
If the treatment of acute pain is not successful, a chronic condition can gradually develop as recurrent pain can induce behavioural, postural and functional changes that increase the likelihood of further pain episodes. While acute pain often has specific causes, chronic pain is a multidimensional problem. Often there are no clear correlations between pain and specific diagnostic findings.
In medicine, the usual approach is to diagnose what the exact causes of a condition are. Then these causes are rectified by means of surgery or other forms of treatment targeting these specific causes. In chronic musculoskeletal pain, the exact physical causes are in most cases not identifiable, and that is why surgery or other specialised treatments often do not produce lasting results.
Chronic musculoskeletal pain involves subtle changes that have taken place in the affected tissues and the central nervous system. These are not identifiable by current clinical methods. Moreover there are changes in behaviour, such as tendency to avoid exertion. In consequence, the musculoskeletal system may develop deficits in control and reflex patterns, thus becoming increasingly susceptible to further problems.
A recent comparison of treatments for musculoskeletal pain showed that exercise therapies provide a good basis for treatment. In the DBC system, the benefits of exercise therapies are enhanced by the inclusion of the cognitive behavioural approach. The Philadelphia Panel, a group of eminent members of American medical societies, carried out comparisons of various treatments. The group has developed a method of its own for systematic and scientific assessment of such medical therapies. While not so popular as the approach of the Cochrane Reviews, the method of the Philadelphia Panel has yielded a methodologically consistent review of treatments of the most important musculoskeletal conditions.
The aim of the Philadelphia Panel study was to formulate evidence based guidelines for the management of low back, knee, neck and shoulder pain (Harris and Susman 2002). The treatments reviewed in the study were therapeutic exercise, massage, transcutaneous electrical nerve stimulation (TENS), thermotherapy, ultrasound, electrical stimulation, and combinations of these therapies. Supporting evidence was found mainly for therapeutic exercise.
According to the findings of the study, for acute low back pain there is strong evidence for the beneficial effects of continuing of normal activities in comparison to enforced bed rest. Continuation of normal activities seems to speed up return to work, while benefits related to pain or function were not clinically important.
In subactute low back pain, the study found therapeutic exercises producing clinically significant improvements in pain, function and overall recovery. Similarly, chronic low back pain therapeutic exercise, including stretching, strengthening and mobility exercises, resulted in clinically significant improvements in pain and function. However, there was no benefit in facilitating return to work.
The Philadelphia Panel located only 8 studies on neck pain that met all the selection criteria. For chronic neck pain, only therapeutic and proprioceptive exercises showed benefits related to pain and function. There was a paucity of high-quality studies on shoulder pain as well. Consequently, the only recommendation that could be given was that ultrasound is beneficial for calcific tendonitis. The recommendations of the Philadelphia Panel show that for various musculoskeletal conditions there is significant evidence mainly for exercise-based approaches. The DBC system produces good results because in addition to carefully designed exercise treatments it covers the cognitive behavioural dimension.
DBC Treatments for Chronic Low Back and Neck Pain
Reviews of randomised controlled trials have shown that functional restoration therapy is an effective treatment for chronic low back pain. Evidence supporting the efficacy of the DBC method system that realises the benefits of functional restoration therapy by combining the benefits of exercise treatments and the cognitive behavioural approach has been accumulating in medical research and clinical practice. Data on treatment results obtained in DBC clinics show that the well-being of a large majority of patients is improved even in severe cases. DBC treatments have been proven effective in chronic pain. (Kankaanpää et al. 1999.) The DBC rehabilitation programmes have been shown to increase strength, mobility and endurance as well as reduce pain (Härkäpää and Taimela 1996; Taimela and Härkäpää 1996). The benefits obtained during the DBC programmes can be sustained for a long time, especially if the patient continues to exercise after the treatment (Kankaanpää et al. 1999; Mannion et al. 1999; Taimela et al. 2000). Of significance is the impact of cognitive behavioural approach on work absenteeism. A Cochrane Review published in 2002 (updated in 2003) concluded that significant reductions can be obtained with functional restoration therapy: ``There is evidence that physical conditioning programs that include a cognitive behavioural approach can reduce the number of sick days lost at 12 months follow-up by an average of 45 days, when compared to general practitioner usual care or advice, for workers with chronic back pain.`` (Schonstein et al. 2002.) Strong evidence from multiple relevant, high quality randomised controlled trials: Exercise therapy is effective Manipulation is more effective than placebo in pain reduction Intensive back school in occupational setting is more effective than no actual treatment A large body of evidence confirms that for a majority of patients exercise therapy reduces impairments in back flexibility and strength and improves endurance. Most studies have noted that after exercise treatment the overall reduction in back pain intensity ranges from 10 % to 50 %. (Rainville et al. 2004.) In 16 high-quality randomised controlled trials, exercise therapy produced positive effects in each and every study (Liddle et al. 2004). Moderate evidence from other randomised controlled trials: Manipulation is more effective than usual care by general practitioner, bed rest, analgesics and massage Epidural steroid injections are more effective than placebo, NSAIDs Antidepressants are not effective Behavioral therapy is effective Muscle relaxants are effective Traction is not effective Biofeedback is not effective While chronic neck conditions have been subjected to less medical research than low back pain, the available evidence supports the DBC approach. In chronic neck pain, continuation of normal physical activities is recommended. Ergonomic factors at work and at home should be considered. In chronic pain, medication is not as straightforward or beneficial as in acute pain. For instance, nonsteroidal anti-inflammatory drugs (NSAID) cannot be recommended for chronic pain. The efficacy of muscle relaxants has not been proven in patients with chronic pain. ACTIVE MULTIMODAL TREATMENT EMPHASIZING PROPRIOCEPTIVE EXERCISES AND THERAPEUTIC EXERCISES A randomised comparative study with a 1-year follow-up produced some evidence for active multimodal treatment strategy emphasising proprioceptive training. Active multimodal treatment was more efficacious than activated home exercises that were in turn clearly more beneficial than mere advice given to patients. (Taimela et al. 2000.)In a review by the Philadelphia Panel, only proprioceptive exercises and therapeutic exercises showed clinical benefits in chronic neck pain. Exercise also improved function. On the basis of these results, it was concluded that therapeutic exercises are the only intervention that have clinically important benefits regarding neck pain and function. (Philadelphia Panel 2001; Harris and Susman 2002.) There are many kinds of physical therapies available for neck pain, but comparative trials involving individual therapies have not been carried out. There is inadequate evidence regarding the efficacy of therapeutic ultrasound, massage, thermotherapy, and electrical stimulation. (Philadelphia Panel 2001.) In October 2001, the American Physical Therapy Association (APTA) unveiled the society’s evidence-based guidelines for clinical practice. The conclusion was that there is scientific evidence to support proprioceptive exercises and therapeutic exercises for chronic neck pain. However, there is a lack of evidence to include or exclude the use of thermotherapy, therapeutic massage, EMG biofeedback, mechanical traction, therapeutic ultrasound, TENS, electrical stimulation, and combined rehabilitation interventions. (Bagnall 2002.)
Reviews of randomised controlled trials have shown that functional restoration therapy is an effective treatment for chronic low back pain. Evidence supporting the efficacy of the DBC method system that realises the benefits of functional restoration therapy by combining the benefits of exercise treatments and the cognitive behavioural approach has been accumulating in medical research and clinical practice.
Data on treatment results obtained in DBC clinics show that the well-being of a large majority of patients is improved even in severe cases. DBC treatments have been proven effective in chronic pain. (Kankaanpää et al. 1999.) The DBC rehabilitation programmes have been shown to increase strength, mobility and endurance as well as reduce pain (Härkäpää and Taimela 1996; Taimela and Härkäpää 1996).
The benefits obtained during the DBC programmes can be sustained for a long time, especially if the patient continues to exercise after the treatment (Kankaanpää et al. 1999; Mannion et al. 1999; Taimela et al. 2000). Of significance is the impact of cognitive behavioural approach on work absenteeism. A Cochrane Review published in 2002 (updated in 2003) concluded that significant reductions can be obtained with functional restoration therapy: ``There is evidence that physical conditioning programs that include a cognitive behavioural approach can reduce the number of sick days lost at 12 months follow-up by an average of 45 days, when compared to general practitioner usual care or advice, for workers with chronic back pain.`` (Schonstein et al. 2002.)
Strong evidence from multiple relevant, high quality randomised controlled trials:
A large body of evidence confirms that for a majority of patients exercise therapy reduces impairments in back flexibility and strength and improves endurance. Most studies have noted that after exercise treatment the overall reduction in back pain intensity ranges from 10 % to 50 %. (Rainville et al. 2004.) In 16 high-quality randomised controlled trials, exercise therapy produced positive effects in each and every study (Liddle et al. 2004).
Moderate evidence from other randomised controlled trials:
While chronic neck conditions have been subjected to less medical research than low back pain, the available evidence supports the DBC approach. In chronic neck pain, continuation of normal physical activities is recommended. Ergonomic factors at work and at home should be considered. In chronic pain, medication is not as straightforward or beneficial as in acute pain. For instance, nonsteroidal anti-inflammatory drugs (NSAID) cannot be recommended for chronic pain. The efficacy of muscle relaxants has not been proven in patients with chronic pain.
A randomised comparative study with a 1-year follow-up produced some evidence for active multimodal treatment strategy emphasising proprioceptive training. Active multimodal treatment was more efficacious than activated home exercises that were in turn clearly more beneficial than mere advice given to patients. (Taimela et al. 2000.)In a review by the Philadelphia Panel, only proprioceptive exercises and therapeutic exercises showed clinical benefits in chronic neck pain. Exercise also improved function. On the basis of these results, it was concluded that therapeutic exercises are the only intervention that have clinically important benefits regarding neck pain and function. (Philadelphia Panel 2001; Harris and Susman 2002.)
There are many kinds of physical therapies available for neck pain, but comparative trials involving individual therapies have not been carried out. There is inadequate evidence regarding the efficacy of therapeutic ultrasound, massage, thermotherapy, and electrical stimulation. (Philadelphia Panel 2001.)
In October 2001, the American Physical Therapy Association (APTA) unveiled the society’s evidence-based guidelines for clinical practice. The conclusion was that there is scientific evidence to support proprioceptive exercises and therapeutic exercises for chronic neck pain. However, there is a lack of evidence to include or exclude the use of thermotherapy, therapeutic massage, EMG biofeedback, mechanical traction, therapeutic ultrasound, TENS, electrical stimulation, and combined rehabilitation interventions. (Bagnall 2002.)
DBC Treatment System and Concept
The DBC treatment concept comprises methods and devices used in the various phases of patient assessment, treatment and outcome monitoring. In acute back, neck or shoulder pain it is important to address the cause and ameliorate the distress of musculoskeletal pain by appropriate medication. The length of the pain episode may be reduced and the risk of chronicity reduced if the patient stays active, keeps spirits high and avoids fixing thoughts on pain. STAYING ACTIVE TO COMBAT MUSCULOSKELETAL CONDITIONS AND ACUTE LOW BACK PAIN Staying active to the extent possible is important in all musculoskeletal conditions. For instance, in acute low back pain it has been shown that ``…it is reasonable to advise people with acute low back pain and sciatica to stay active``. This recommendation is based on a systematic review of randomised clinical trials in which advice to stay active was compared with advice to rest in bed. The recommendation is based on the potentially harmful effects of bed rest. (Hilde et al. 2001.) If the treatment of acute pain is not successful, a chronic condition can gradually develop as recurrent pain can induce behavioural, postural and functional changes that increase the likelihood of further pain episodes. While acute pain often has specific causes, chronic pain is a multidimensional problem. Often there are no clear correlations between pain and specific diagnostic findings. TREATING CHRONIC MUSCULOSKELETAL PAIN, ADDRESSING DEFICITS IN MUSCULOSKELETAL SYSTEM In medicine, the usual approach is to diagnose what the exact causes of a condition are. Then these causes are rectified by means of surgery or other forms of treatment targeting these specific causes. In chronic musculoskeletal pain, the exact physical causes are in most cases not identifiable, and that is why surgery or other specialised treatments often do not produce lasting results. Chronic musculoskeletal pain involves subtle changes that have taken place in the affected tissues and the central nervous system. These are not identifiable by current clinical methods. Moreover there are changes in behaviour, such as tendency to avoid exertion. In consequence, the musculoskeletal system may develop deficits in control and reflex patterns, thus becoming increasingly susceptible to further problems. Features of DBC Treatment System The DBC treatment system is available for licensing. The DBC treatment system is available for clinics specialising in the treatment of musculoskeletal conditions. In addition to the ready-made treatment devices and protocols for using them, DBC International provides DBC clinics with training, manuals, support services as well as management and marketing tools. At the root of DBC treatment protocols is the DBC treatment concept. Its aim is to reduce musculoskeletal pain by restoring the normal function of the afflicted musculoskeletal system. Treatment programmes start with a careful, multidimensional initial assessment of each patient. On the basis of the initial assessment, an individual treatment plan is designed for each patient. The treatment programmes include not only exercise treatment but involve also cognitive and behavioural factors. Treatment takes advantage of special features of DBC equipment. DBC treatment protocols are available for back, neck and shoulder conditions. The treatment methods developed by DBC International are effective, because they rely on methods that have been tested in medical research and clinical practice. DBC Treatment Concept The DBC treatment concept is well suited for all care-giving settings in which treatment and rehabilitation of severe musculoskeletal problems is given a special emphasis. Reflecting the versatility of the DBC system, potential customers of DBC International include Hospital outpatient rehabilitation units Rehabilitation units Physiotherapy centres Occupational health care units Research centres The DBC treatment concept consists of four phases: baseline assessment, design of individual treatment programmes, monitoring of outcomes and maintenance of results. There are specific protocols and devices available for all of the phases that are carried out in the clinic. Initial or baseline assessment forms the basis of treatments given at DBC clinics. The assessment focuses on factors that have been proven to be of relevance in rehabilitation and recovery. The initial assessment is based on a structured interview with the patient and results obtained with specific measurements. The assessment is repeated later during the programme in order to gain insight on the progress of recovery. At the end of the programme an outcome assessment is carried out. Baseline Assessment Forms the basis of individualised treatment plans Produces information on range-of-motion and muscle activity Questionnaires used in the interview provide information on cognitive and behavioural factors that have a bearing on recovery DBC software essential in the design of individualised treatment programmes Progress Assessment Yields feedback on the progress of recovery Measurable improvements are usually gained and motivate patients to continue rehabilitation efforts Information on fatigue, postural control, physical function and pain DBC software essential Outcome Assessment Shows the results of rehabilitation treatment for each patient DBC software also produces aggregated reports on patient outcomes for quality assurance purposes of the clinic management All patient information is treated as highly confidential and is carefully protected
The DBC treatment concept comprises methods and devices used in the various phases of patient assessment, treatment and outcome monitoring. In acute back, neck or shoulder pain it is important to address the cause and ameliorate the distress of musculoskeletal pain by appropriate medication. The length of the pain episode may be reduced and the risk of chronicity reduced if the patient stays active, keeps spirits high and avoids fixing thoughts on pain.
Staying active to the extent possible is important in all musculoskeletal conditions. For instance, in acute low back pain it has been shown that ``…it is reasonable to advise people with acute low back pain and sciatica to stay active``. This recommendation is based on a systematic review of randomised clinical trials in which advice to stay active was compared with advice to rest in bed. The recommendation is based on the potentially harmful effects of bed rest. (Hilde et al. 2001.)
Features of DBC Treatment System
The DBC treatment system is available for licensing. The DBC treatment system is available for clinics specialising in the treatment of musculoskeletal conditions. In addition to the ready-made treatment devices and protocols for using them, DBC International provides DBC clinics with training, manuals, support services as well as management and marketing tools. At the root of DBC treatment protocols is the DBC treatment concept. Its aim is to reduce musculoskeletal pain by restoring the normal function of the afflicted musculoskeletal system.
DBC Treatment Concept
The DBC treatment concept is well suited for all care-giving settings in which treatment and rehabilitation of severe musculoskeletal problems is given a special emphasis. Reflecting the versatility of the DBC system, potential customers of DBC International include
The DBC treatment concept consists of four phases: baseline assessment, design of individual treatment programmes, monitoring of outcomes and maintenance of results. There are specific protocols and devices available for all of the phases that are carried out in the clinic. Initial or baseline assessment forms the basis of treatments given at DBC clinics. The assessment focuses on factors that have been proven to be of relevance in rehabilitation and recovery.
The initial assessment is based on a structured interview with the patient and results obtained with specific measurements. The assessment is repeated later during the programme in order to gain insight on the progress of recovery. At the end of the programme an outcome assessment is carried out.
Baseline Assessment
Progress Assessment
Outcome Assessment
DBC Clinic, Process Documentation, Treatment and Devices
The DBC clinics are supported by special protocols, equipment, software, guidelines and manuals developed by DBC International. Moreover, clinics joining the DBC Network are given training on the application of the DBC treatment protocols, equipment and software. That is why the quality of treatment results at newly started DBC clinics soon reaches that achieved among long-standing clinics. DBC Treatment Programmes In DBC functional restoration programmes, exercises are directed at specific deficits of the ailing musculoskeletal system. Reductions in pain and disability are achieved as improvements are gained in function, control and cognitive behavioural dimension. After a doctor`s examination has ruled out severe specific conditions, each patient is assessed according to a DBC protocol specifically developed for the purpose. Each patient gets a verbal and a written report on the results of the assessment. On the basis of the baseline assessment an individual rehabilitation programme and its targets are set with each patient. Usually the programme lasts 6 or 12 weeks with two weekly treatment sessions. The selection of specific features of the programme is facilitated by DBC software. The exercise sessions are supervised by qualified staff specially trained for the use of the DBC system. DBC training for the staff is essential, since, for instance, the exact position in which exercises are carried has a strong bearing on the efficacy of the treatment. In practice the contents and duration of the programmes vary according to patients` individual needs. DBC Clinic Model Interested clinics can find information about the concrete benefits that are obtained by purchasing a DBC license. The benefits include Process documentation Treatment devices Support functions License and service agreements When planning the transition, the prospective DBC clinic receives all the necessary guidance from DBC International. A turnkey installation of the DBC devices as well as training for doctors and therapists is included in the price of the license. Leading clinics in 22 countries have selected the DBC system because of its capacity to improve productivity and patient outcomes. DBC Process Documentation The process documentation items include everything necessary to manage the DBC clinic and to provide DBC treatments. The main components of the process documentation package are the following: DBC treatment manuals (separately for back, neck and shoulder) explain in detail all of the components of DBC treatments. The manuals provide full descriptions of the treatment concept: various tests, devices, exercises, protocols and explain the basis of related recommendations. DBC patient assessment is based on standardized patient questionnaires and tests yielding information on factors that in medical research and clinical practice have been proven to be of relevance for rehabilitation and recovery. DBC software is a daily tool for therapists and medical doctors. The computer software supports the management of treatment processes at the clinic. It facilitates documentation of treatments and outcomes as well as preparation of reports to interested parties. DBC trademark package includes all of the DBC trademark items, marketing and scientific materials, interior decoration items and additional manuals for managing the clinic. DBC Treatment Devices DBC treatment devices represent a leading edge in the field of musculoskeletal rehabilitation and incorporate exclusive features. The devices support the gradual regaining of correct physiological arcs of movement. Therapeutic exercises are facilitated by correct body positions supported in the DBC devices. A patented hip-lock system allows precise targeting of exercise impacts on the most important muscles in the back. Anatomical cushions complement the ergonomic designs of the equipment. The quality of components used in DBC treatment devices is carefully controlled for patient safety and ease of use. Controllers for range of motion and loading as well as patient supporting mechanisms ensure the safety of patients. Each device can be easily adapted to meet individual requirements, thus reducing further any risk of excessive strain or injury. Light metal and stainless steel components are combined with high-quality bearings to minimize inertia and friction. The devises are intended for sustained use in professional settings with large numbers of patients. The requirements of the therapists are also taken into account. Electronic controls and automatic adjustments contribute to efficient use of therapists` attention. Ease of adaptation is also a safety factor. DBC Measurement Devices Muscle Monitor (EMG) Strength Tester BACK AND CONDITIONING DEVICES: LUMBAR THORACIC EXTENSION, (LATERAL) FLEXION AND ROTATION Lumbar Thoracic Extension Lumbar Thoracic (Lateral) Flexion Lumbar Thoracic Flexion Lumbar Thoracic Rotation Cervical Extension NECK DEVICES: CERVICAL 3-DIMENSIONAL ROTATION AND ELLIPTIC EXTENSION Cervical 3-Dimensional Rotation Cervical Elliptic Extension SHOULDER DEVICE: GLENOHUMERAL ROTATION Glenohumeral Rotation MULTIPURPOSE DEVICES: ABDOMINAL CRUNCH, SHOULDER BLADE ADDUCTION AND HORIZONTAL LEG PRESS Abdominal Crunch Shoulder Blade Adduction Multipurpose Low-Friction Unit Horizontal Leg Press
The DBC clinics are supported by special protocols, equipment, software, guidelines and manuals developed by DBC International. Moreover, clinics joining the DBC Network are given training on the application of the DBC treatment protocols, equipment and software. That is why the quality of treatment results at newly started DBC clinics soon reaches that achieved among long-standing clinics. DBC Treatment Programmes
In DBC functional restoration programmes, exercises are directed at specific deficits of the ailing musculoskeletal system. Reductions in pain and disability are achieved as improvements are gained in function, control and cognitive behavioural dimension. After a doctor`s examination has ruled out severe specific conditions, each patient is assessed according to a DBC protocol specifically developed for the purpose. Each patient gets a verbal and a written report on the results of the assessment.
On the basis of the baseline assessment an individual rehabilitation programme and its targets are set with each patient. Usually the programme lasts 6 or 12 weeks with two weekly treatment sessions. The selection of specific features of the programme is facilitated by DBC software. The exercise sessions are supervised by qualified staff specially trained for the use of the DBC system. DBC training for the staff is essential, since, for instance, the exact position in which exercises are carried has a strong bearing on the efficacy of the treatment. In practice the contents and duration of the programmes vary according to patients` individual needs.
DBC Clinic Model
Interested clinics can find information about the concrete benefits that are obtained by purchasing a DBC license. The benefits include
When planning the transition, the prospective DBC clinic receives all the necessary guidance from DBC International. A turnkey installation of the DBC devices as well as training for doctors and therapists is included in the price of the license. Leading clinics in 22 countries have selected the DBC system because of its capacity to improve productivity and patient outcomes.
DBC Process Documentation
DBC Treatment Devices
DBC treatment devices represent a leading edge in the field of musculoskeletal rehabilitation and incorporate exclusive features. The devices support the gradual regaining of correct physiological arcs of movement. Therapeutic exercises are facilitated by correct body positions supported in the DBC devices. A patented hip-lock system allows precise targeting of exercise impacts on the most important muscles in the back. Anatomical cushions complement the ergonomic designs of the equipment.
The quality of components used in DBC treatment devices is carefully controlled for patient safety and ease of use. Controllers for range of motion and loading as well as patient supporting mechanisms ensure the safety of patients. Each device can be easily adapted to meet individual requirements, thus reducing further any risk of excessive strain or injury. Light metal and stainless steel components are combined with high-quality bearings to minimize inertia and friction. The devises are intended for sustained use in professional settings with large numbers of patients.
The requirements of the therapists are also taken into account. Electronic controls and automatic adjustments contribute to efficient use of therapists` attention. Ease of adaptation is also a safety factor.
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