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.
