O papel da atividade física como fator prognóstico e tratamento no contexto da dor musculoesquelética
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Data
2020-07-10
Autores
Oliveira, Crystian Bitencourt Soares de [UNESP]
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
A dor musculoesquelética é uma condição prevalente, responsável por altos custos para os indivíduos e sistemas de saúde de todo mundo. Dentre as condições existentes, a dor lombar destaca-se por ser uma das condições musculoesqueléticas mais prevalentes e por liderar o ranking de anos vividos com incapacidade no Brasil e no mundo. Apesar dos tratamentos a base de atividade física serem consistentemente recomendados para o tratamento da dor musculoesquelética, existem limitadas evidências investigando a influência da atividade física e de comorbidades possivelmente relacionadas a prática insuficiente de atividade física em pessoas com dor crônica musculoesquelética. Portanto, essa tese possui o objetivo de entender melhor a relação da atividade física e de fatores relacionados a prática insuficiente de atividade física na dor musculoesquelética, incluindo dor lombar. O objetivo do capítulo 2 desta tese foi conduzir uma revisão sistemática para investigar o papel prognóstico da atividade física no curso da dor lombar. Identificar fatores que influenciam o curso da dor lombar é importante para ajudar clínicos a identificarem aqueles pacientes com alto risco de não se recuperarem. Os estudos identificados foram heterogêneos em termos de avaliação da atividade física, resultados, duração do acompanhamento e métodos estatísticos. Nossa revisão encontrou evidências limitadas para apoiar o papel prognóstico da atividade física no curso da dor lombar. Do ponto de vista da atenção primária, a coexistência de dor musculoesquelética crônica e doenças cardiovasculares revelaria a necessidade de desenvolver novas estratégias de prevenção e tratamento que abordem doenças cardiovasculares e fatores de risco associados, além de reduzir a dor e a incapacidade. No capítulo 3 desta tese investigou-se a magnitude da associação entre doença cardiovascular e dor musculoesquelética crônica. Nós encontramos evidências de alta qualidade de que as pessoas com dor musculoesquelética crônica têm 1,91 vezes mais chances de relatar uma doença cardiovascular em comparação com aquelas sem dor musculoesquelética crônica (razão de risco: 1,91, Intervalo de Confiança de 95%: 1,64 a 2,21). Portanto, nossos achados demonstraram associações entre dor musculoesquelética crônica e quaisquer doenças cardiovasculares. Desde 2001, revisões comparando diretrizes de práticas clínicas para o manejo de pacientes com dor lombar não específica têm sido conduzidas com o objetivo de apontar as mensagens com consenso e as diferenças entre as diretrizes da prática clínica. Portanto, o objetivo capítulo 4 foi atualizar a ultima versão destas revisões publicada em 2011 investigando as recomendações relativas ao diagnóstico e tratamento de pacientes com dor lombar não específica para na atenção primária. Para diagnóstico da dor lombar não específica, as diretrizes da prática clínica recomendam coletar a história clínica e o exame físico, identificar bandeiras vermelhas, testes neurológicos para identificar a síndrome radicular, uso de imagens em caso de suspeita de patologias sérias e avaliação de fatores psicossociais. Para o tratamento de pacientes com dor lombar aguda, as diretrizes recomendam assegurar quanto ao prognóstico favorável e aconselhar sobre o retorno às atividades normais, evitar repouso no leito, uso de anti-inflamatórios não esteróides e opióides fracos por curtos períodos. Para tratamento de pacientes com dor lombar crônica, as diretrizes recomendam o uso de antiinflamatórios não esteróides e antidepressivos, terapia por exercício e intervenções psicossociais. Além disso, o encaminhamento a um especialista é recomendado em caso de suspeita de patologias específicas ou radiculopatia ou se não houver melhora após 4 semanas. Apesar de intervenções a base de atividade física serem recomendadas para tratamento da dor crônica musculoesquelética, ainda é incerto os efeitos das intervenções de atividade física nos níveis de atividade física auferidos objetivamente em pacientes com dor musculoesquelética crônica (por exemplo, osteoartrite, dor lombar) em comparação com nenhuma / mínima intervenção. Portanto, no capítulo 5 foi realizada uma revisão sistemática com meta-análise, a qual identificou baixa qualidade da evidência sugerindo que estas intervenções podem levar a pouca ou nenhuma diferença mediram os níveis de atividade física de pacientes com dor musculoesquelética crônica em comparação com nenhuma / mínimas intervenções. Além dos efeitos no nível de atividade física, também não se sabe os efeitos de tratamento de intervenções baseadas em atividade física usando feedback eletrônico em pacientes com dor crônica musculoesquelética. Por meio de revisão sistemática, no capítulo 6 foram identificados apenas quatro ensaios clínicos randomizados publicados e quatro ensaios clínicos randomizados não publicados registrados foram incluídos. Nossos resultados sugerem que intervenções baseadas em atividade física usando feedback eletrônico podem ser ineficazes na redução da dor e incapacidade em comparação com intervenções mínimas em pacientes com dor musculoesquelética crônica. Após extensa investigação da literatura disponível, observou-se que o efeito de terapias a base de exercício na dor e na incapacidade é, na melhor das hipóteses, moderado e não sustentado ao longo do tempo. Uma das razões pode estar relacionada a limitação dos atuais programas de exercícios para dor lombar crônica de não serem projetados para mudar o comportamento dos pacientes para um estilo de vida ativo. Portanto, nos capítulos 7 e 8 desta tese foi investigado a eficácia, a curto e longo prazo, da adição do coaching em saúde e uso de um monitor de atividades (isto é, Fitbit Flex) aos exercícios supervisionados em comparação com um grupo recebendo apenas exercícios supervisionados, nos níveis de atividade, intensidade da dor e incapacidade de pacientes com dor lombar crônica não-específica. Os desfechos clínicos foram analisados por avaliadores cegos antes da intervenção, 3, 6 e 12 meses após a randomização. Os desfechos primários foram atividade física, medida objetivamente com um acelerômetro, bem como intensidade e incapacidade da dor aos 3 meses após a randomização. Um total de 160 adultos com dor lombar crônica foram aleatoriamente distribuídos nos dois grupos. Em relação as avaliações autorrelatadas, 139 (87%) pacientes completaram a avaliação de três meses, 107 (67%) completaram a avaliação de seis meses e 111 (69%) completaram a avaliação de 12 meses. Nas avaliações utilizando o acelerômetro, houveram grandes perdas nos acompanhamentos e, por isso, optou-se por reportar apenas os resultados dos desfechos autorrelatados. Não houve nenhuma diferença entre grupos nas avaliações de 3, 6, e 12 meses para nenhum dos desfechos primários, assim como, para nenhum dos desfechos secundários. A adição do coaching de saúde aos exercícios supervisionados não foi capaz de reduzir a intensidade dor de incapacidade de pacientes com dor lombar crônica quando comparado ao grupo placebo.
Musculoskeletal pain is a prevalent condition responsible to high costs for the individuals and health care systems worldwide. Among the existent conditions, low back pain stands out for being one of the most prevalent musculoskeletal conditions and for leading the ranking of years lived with disability in Brazil and worldwide. Although physical activity-based treatments have been consistently recommended for treatment of musculoskeletal pain, there is limited evidence around the influence of physical activity and comorbidities due to the lack of physical activity in people with musculoskeletal pain. Therefore, this thesis aims to investigate the relationship between physical activity and factors related to the lack of physical activity with musculoskeletal pain, including low back pain. The objective of chapter 2 of this thesis was to conduct a systematic review to investigate the prognostic role of physical activity in the course of low back pain. Identifying factors that influence the course of low back pain is important to help clinicians to identify those patients at higher risk of non‐recovery. Included studies were heterogeneous in terms of physical activity assessment, outcomes, follow‐up duration, and statistical methods, therefore, pooling of results was not performed. Our review identified limited evidence supporting physical activity as a prognostic factor in low back pain. From a primary care perspective, the co-occurrence of chronic musculoskeletal pain and cardiovascular diseases would reveal a need to develop new preventive and treatment strategies that address cardiovascular diseases and associated risk factors in addition to reducing pain and disability. In chapter 3 of this thesis, we investigated the magnitude of the association between cardiovascular disease and chronic musculoskeletal pain. We found high-quality evidence that people with chronic musculoskeletal pain are 1.91 times more likely to report having a cardiovascular disease compared with those without chronic musculoskeletal pain (risk ratio = 1.91; 95% confidence interval: 1.64–2.21). Our findings demonstrated associations between chronic musculoskeletal pain and any cardiovascular diseases. Since 2001, overviews comparing clinical practice guidelines for the management of patients with non-specific LBP in primary care settings have been conducted with the objective of summarising the consensus messages and differences between clinical practice guidelines. Therefore, the aim of chapter 4 was to update the last version of the overview published in 2011 investigating the recommendations regarding the diagnosis and treatment contained in current clinical practice guidelines for patients with non-specific low back pain in primary care. For diagnosis of patients with non-specific low back pain, the clinical practice guidelines recommend history taking and physical examination to identify red flags, neurological testing to identify radicular syndrome, use of imaging if serious pathology is suspected (but discourage routine use), and assessment of psychosocial factors. For the treatment of patients with acute low back pain, the guidelines recommend reassurance on the favourable prognosis and advice on returning to normal activities, avoiding bed rest, the use of nonsteroidal anti-inflammatory drugs and weak opioids for short periods. For the treatment of patients with chronic low back pain, the guidelines recommend the use of nonsteroidal anti-inflammatory drugs and antidepressants, exercise therapy, and psychosocial interventions. In addition, referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks. Although the efficacy of physical activity-based interventions in reducing pain and disability is well recognised, it is still uncertain the effects of physical activity interventions increase objectively measured physical activity levels of patients with chronic musculoskeletal pain (e.g., osteoarthritis, low back pain) compared to no/minimal intervention. Therefore, in chapter 5, a systematic review with meta-analysis was performed which identified low quality of evidence suggesting that these interventions may lead to little or no difference in objectively measured physical activity levels of patients with chronic musculoskeletal pain compared with no/minimal interventions. Besides of the effects on physical activity levels, it’s also uncertain the effects of physical activity-based interventions using electronic feedback in reducing pain and disability compared to minimal or no interventions in patients with chronic musculoskeletal pain. In another systematic review reported in chapter 6, we identified only four published randomized controlled trials and 4 registered unpublished randomized controlled trials were included. Our results suggest that physical activity-based interventions using electronic feedback may be ineffective in reducing pain and disability compared to minimal interventions in patients with chronic musculoskeletal pain. After an extensive review of the available literature, we found that the effect of treatments using exercise therapy on pain and disability are at best moderate and not sustained over time. One of the reasons can be related to the limitation of current exercises programmes for chronic LBP is that these programmes are not designed to change patients’ behaviour toward an active lifestyle. Therefore, in the chapters 7 and 8 of this thesis, we investigated the short- and longterm efficacy of the addition of health coaching and the use of an activity monitor (i.e. Fitbit Flex) to the supervised exercises compared to a group receiving only supervised exercises on physical activity levels, pain intensity and disability, in patients with chronic, nonspecific LBP. Outcome measures were analysed by blinded assessors at baseline and 3, 6 and 12 months postrandomisation. The primary outcomes were physical activity, measured objectively with an accelerometer measured 3 months post-randomisation as well as pain intensity and disability at 3 months post randomisation. One hundred and sixty adults with chronic, nonspecific LBP were recruited and randomly allocated into two groups. Regarding the self-reported assessments, 139 (87%) participants completed the 3-month follow-up assessment, 107 (67%) participants completed the 6-month follow-up assessment e 111 (69%) participants completed the 12-month follow-up assessment. In the assessments using the accelerometer, there were a high proportion of invalid data at follow-up assessments and, therefore, we reported only the results for the self-reported outcomes. There were no differences between groups in the 3, 6 and 12 months follow-up for any primary or secondary outcome. The addition of health coaching to the supervised exercises was not able to reduce pain intensity and disability levels of patients with chronic low back pain when compared to the placebo group.
Musculoskeletal pain is a prevalent condition responsible to high costs for the individuals and health care systems worldwide. Among the existent conditions, low back pain stands out for being one of the most prevalent musculoskeletal conditions and for leading the ranking of years lived with disability in Brazil and worldwide. Although physical activity-based treatments have been consistently recommended for treatment of musculoskeletal pain, there is limited evidence around the influence of physical activity and comorbidities due to the lack of physical activity in people with musculoskeletal pain. Therefore, this thesis aims to investigate the relationship between physical activity and factors related to the lack of physical activity with musculoskeletal pain, including low back pain. The objective of chapter 2 of this thesis was to conduct a systematic review to investigate the prognostic role of physical activity in the course of low back pain. Identifying factors that influence the course of low back pain is important to help clinicians to identify those patients at higher risk of non‐recovery. Included studies were heterogeneous in terms of physical activity assessment, outcomes, follow‐up duration, and statistical methods, therefore, pooling of results was not performed. Our review identified limited evidence supporting physical activity as a prognostic factor in low back pain. From a primary care perspective, the co-occurrence of chronic musculoskeletal pain and cardiovascular diseases would reveal a need to develop new preventive and treatment strategies that address cardiovascular diseases and associated risk factors in addition to reducing pain and disability. In chapter 3 of this thesis, we investigated the magnitude of the association between cardiovascular disease and chronic musculoskeletal pain. We found high-quality evidence that people with chronic musculoskeletal pain are 1.91 times more likely to report having a cardiovascular disease compared with those without chronic musculoskeletal pain (risk ratio = 1.91; 95% confidence interval: 1.64–2.21). Our findings demonstrated associations between chronic musculoskeletal pain and any cardiovascular diseases. Since 2001, overviews comparing clinical practice guidelines for the management of patients with non-specific LBP in primary care settings have been conducted with the objective of summarising the consensus messages and differences between clinical practice guidelines. Therefore, the aim of chapter 4 was to update the last version of the overview published in 2011 investigating the recommendations regarding the diagnosis and treatment contained in current clinical practice guidelines for patients with non-specific low back pain in primary care. For diagnosis of patients with non-specific low back pain, the clinical practice guidelines recommend history taking and physical examination to identify red flags, neurological testing to identify radicular syndrome, use of imaging if serious pathology is suspected (but discourage routine use), and assessment of psychosocial factors. For the treatment of patients with acute low back pain, the guidelines recommend reassurance on the favourable prognosis and advice on returning to normal activities, avoiding bed rest, the use of nonsteroidal anti-inflammatory drugs and weak opioids for short periods. For the treatment of patients with chronic low back pain, the guidelines recommend the use of nonsteroidal anti-inflammatory drugs and antidepressants, exercise therapy, and psychosocial interventions. In addition, referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks. Although the efficacy of physical activity-based interventions in reducing pain and disability is well recognised, it is still uncertain the effects of physical activity interventions increase objectively measured physical activity levels of patients with chronic musculoskeletal pain (e.g., osteoarthritis, low back pain) compared to no/minimal intervention. Therefore, in chapter 5, a systematic review with meta-analysis was performed which identified low quality of evidence suggesting that these interventions may lead to little or no difference in objectively measured physical activity levels of patients with chronic musculoskeletal pain compared with no/minimal interventions. Besides of the effects on physical activity levels, it’s also uncertain the effects of physical activity-based interventions using electronic feedback in reducing pain and disability compared to minimal or no interventions in patients with chronic musculoskeletal pain. In another systematic review reported in chapter 6, we identified only four published randomized controlled trials and 4 registered unpublished randomized controlled trials were included. Our results suggest that physical activity-based interventions using electronic feedback may be ineffective in reducing pain and disability compared to minimal interventions in patients with chronic musculoskeletal pain. After an extensive review of the available literature, we found that the effect of treatments using exercise therapy on pain and disability are at best moderate and not sustained over time. One of the reasons can be related to the limitation of current exercises programmes for chronic LBP is that these programmes are not designed to change patients’ behaviour toward an active lifestyle. Therefore, in the chapters 7 and 8 of this thesis, we investigated the short- and longterm efficacy of the addition of health coaching and the use of an activity monitor (i.e. Fitbit Flex) to the supervised exercises compared to a group receiving only supervised exercises on physical activity levels, pain intensity and disability, in patients with chronic, nonspecific LBP. Outcome measures were analysed by blinded assessors at baseline and 3, 6 and 12 months postrandomisation. The primary outcomes were physical activity, measured objectively with an accelerometer measured 3 months post-randomisation as well as pain intensity and disability at 3 months post randomisation. One hundred and sixty adults with chronic, nonspecific LBP were recruited and randomly allocated into two groups. Regarding the self-reported assessments, 139 (87%) participants completed the 3-month follow-up assessment, 107 (67%) participants completed the 6-month follow-up assessment e 111 (69%) participants completed the 12-month follow-up assessment. In the assessments using the accelerometer, there were a high proportion of invalid data at follow-up assessments and, therefore, we reported only the results for the self-reported outcomes. There were no differences between groups in the 3, 6 and 12 months follow-up for any primary or secondary outcome. The addition of health coaching to the supervised exercises was not able to reduce pain intensity and disability levels of patients with chronic low back pain when compared to the placebo group.
Descrição
Palavras-chave
Atividade física, Dor musculoesquelética, Dor lombar, Doenças cardiovasculares, Acelerometria, Physical activity, Musculoskeletal pain, Low back pain, Cardiovascular diseases, Accelerometry