FOR LOW BACK PAIN : A PROPOSAL FOR CLINICAL USE

Low back pain represents a serious public health problem. Therefore, great efforts have been made in order to improve and assess the efficacy of its treatment. Reports in international literature have presented important studies concerning instruments to assess pain and functional incapacity in patients with low back pain. This study presents a clinical protocol which was developed by a multidisciplinary team. This protocol consists of the evaluation and distribution of pain, The Spitzer Quality of Life, The Oswestry Low Back Pain Disability Questionnaire, and The Center for Epidemiological Studies Depression Scale. Instruments must be urgently developed or adapted in order to be used according to the Brazilian reality.

Los dolores de espalda, en particular las lumbalgias, representan un gran problema en términos de salud pública.Así, grandes esfuerzos han sido hacia la evaluación y el mejoramiento de la eficacia de su tratamiento.La literatura internacional ha presentado importantes estudios sobre instrumentos para evaluar el dolor y la incapacidad funcional en pacientes con dolor lumbar.El presente estudio presenta un protocolo clínico desarrollado por un equipo multidisciplinario.Este protocolo es compuesto por la evaluación y distribución del dolor, The Spitzer Quality of Life, The Oswestry Questionnaire, y The Center for Epemidiologic Studies Depression Scale.Necesitamos con urgencia desarrollar o realizar adaptaciones de instrumentos para ser utilizados en la realidad brasileña.

INTRODUCTION
Musculoskeletal disorders, especially back pain, are an important public health problem with a substantial effect on health care utilization and costs, and are the most frequent cause of activity limitation in people below age 45 (1-7)   .Therefore, general aspects of the back pain treatment such as treatment response, rehabilitation, outcome, disability and compliance have been studied for several researches (8-14)   .
Great efforts have been made to improve and evaluate the treatment of low back pain.Because the low back pain assessment is complex, the effectiveness of treatment may be evaluated by measures of disability, severity, and frequency of symptoms (15) .Reports in the literature has presented relevant studies and measurements in low back pain related with pain assessment, functional status, work disability and quality of life (16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26) .
The current study presents the data routinely collected as part of the Model Clinic for Occupational Musculoskeletal Disorders (6,27)   .A standard clinical protocol was developed by clinicians and researchers from the Occupational and Industrial Orthopaedics Center (OIOC), Hospital for Joint Disease, Mt Sinai NYU Health, in New York City.The OIOC Model Clinic Team is an interdisciplinary group that established a Model Clinic for the treatment of low back pain and the prevention of chronic disability.The theory underlying the model is that standard practice guidelines for evaluation and treatment of low back pain can reduce morbidity, suffering and cost (6) .
The purpose of the present study is to presents a standardized set of instruments that is part of a Model Clinic.

PROPOSED INSTRUMENTS
Patients visiting the OIOC for low back pain are requested to complete self-administered questionnaires at the time of their initial and final evaluation.These questionnaires describe intensity and distribution of pain, quality of life, functional disabilities and depression.
Instruments were chosen for their face validity, reliability, and for their time consuming.They also sampled all aspects of low back pain.The low back pain is understood from a biopsychosocial perspective.One study (28) has described that psychosocial factors are at least as important and often more important than physical factors in determining pain and disability.

Intensity and Distribution of Pain:
Pain intensity is measured by a numerical rating scale (0 -100) with 0 indicating no pain and 100 indicating worst pain imaginable (29) .The spatial distribution of the pain is demonstrated by drawings of the body (30)(31) .

Quality of Life:
The Spitzer Quality of Life Index is used to measure the patient's perception of their quality of life.It was intended as a brief instrument for evaluating the effects of treatment and programs (32) .In the index, quality of life was conceptualized as a construct with several difficult dimensions: day-to-day activity patterns, self care capabilities, general health, outlook on life and support of family and friends (33)   .The index is comprised of five items with three point responses, each scored on a 0, 1, and 2 point scale giving a summated maximum possible score of 10.The index has been used successfully to measure the general well-being of patients with cancer and other diseases, and has been well validated (32)(33) .
Perceived Functional Disability: The patient's perceived functional limitation is measured by the Oswestry scale (34) .This questionnaire includes ten six-point scales.
The first scale evaluates the intensity of pain and the remaining nine cover the disabling effect of pain on typical daily activities: personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and travelling (32) .back pain and has high reliability (R= 0.99) (6,34) .

All items of the
Depression: Depression is assessed by using the Center for Epidemiologic Studies Depression Scale -(CES-D) (35)  the National Institute of Mental Health and tested as a measure of depressive symptomatology for use in studies of the general population.Each response is scored from 0 to 3 on a scale of the frequency of the occurrence of the symptom.For four questions (4, 8, 12, and 16), the scores are reversed.The possible range of scores is 0 to 60, with the higher scores indicating more symptoms, weigthed by the frequency of occurrence during the past week.A CES-D score of 16 or higher is used as a screening criterion for depressive symptoms.Studies indicated that the scales is internally consistent, has an acceptable test-retest reliability, and has high construct validity (36)(37)(38) .

CONCLUSION
There are several advantages to the use of a standardized clinical protocol for low back pain treatment.
In order to have a valid assessment of treatment impact, it is relevant to use instruments with adequate measurements characteristics.They need evaluate all dimensions of the low back pain treatment.The adoption of these measures will help in the exchange of information among the scientific community.Standardized measurements of outcomes would also facilitate scientific advances in clinical and research practice.
Oswestry, excluding questions about sexual activity, are used in calculating a total score.The overall Oswestry score is obtained by scaling the sum of the component scores on an ordinal scale from 0 to 100, with the results interpreted as follows: scores from 0 to 20 represents minimal disability, 20 to 40 represent moderate disability, 40 to 60 represents severe disability, and scores of 60 and above indicates that the patient is severely disabled by pain in several areas of life.The Oswestry scale has been validated for use with patients with low As dores nas costas, particularmente as lombalgias representam um grande problema em termos de saúde pública.Dessa forma, grandes esforços têm sido dirigidos para melhorar e avaliar a eficácia de seu tratamento.A literatura internacional tem apresentado importantes estudos sobre instrumentos para avaliar a dor e a incapacidade funcional em pacientes com dor lombar.O presente estudo apresenta um protocolo clínico desenvolvido por uma equipe multidisciplinar.Este protocolo é composto pela avaliação e distribuição da dor, The Spitzer Quality of Life, The Oswestry Low Back Pain Disability Questionnaire, and The Center for Epidemiologic Studies Depression Scale.Precisamos com urgência desenvolver ou realizar instrumentos para serem utilizados na realidade brasileira.