Lumarjaja

06-‐08-‐19
Enfoque
Biopsicosocial
del Dolor
Lumbar
Klgo. E. Nicolás Sepúlveda
Especialista en Traumatología y Ortopedia
DENAKE
Objetivos
•  Analizar el modelo biopsicosocial en el contexto clínico

•  Conocer estrategias de examinación psicológicamente
informadas
•  Conocer estrategias para adaptar nuestras intervenciones de
acuerdo a los resultados de la evaluación
1
This is a weakness as domains can feasibly
0 years on. Which way is the be interpreted as interventional models.4
endulum swinging? WHICH WAY IS THE PENDULUM

SWINGING? 06-‐08-‐19
endolen Jull It could be expected that in 40 years,
there would have been widespread adop-
tion and implementation of the biopsy-
biopsychosocial model came to progresses through the course of the dis- chosocial model, given its rapid initial
minence in 1977 when it was intro- order. The model provides a background adoption and the enthusiasm with which
d by Engel1 who argued against the philosophy to holistic evaluation, but it was greeted especially in the chronic
ctionist biomedical model of disease there is no assumption of proportional musculoskeletal pain field. Yet despite this
for concomitant consideration of Modelo Biopsicosocial como respuesta al modelo
representation of domains. Failure to rec- history, the pendulum is continuing to
vioural, psychological and social ognise this ‘fluidity’ in the model lessens swing!
nsions in understanding a person’s biomédico
the appreciation of the variety within, the In some quarters, the pendulum
cal condition. This conceptual model associations between and relative import- appears to have swung back to the bio-
initially proposed within the field of ance
•  La ofpresencia
each domain de un intrastorno
the individual biológico no model. For instance, there has
logical
hiatry, but it quickly expanded to patient at initial and progressive
aclara el significado de los síntomas time been criticism of interventional pain
r fields of medicine. In 1987, points which could negatively impact on medicine for its departure from the prem-
dell2 proposed a new conceptual •  Las variables psicosociales son más ises of a biopsychosocial model back to a
management.
el for the treatment of chronic low The importantes
biopsychosocial en la suscepXbilidad,
model is verygravedad narrow focus on nociception as a sole
pain, which encompassed the biopsy- broad, whichdis
y curso e laa major limitation.
enfermedad que It doeslo que target
se creía
of pain treatment without any due
ocial framework and brought it into not guide, recommend or restrict which regard and consideration of pain-related
phere of musculoskeletal disorders. •  El éxito
features should de los betratamientos
evaluated in biológicos está
any psychological factors.5 In other quarters,
w would question the merits of the domain. influenciado
The clinician por factores
is free to psicosociales
choose the pendulum has swung in the opposite
el as it is unreasonable to separate the from a variety of potential tests, so direction away from the biological
on and their personal circumstances •  La relación
approaches to ppatient
aciente-‐clínico
evaluation influye
risk en los to focus on psychosocial domains
domain
their medical condition and to resultados
reflecting the professional médicos or attitudinal with behavioural treatments being the sole
rd physical and psychosocial compo- bias of the clinician. Neither does the intervention.6 Yet chronic conditions are
s as independent entities. The model model inform on how one domain may or not always automatically accompanied by
relevance for all musculoskeletal pain may not influence or interact with dominant adverse psychosocial features,7
s, acute or chronic, but it has been another domain. and peripheral nociception and inflamma-
widely advocated in chronic pain The model has underpinned the growth tion continue to play a role in many
ders.3 It has wide perspectives and of multidisciplinary rehabilitation pro- chronic pain conditions.
motes consideration and evaluation of The need for
grammes a new medical but
especially, model: not
a challenge for biomedicine. Engel GL Science. 1977 Apr 8; 196(4286):129-‐36
exclusively In recent decades, there has been an
otential biological, psychological and for, chronic low back pain and with some explosion of knowledge in pain neurosci-
l determinants of a patient’s success. Such programmes target features ence. From the simple Descartes’ pain
entation. from the three different domains and are pathway, there is ever increasing knowl-
usually delivered by a multidisciplinary edge about central neural mechanisms to
W IS THE MODEL JOURNEYING team of health professionals. Even though understand the patient’s pain experience.
E 40 YEARS ON, IN ITS it has been used to support these pro- This has led some researchers and clini-
RPRETATION AND USE? grammes, the biopsychosocial model does cians to focus treatment strategies on
biopsychosocial model is often pre- not provide any specific guidance to what central nervous system processes. For
ed graphically as three symmetrical
es which can mislead clinical reason-
Such diagrams suggest ‘equal’ contri-
ons of the three broad domains in
y person’s clinical presentation at all
s. This is far from reality. Rather, the
ance and contribution of each
ain can vary greatly among patient
entations (figure 1). Likewise each
ain’s relevance and contribution will
likely change as the patient
spondence to Professor Gwendolen Jull,

tment of Physiotherapy, School of Health and
ilitation Sciences, The University of Queensland, Figure 1 The relative contributions of each domain of the biopsychosocial model to patients’
a Campus, Brisbane, QLD 4072, Australia; Paciente
presentations 1
are neither predetermined Paciente 2 their relevance and contribution
nor static and Paciente 3 vary
@uq.edu.au between patients.
Jull G. Biopsychosocial model of disease: 40 years on. Which way is the pendulum swinging? Br J Sports Med August 2017. 51(16)
2
rd physical and psychosocial compo- bias of the clinician. Neither does the intervention. Yet chronic conditions are
s as independent entities. The model model inform on how one domain may or not always automatically accompanied by
relevance for all musculoskeletal pain may not influence or interact with dominant adverse psychosocial features,7
s, acute or chronic, but it has been another domain. and peripheral nociception and inflamma-
widely advocated in chronic pain The model has underpinned the growth tion continue to play a role in many
ders.3 It has wide perspectives and of multidisciplinary rehabilitation pro- chronic pain conditions. 06-‐08-‐19
motes consideration and evaluation of grammes especially, but not exclusively In recent decades, there has been an
otential biological, psychological and for, chronic low back pain and with some explosion of knowledge in pain neurosci-
l determinants of a patient’s success. Such programmes target features ence. From the simple Descartes’ pain
entation. from the three different domains and are pathway, there is ever increasing knowl-
usually delivered by a multidisciplinary edge about central neural mechanisms to
W IS THE MODEL JOURNEYING team of health professionals. Even though understand the patient’s pain experience.
E 40 YEARS ON, IN ITS it has been used to support these pro- This has led some researchers and clini-
RPRETATION AND USE? grammes, the biopsychosocial model does cians to focus treatment strategies on
biopsychosocial model is often pre- not provide any specific guidance to what central nervous system processes. For
ed graphically as three symmetrical
es which can mislead clinical reason-
Such diagrams suggest ‘equal’ contri-
ons of the three broad domains in
y person’s clinical presentation at all
s. This is far from reality. Rather, the
ance and contribution of each
ain can vary greatly among patient
entations (figure 1). Likewise each
ain’s relevance and contribution will
likely change as the patient
spondence to Professor Gwendolen Jull, Paciente 1 Paciente 1 Paciente 1

tment of Physiotherapy, School of Health and
ilitation Sciences, The University of Queensland, Figure 1 The relative contributions of each domain of the biopsychosocial model to patients’
a Campus, Brisbane, QLD 4072, Australia; presentations are neither predetermined nor static and their relevance and contribution vary
@uq.edu.au between patients.
Jull G. Biopsychosocial model of disease: 40 years on. Which way is the pendulum swinging? Br J Sports Med
August 2017. 51(16)
¿Qué dicen las guías clínicas?
3
06-‐08-‐19
¿Qué dicen las Guías Clínicas en DL?

•  Se revisaron guías clínicas publicadas
entre 2008 y 2017
•  Dentro de las diferencias más
importantes estaban:
–  evaluación de factores psicosociales
–  uso de paracetamol (8 a favor y 5 contra),
relajantes musc (6 favor y 5 contra)
–  gran info sobre disXntas formas de ejercicios
(alta variabilidad)
Oliveira CB et al. Clinical pracXce guidelines for the management of non-‐specific low back pain in primary care: an updated
overview. Eur Spine J. 2018
4
06-‐08-‐19
¿Qué dicen las Guías Clínicas en DL?

Los factores psicosociales que más se
recomendaron evaluar (67% de las
guías) fueron:
•  Creencia de que el dolor y la acXvidad
pueden ser peligrosos
•  Preferencias de tratamiento que no son
recomendadas por las mejores prácXcas
•  Falta de apoyo social
Oliveira CB et al. Clinical pracXce guidelines for the management of non-‐specific low back pain in primary care: an updated
overview. Eur Spine J. 2018
¿Tiene alguna ventaja seguir las guías?
•  La mayoría de los estudios

publicados a la fecha muestra
diferencias entre 1-‐2 sesiones de
KNT entre quienes siguen v/s no
siguen las guías
•  En relación a los costos la tendencia
es una leve tendencia a un menor
gasto en KNT
Hanney WJ, Masaracchio M, Liu X, Kolber MJ (2016) The Influence of Physical Therapy Guideline Adherence on Healthcare UXlizaXon and Costs
among PaXents with Low Back Pain: A SystemaXc Review of the Literature. PLOS ONE 11(6): e0156799.
hmps://journals.plos.org/plosone/arXcle?id=10.1371/journal.pone.0156799
5
06-‐08-‐19
Adherencia de los kinesiólogos a las Guías

Clínicas
•  61 kinesiólogos
•  145 pacientes
Objs de
•  Dutch physical therapy and manual examinación
therapy guidelines for low back pain
Examinación
Plan de tto

Adherencia 67.2%
Geert M.R, et al. Adherence to Clinical PracXce Guidelines for Low Back Pain in Physical Therapy: Do PaXents Benefit?, Physical
Therapy, Volume 90, Issue 8, 1 August 2010
Adherencia de los kinesiólogos a las Guías

Clínicas
•  189 kinesiólogos
•  6 casos clínicos
•  Hubo mayor idenXficación de banderas
amarillas que de banderas rojas
Adherencia completa 5-24%

Adherencia parcial 32-75%
de Souza FS. et al. Adherence to Back Pain Clinical PracXce Guidelines by Brazilian Physical Therapists: A Cross-‐secXonal Study.
Spine (Phila Pa 1976). 2017
6
06-‐08-‐19
OK, reconocemos las banderas.. ¿y ahora

qué?
•  Enviaron viñetas a 518 kinesiólogos UK
•  3 casos con disXntos riesgos
•  OBJ: determinar la capacidad de evaluar el riesgo de discapacidad
Physical Therapists in UK • Bishop and Foster 1317
Table 1. ALBPSQ Scores, Expert Agreement, and Risk Rating of the Patient Vignettes
No. of Experts
ALBPSQ Agreeing With Chronicity Risk Relative % of Respondents Agreeing
Vignette Score ALBPSQ Risk (n ! 6) to the Other Patients With ALBPSQ Risk
1 112 4 Moderate 25.4

2 102 4 Low 56.6
3 139 6 High 89.1
found a persistence of a biomedical model in the practice to physical therapy. As a result, a cutoff point for poor outcome
of many physical therapists.23,24 of 112, described by Hurley et al28 was used to categorise the
Available practice guidelines recommend clinical as- patients in this study. Three patients were chosen for the vi-
sessment to identify psychosocial factors in the first in- gnettes, one patient each at low and high risk and one patient
with a borderline score.
stance, with the use of validated questionnaires being
Bishop A, Foster NE. Do physical therapists in the United kingdom recognize
In pline
sychosocial factors in paXents 29
with recommendations, with
–31acute low back
the vignettes were
reserved for patients who do
pain? Spine (Phila Pa 1976). 213,15 not
005 make adequate progress tested by a panel of U.K. experts (identified through publica-
after initial intervention, as these can be unwieldy tion history or clinical expertise, by the authors) (n ! 6), to
and time-consuming and are not commonly used by ensure the vignettes were realistic and to test that they demon-
physical therapists, particularly in acute patients or in strated examples of patients at low, moderate, and high risk of
primary care situations.22,25,26 chronicity. The experts consisted of one consultant physical
The current study aimed to investigate if physical ther- therapist, one senior physical therapy clinician, and four mus-
apists working in the musculoskeletal field, in the United culoskeletal researchers (three physical therapists and one os-
Kingdom, can identify patients with acute LBP at risk of teopath). The cutoff scores, expert agreement, and risk rating of
developing chronicity from psychosocial factors in com- the patients and the percentage of respondents agreeing with
mon clinical scenarios. Second, the study aimed to ex- the ALBPSQ risk are summarized in Table 1. Of the six experts,
OK, reconocemos las banderas.. ¿y ahora

two commented that Patient 1 had more psychosocial risk fac-
plore whether the advice that physical therapists provide
tors and Patient 2 had more physical risk factors. As a result,
to acute LBP patients related to work and activity is some minor modifications were made to the low-risk patient
qué?
consistent with current published best evidence guide-
lines.
vignette (Patient 2) to reduce the physical risk factors, in order
to aid differentiation with the borderline risk case (Patient 1).
Materials and Methods The vignettes were then incorporated into a postal, self-
Physical Therapists in UK • Bishop
completed and Foster
questionnaire, which1319
sought demographic details of
The design was a cross-sectional, descriptive survey of clini- the respondents and responses to questions about the patient
cally active physical therapists working in the musculoskeletal vignettes. The questions asked about each vignette can be
field, between July and October 2002, registered with the Char- found in Appendix B (available for viewing on ArticlePlus
tered Society of Physiotherapy in the United Kingdom. Ethical only). The questions on work recommendation and activity
approval was obtained from the West Midlands Multicenter advice were taken from a previously successful questionnaire
Research Ethics Committee in the United Kingdom, in June sent to physicians.32
2002. Written consent was not sought from each participant,
but consent of respondents was assumed if they completed and Sample. A simple random sample of Chartered Physiother-
returned the questionnaire. apists working in the musculoskeletal field in the United King-
dom was used. The professional body generated the sample
from a database of physical therapists who had previously self-
Survey Instrument
reported the musculoskeletal field as their speciality, based on
Patient Vignettes or Case Scenarios. Three vignettes (case data gathered in the year 2000. Although the database was 2
scenarios) of patients with acute LBP were constructed (Appen- years out of date, it was considered to be the best sampling
dix A, available for viewing on ArticlePlus only). The vignettes frame available at the time. Further inclusion criteria were that
Figure 1. Summary of work rec- included descriptions of history, symptoms, and relevant phys- the physical therapist was involved in the treatment of LBP and
ommendations for the three pa- ical findings and did not attempt to describe in detail any test- had treated at least one case of acute LBP in the previous 12
tient vignettes. Patient one, mod- ing procedures that may not be used by all physical therapists. months. Filter questions atAdvice the beginning to "ofnot
the w ork”…
questionnaire
The vignettes were based on actual patients attending a physi- ascertained whether these two criteria were met and, if not, the
erate risk; Patient two, low risk;
cal therapy clinic in the West Midlands, in the United Kingdom.
suggesXng
respondent was asked to return the questionnaire without com-
p ersistence
Patient three, high risk.
Before usual assessment and treatment, patients consented to pleting the rest of the items. of the biomedical
the use of their case as a vignette and completed the Acute Low A pilot study (n ! 50) demonstrated that the questionnaire
Back Pain Screening Questionnaire (ALBPSQ). The ALBPSQ 27 model for LBP
generated a response rate in keeping with other postal surveys
advised some restriction of physical
was developed activities,
to screen for patients
Pa- withDiscussion
pain of less than 12 of physical therapists,22,24,33 and levels of missing data were
tients 1, 2, and 3, respectively. weeks’Again,duration,there at riskwereof no poor outcome from psychosocial low. Missing data constituted less than 1% for all but 5 ques-
risk factors, andNits Dutility and This in survey is risk
the firstrecognize
nationwide survey in the in pUnited
statistical differences between Bishop
those Atherapists
, Foster E. seeing pa-tcutoff
o physical points
herapists forUhigh
the nited have
kingdom tionnaire items, and
psychosocial the maximum
factors level
aXents ofamissing
with cute low data
back for any
been Spreviously
pain? pine (Phila Pinvestigated Kingdom
a 1976). 2005 in Sweden and Northern to exploreIre- whether physical
single item was therapists
3.3%. Given working the estimation from the pilot
tients with acute LBP more often land. 27,28(at least one case
The patient population of the
a current study was sim- field study,
in the musculoskeletal havethat there would
adopted be approximately 52% of applicable
a biopsychoso-
week) or less often (less thanilarone to the case a week),
Northern Ireland with
population, cialinapproach
that there was to the a mix responses,of
management and that The
LBP. less than
responses 5% error in the key survey esti-
70.3% and 73.4%, respectively, advising
of working Patient 1 to
and nonworking patients and all had been referred mates was desirable, it was estimated that approximately 900
to questions about work and activity levels, and per-
“work.”
ceived severity of spinal pathology provide insights into
Chronicity Rating and Work Recommendation the therapists’ ability to recognize patients who are at
The therapists’ assessments of each patient’s chronicity risk of chronicity and their recommendations for work
risk were not consistently associated with their work and activity.
Clinical vignettes were used as this allows data to be
recommendations. There was no significant association
between the reported chronicity risk and work recom- gathered about a specific situation from a large sample
7
mendation for Patient 1 (!2 ! 1.7, P ! 0.421). However, when obtaining this information in real life is impracti-
there was a significant association between these vari- cal. The advantages of using vignettes include the ability
ables for Patient 2 with those rating this patient as at to control and manipulate variables easily, the sugges-
“high risk” of chronicity being more likely to recom- tion of reduced Hawthorne effects,37 reduced social de-
2 37,38
06-‐08-‐19
“no seguro
de lo que
significa
PS”
Necesidad
“evalúo
de Evaluación basado en
entrenami
ento Psicosocial sensación
de guata”
formal
Limitada
educación
Singla M et al. Physiotherapists' assessment sobre FPS
of paXents' psychosocial status: are we
standing on thin ice? A qualitaXve
descripXve study. Man Ther. 2015
•  Estamos más cómodos viendo el DL como mecánico (en línea con con el
entrenamiento de los kines en terapia manual y ejercicios dirigidos a
desórdenes específicos)
•  EsXgmaXzamos a aquellos con FPS negaXvos presentes
•  Percibimos que tenemos un rol limitado en el manejo de los FPS
8
06-‐08-‐19
EXAMINACIÓN DE FACTORES

PSICOSOCIALES EN KINESIOLOGÍA
MUSCULOESQUELÉTICA
“Sugerimos que es apropiado que los kinesiólogos

mejoren sus habilidades profesionales al incluir
factores psicosociales
como posibles obstáculos para la reacXvación y como
objeXvos terapéuXcos valiosos… el Xpo de
cambio filosófico que recomendamos será esencial
para el desarrollo conXnuo de la prácXca basada en la
evidencia”
9
06-‐08-‐19
Los Factores Psicosociales cambian el resultado

del tratamiento
Mediciones que influencian el resultado

PRONÓSTICOS independiente del mo. Ej: Depresión de base predice
mal resultado del mo

Mediciones que influencian la relación entre

MODIFICADORES DEL intervenciones específicas y el resultado. Ej: Miedo
EFECTO DEL TTO ↓ eficacia de la manipulación vertebral

Factores que cambian durante o como consecuencia
MEDIADORES DEL del tratamiento y se correlacionan con un resultado
TTO específico. Ej: Catastrofización media entre ejercicio
y mejorar resistencia de la marcha

Hill y Fritz. Psychosocial Influences on Low Back Pain, Disability, and Response to Treatment. Phys Ther 2011.
Transición de dolor lumbar agudo a crónico

•  Pobre salud general
•  Intensidad del dolor
•  CiáXca
•  Discapacidad
•  LiXgios judiciales
•  Vulnerabilidad genéXca
•  Depresión
•  Trabajo alta demanda xsica
•  Evitación del miedo y catastrofización
Pincus T et al. A systemaXc review of psychological factors as predictors of chronicity/disability in prospecXve cohorts of low back
pain. Spine (Phila Pa 1976). 2002
Hayden JA et al. What is the prognosis of backpain? Best Pract Res Clin Rheumatol. 2010
10
06-‐08-‐19
¿Qué son los factores Psicosociales?
“Se describen como la combinación del estado cogniXvo,

emocional y social de un individuo que puede influir en su
estado de salud” (Singla et al., 2015)

Incluyen “creencias de los pacientes sobre el dolor y acXvidad,
creencias de miedo-‐evitación, conductas posiXvas/negaXvas, red
de apoyo, éêprotección familiar, condición xsica, Xpo de
personalidad, estrategias de afrontamiento y creencias
religiosas” (Adaptado de Overmeer et al., 2004).
¿Qué son los factores Psicosociales?
La Organización mundial de la salud los define como cualquier

factor que determine la manera en que las personas "manejan
las demandas y los desa-os de la vida co1diana [...],
man1enen un estado de bienestar mental y [se
comportan] mientras interactúan con otros, su cultura
y su entorno”

Ramond et al. Psychosocial risk factors for chronic low back pain in primary care—a systemaXc review, Family PracXce, Volume
28, Issue 1, 2011
11
06-‐08-‐19
Conceptos erróneos en relación a los PSC

PSC no son desórdenes de salud mental
•  No requieren atención especializada por un profesional de la salud mental
•  La mayoría de esos casos son la excepción no la regla
•  Miedo al movimiento, estrés por los exámenes, depresión por alt de AVD,
pueden ser manejadas por kinesiólogos m.e.
O’Keeffe M. et al Psychosocial factors in low back pain: le|ng go of our misconcepXons can help management Br J Sports Med
2018

PSC también son factores biológicos
•  Factores psicológicos Xenen efectos xsicos (éPA, úlceras GI)
•  Postura y movimiento son afectados por FSC (evitación de un mov,
aumento del tono musc, etc.)
•  Se necesita un enfoque verdaderamente BPS para apreciar la interrelación
entre todas las variables involucradas en la vida de un paciente con dolor
2018
12
06-‐08-‐19

PSC no sólo están presentes en el dolor persistente
•  Usualmente se consideran sólo cuando no funciona el “tratamiento
normal”
•  “Demandante”
•  “Busca atención”
•  “Tiene poca moXvación”
2018
¿Qué son las Banderas Amarillas?
•  No son sinónimo de “factores psicosociales”

•  Factores que incrementan el riesgo de desarrollar o perpetuar
discapacidad y pérdida de días laborales
•  La evaluación de las banderas amarillas debería generar 2 resultados:
–  Necesidad de una evaluación más detallada
–  IdenXficación de factores “silentes” que pueden ser sujeto de intervenciones
específicas
13
06-‐08-‐19
URGENCIA
DERIVAR PSIC
ALLÁ
VAMOS…
MIXTO
OTROS
Nicholas et cols. Early idenXficaXon and management of psychological risks factors (“yellow flags”) in paXents with low back pain:
A reappraisal. Phys Ther 2011
Banderas Amarillas
•  Creencia que el dolor es dañino

•  Comportamiento de enfermedad (reposo prolongado)
•  Aislamiento social
•  Problemas emocionales
•  InsaXsfacción con el trabajo
•  Licencias médicas o demandas por sueldo
•  Familia sobreprotectora/falta de apoyo
•  ExpectaXvas inapropiadas del tratamiento
14
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¿Qué factores influencian la relación terapeuta-

paciente en kinesiterapia musculoesquelética?
Las principales habilidades comunicaXvas que se destacaron son:
•  Escucha acXva
•  Empa~a
•  Ser amistoso
•  MoXvación y aseguramiento
•  Confianza
•  Comunicación no verbal CONCEPTOS CLAVE
O'Keeffe M et al. What Influences PaXent-‐Therapist InteracXons in Musculoskeletal Physical Therapy? QualitaXve SystemaXc
Review and Meta-‐Synthesis. Phys Ther. 2016
15
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La entrevista
Un abordaje biopsicosocial necesita la transformación de la

entrevista hacia la atención centrada en el paciente, que
es la clave para una comunicación personal, recepXva y
saXsfactoria entre pacientes y clínicos
Roter D 2000 The medical visit context of treatment decision-‐making and the therapeuXc relaXonship. Health ExpectaXons 3: 17–
25.
Comunicación efectiva
•  Realizar preguntas claras, sin dobles interpretaciones
•  Evitar el uso de palabras técnicas
•  Asegurarse que el paciente entendió correctamente las preguntas y
respuestas
•  Evitar nocebo

Pincus et cols. CogniXve and affecXve reassurance and paXent outcomes in primary care: A systemaXc review. Pain
2013, 154:2407-‐2416
16
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Antes de abrir la boca, pensemos..
Barker K et al. (2009) Divided By A Common Language? A QualitaXve Study Exploring The use Of Language By Health
Professionals TreaXng Back Pain. BMC Musculoskeletal Disorders 123, (10); 1-‐10.
Roberts L et al. (2013) Measuring Verbal CommunicaXon in IniXal Physical Therapy Encounters. Physical Therapy; 93:
479-‐491.
Palabras a evitar AlternaBvas posibles

Cambios degeneraXvos crónicos Cambios normales de la edad
Test con resultados negaXvos Todo parece normal
Inestabilidad Necesidad de más fuerza y control
Hueso con hueso Estrechez arXcular
Lordosis Curvatura normal lumbar
Lesión Daño reparable
Parestesia Sensación alterada
Inflamación Hinchazón
Crónico Persistente, pero puedes superarlo
Stewart & Lo‚us. SXcks and Stones: The Impact of Language in Musculoskeletal RehabilitaXon. J Orthop Sports Phys Ther. 2018
17
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“Las palabras del profesional de la salud pueden

promover la recuperación o pueden incrementar el
sufrimiento de los pacientes”

“Cómo usa este poder el profesional
es una importante
pregunta éBca para la medicina”

Howard Brody PhD, Médico de familia, especialista en
bioéXca
La entrevista
El kinesiólogo debe saber cómo le está yendo al paciente, la
percepción de su propio problema, cuál es el impacto que este
problema Xene en su vida y viceversa, y cómo su esXlo de vida
impacta su problema
Diener I et al. Listening is therapy: PaXent interviewing from a pain science perspecXve. Physiother Theory
Pract. 2016
18
06-‐08-‐19
La entrevista y el contacto inicial
•  Siéntate frente a tu paciente

•  Sin una mesa entremedio
•  Lo suficientemente lejos como para que sus piernas no se toquen si
ambos las cruzan
•  Las charlas informales sólo generan ganancias modestas…
Gardner T et al. (2015) PaXent led goal se|ng in chronic low back pain-‐What goals are important to the paXent and are they aligned
to what we measure? PaXent Educ Couns. 98(8):1035-‐8.
La entrevista
Realizar preguntas abiertas

•  “Cuéntame tu historia”
•  “¿Cuéntame… qué te trae por acá?”
•  “¿Cómo has visto afectada tu vida coXdiana por el dolor?”
Miller, W. & Rollnick, S. MoXvaXonal Interviewing: Helping People Change (ApplicaXons of MoXvaXonal Interviewing) 3rd Ed.
(2012). Guilford Press.
19
06-‐08-‐19
No interrumpas a tu paciente…aún
•  En promedio un médico interrumpe a su paciente a los 11’’

•  Descarrilar al paciente, cambia el foco de la entrevista del paciente al
tratante
•  No existe un “Xempo estándar”, tomar en consideración pistas
verbales, cambios de temas y expresiones emocionales
Beckman & Frankel. The effect of physician behavior on the collecXon of data. An Inter Med. 1984;101(5):692-‐96.
Marvel MK et al. SoliciXng the paXent’s agenda: have we improved? JAMA. 1999;281(3):283-‐287.
Phillips KA, Ospina NS, Mauksch, L. Physicians InterrupXng PaXents. JAMA. 2017;318(1):93–94.
Escucha acXva
•  Mira a los ojos… relaja la mirada
•  No te preocupes por escribirlo todo
•  Decir cosas “ahá”, “mmm”, acentuar con la cabeza y mirar a
los ojos mientras el paciente habla
•  No te quedes pegado en algo que dijo el paciente hace 2
minutos
Pincus et cols. CogniXve and affecXve reassurance and paXent outcomes in primary care: A systemaXc review. Pain 2013
20
06-‐08-‐19
Acentuar lo posiXvo

•  ParXr diciendo lo que el paciente está haciendo bien (sea o no
consciente de aquello)
•  ¡¡No ponXficar!! …”o sea, no haces deporte?” “estás todo el día
sentado viendo televisión…mal poh”, “estás bien pasadito de peso”,
y un largo etcétera
Resumir la historia al final

•  Resumir la historia del paciente
•  Usa las palabras del paciente
•  Valide la historia del paciente “es entendible te hayas senXdo
bajoneada”
•  Evite decir frases del Xpo “todo estará bien” o “no Xenes nada grave”
•  Al final preguntar ¿Entendí bien tu historia? ¿Hay algo más que
quieras agregar o cambiar?
21
06-‐08-‐19
"
PAIN 154 (2013) 2407–2416
www.elsevier.com/locate/pain
Cognitive and affective reassurance and patient outcomes in primary

care: A systematic review
Tamar Pincus a,⇑, Nicola Holt a, Steven Vogel b, Martin Underwood c, Richard Savage d,
David Andrew Walsh e, Stephanie Jane Caroline Taylor f
•  Aseguramiento cogniXvo (explicaciones claras sobre la eXología,

a
Department of Psychology, Royal Holloway University of London, Egham, UK
b
Research Centre, British School of Osteopathy, London, UK
c
Division of Health Sciences, Warwick Medical School, Coventry, UK
d
e el pronósXco, el plan de tratamiento, etc.) mejora los resultados

Stockwell Group Practice, London, UK
Arthritis Research UK Pain Centre, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
a corto y largo plazo

f
Queen Mary University of London, Barts and The London School of Medicine, London, UK
•  Aseguramiento afecXvo (cambio respuesta emocional del

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
a r t i c l e i paciente
n f o por ua n
b sm t ensaje
r a c t emocional del terapeuta) é saXsfacción
Article history:de los pacientes
Received 12 April 2013
In thea l
context s alir d e
of uncertainty la about
consulta,
aetiology and p ero tgood
prognosis, ambién hubo
clinical practice commonly recom-
mends both affective (creating rapport, showing empathy) and cognitive reassurance (providing explana-
asociación con
Received in revised form 12 July 2013
Accepted 15 July 2013 peores resultados
tions and education) to increase self-management in groups with nonspecific pain conditions. The
specific impact of each of these components in reference to patients’ outcomes has not been studied. This
review aimed to systematically evaluate the evidence from prospective cohorts in primary care that mea-
sured patient–practitioner interactions with reference to patient outcomes. We carried out a systematic
Keywords:
Primary care
Reassurance
“con el aseguramiento afec1vo el paciente se va de la consulta y
literature search and appraisal of study methodology. We extracted measures of affective and cognitive
reassurance in consultations and their associations with consultation exit and follow-up measures of
no 1ene nada para enfrentar su problema”

Systematic review patients’ outcomes. We identified 16 studies from 16,059 abstracts. Eight studies were judged to be high
in methodological quality. Pooling could not be achieved as a result of heterogeneity of samples and
measures. Affective reassurance showed inconsistent findings with consultation exit outcomes. In 3
high-methodology studies, an association was found between affective reassurance and higher symptom
burden and less improvement at follow-up. Cognitive reassurance was associated with higher satisfaction
and enablement and reduced concerns directly after the consultations in 8 studies; with improvement in
symptoms at follow-up in 7 studies; and with reduced health care utilization in 3 studies. Despite limi-
tations, there is support for the notion that cognitive reassurance is more beneficial than affective reas-
surance. We present a tentative model based on these findings and propose priorities for future research.
! 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
1. Introduction such uncertainty, the consultation can be challenging for practitio-

ners and patients, yet a primary goal of the consultation is to reas-
In primary care, where a large proportion of consultations are sure patients and to support them to manage their condition.
for self-limiting or medically unexplained disorders, delivering Delivering reassurance to those with nonspecific pain is advised
effective reassurance is a core skill for all practitioners. Doing this by many guidelines, including low back pain [1,48], neck pain
effectively has the potential to improve health outcomes and, by [4,47], and irritable bowel syndrome [38].
reducing onward referrals, reduce health care costs. The effects of Most models of good practice during consultations are based on
patient–practitioner interactions, including reassurance, on patient the principles of patient-centred care, which typically include an
outcomes are most likely to be demonstrable in groups with con- element of reassurance [59]. The method of ‘reassurance’ is in
Testimonio real de una paciente

ditions that are defined by subjective symptoms [35]. Amongst
the commonest of these groups are patients with nonspecific pain
conditions, in which a clear cause cannot be established [30]. With
the behaviour of the health care provider. Thus, data gathering in
relation to signs, symptoms, and concerns as well as the impact
of the problem is a prerequisite to reassurance, but reassurance it-
self is in the response of the health care provider to the data
“creo que cuando estás con dolor fuerte y te acostumbras a llevarlo,
⇑ Corresponding author. Address: Royal Holloway, University of London, Egham gathered.
Hill, Egham, Surrey TW20 0EX, UK. Tel.: +44 1784443523; fax: +44 1784434347. We were able to identify only one evidence-informed model
E-mail address: t.pincus@rhul.ac.uk (T. Pincus). that explicitly focuses on reassurance [8]. The model is deduced
lo que más cuesta sobrepasar es el hecho de que no te creen
0304-3959/$36.00 ! 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.pain.2013.07.019
cuanto te duele.

No creen que aunque te duela como pa’ desmayarte puedas andar
sonriendo, y que si no ven una fractura o un daño más notorio, no
creen que debiese dolerte, lo que de alguna forma termina en que no
te creen a B, y cuando te estai tragando todo el dolor y la pena
por la disfuncionalidad, y haces el esfuerzo de sobrepasarlo, lo peor
que te pueden hacer es dudar de X, como paciente es lo que más me
ha costado.”

22
06-‐08-‐19
•  é Percepción del efecto del tratamiento

Alianza •  é Función
terapéuXca •  ê Dolor
•  ê Discapacidad
AL: IF + AT DISMINUIDA

SL: IF PLACEBO + AT DISMINUIDA
AE: IF + AT ESTIMULADA
SE: IF PLACEBO + AT ESTIMULADA

*AT: ALIANZA TERAPEUTICA
*IF: INTERFERENCIAL
Fuentes J. et al. Enhanced TherapeuXc Alliance Modulates Pain Intensity and Muscle Pain SensiXvity in PaXents With Chronic
Low Back Pain: An Experimental Controlled Study, Physical Therapy, Volume 94, Issue 4, 1 April 2014
23
06-‐08-‐19
Dimensiones que debemos preguntar

durante la entrevista
1.  Historia del dolor y factores contextuales
2.  Factores/posturas/movimientos agravantes y atenuantes
3.  Creencias del paciente
4.  Hallazgos imagenológicos
PB O’Sullivan,et al. CogniXve FuncXonal Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling
Low Back Pain, Physical Therapy, Volume 98, Issue 5, 1 May 2018, Pages 408–423
Dimensiones que debemos preguntar

durante la entrevista
5.  Respuesta emocional y contexto social
6.  Comportamiento en respuesta al dolor
7.  AcXvidades importantes dolorosas, evitadas, temidas, etc.
8.  Niveles globales de salud
9.  Metas personales importantes
24
06-‐08-‐19
Experiencia de la persona con dolor
DEBEMOS CONCENTRARNOS EN LOS FACTORES MODIFICABLES Y EDUCAR

SOBRE LOS FACTORES NO MODIFICABLES
Figure 4.
Interplay of clinician- and patient-specific factors in the clinical journey with cognitive functional th
exposed to movements or activities These new functional strategies are req

that they nominated are painful, feared, immediately integrated into activities be
or avoided. During this process, body of daily living in order to generalize an
1.  Historia dcontrol el dolor y factores
is focused away cfrom ontextuales
pain and the learning and build self-efficacy
toward key points, such as the lower during these tasks. These are gradually Ra
•  ¿Hace cuándo y cómo empezó?
limbs, pelvis, thorax, and head. Pain progressed on the basis of the is
•  ¿Cuánto esperas que dure istu frequently
reduction dolor? reported during individual’s personally relevant goals, en
•  ¿Estaba ocurriendo this aprocess,
lgo “disXnto” disconfirming
o “importante” previously
en tu vida elevel of conditioning, and perceived
n la época res
que empezó el dolor? held beliefs that functional activation control over pain. Individuals are act
will result in pain escalation, functional initially seen weekly for 2 or 3 sessions, pa
•  ¿Qué tratamientos loss,ha and tenido? harm ¿Cómo
(Tab.crees 1: qcases
ue han
1 resultado?
and after which sessions are extended to thi
•  ¿Conoces cuál 2). es tu Targeted
diagnósXco? ¿EnXendes conditioning
functional qué significa? (Ej every¿Qué c2rees
or 3 weeks in order to build ed
is provided
que significa “enfermedad degenera1va discal”?) when there are deficits in confidence to self-manage over a 12- an
muscle strength and endurance that week period.62–64 During this process, de
act as barriers to achieving personally pain flares are seen as an opportunity mi
relevant goals (Tab. 1: case 1). When for reinforcing new ways to respond dis
pain control is not achievable during to pain without safety behaviors and pe
this process, the focus is placed away avoidance. An exacerbation plan is use
from pain and toward body relaxation, provided on discharge in order to pe
replacing safety behaviors while positively orientate the individual’s spi
achieving
Low Back Pain, Physical Therapy, personally
Volume 98, Issue relevant
5, 1 May 2018, Pages 408–423 functional emotional and behavioral responses fee
and lifestyle goals. to pain, and booster sessions may be sym
May 2018 Volume 98

Downloaded from https://academic.oup.com/ptj/article-abstract/98/5/408/4925487
by guest
on 11 June 2018 25
06-‐08-‐19
Severidad ≠ Intensidad
•  La intensidad del dolor no es una medición del daño Xsular
•  Una revisión sistemáXca mostró que en pacientes con dolor crónico
realizar acXvidades dolorosas era seguro y podía generar mayores
beneficios que evitarlas.
•  Entender que el dolor es un signo de sensibilidad o alarma y no de daño es
vital para el retorno del paciente a sus acXvidades
Belavy DL et al. (2017) Running exercise strengthens the intervertebral disc. Sci Rep, 7:45975.
Campbell A et al. (2016) Abdominal bracing increases ground reacXon forces and reduces knee and hip flexion during landing. J
Orthop Sports Phys Ther, 46(4): 286-‐292.
Smith BE et al Should exercises be painful in the management of chronic musculoskeletal pain? A systemaXc review and meta-‐
analysis. Br J Sports Med (2017)
Expectativas
•  ¿Qué esperas de mi?
•  ¿Qué crees que puedo hacer para ayudarte?
•  ¿Crees que la terapia puede ayudar en tu caso? ¿Cómo?
•  Terminada la terapia, ¿Qué sería un resultado exitoso para X?
Rob Oostendorp et al., “Manual Physical Therapists’ Use of Biopsychosocial History Taking in the Management of PaXents with
Back or Neck Pain in Clinical PracXce,” The ScienXfic World Journal, 2015
26
06-‐08-‐19
Expectativas en Dolor m.e.

•  En un estudio con individuos con DL agudo +1 punto expectaXva de
recuperación generaba una mejoría de 0.96 puntos en la escala de Roland-‐
Morris
•  En un estudio de DL asociado al trabajo aquellos sujetos que creían que su
posibilidad de volver a trabajar era ≤9 (10 era una “posibilidad muy grande
de volver”) tenían 4.6 veces más probabilidades de no volver a trabajar en
3 meses
•  La expectaXva del resultado de una intervención incluso puede superar el
efecto mismo de la intervención
Myers SS et al. PaXent expectaXons as predictors of outcome in paXents with acute low back pain. J Gen Intern Med. 2008
Du Bois et al. A screening quesXonnaire to predict no return to work within 3 months for low back pain claimants. Eur Spine J 2008
Bialosky et al. Individual expectaXon: an overlooked, but perXnent, factor in the treatment of individuals experiencing msk pain.
Phys Ther. 2010
2.  Factores/posturas/movimientos agravantes y atenuantes

•  No sólo preguntar, solicitar al paciente que realice movimientos acXvos
•  En esta parte podemos determinar si es que hay una relación “mecánica”
entre dolor y movimiento
•  ¿Sientes que tu dolor es predecible?
•  ¿Puedes evitar “quedar bloqueado” o “tener crisis” de dolor?
•  ¿Qué crees que pasará si__________ tu espalda?
•  ¿Crees que si haces ______ dañarás tu espalda?
**Se puede combinar con palpación

***Es completamente compa1ble con cualquier es1lo de examinación
(basado en alt de movimiento, terapia manual, control motor, etc.)
Bunzli S et al. Making sense of low back pain and pain-‐related fear. J Orthop Sports Phys Ther 2017;47:628–36

27
06-‐08-‐19
3.  Creencias del paciente.

•  ¿Cuál crees TÚ que es la causa de tu dolor?
•  ¿Crees que hay algún factor que pudiese estar favoreciendo que
mantengas tu dolor?
•  ¿Sientes que puedes controlar tu dolor cuando quieres?
•  ¿Qué crees que pasará si no lo tratas?
3.  Creencias del paciente.
“Las creencias de los pacientes

sobre su condición frecuentemente
distan de las de sus tratantes. El
personal de salud usualmente
desconoce las ideas de los
pacientes sobre su condición y rara
vez preguntan estas ideas durante
las atenciones clínicas”
Petrie et cols. The role of illness percepXons in paXents with medical condiXons. Curr Opin Psychiatry
2007.
28
06-‐08-‐19
“Más del 40% de los pacientes con DLC reportan haber
recibido un diagnósXco, pero también creen tenían
algo más, no detectado y grave que estaba causando
su dolor”
Serbic D, Pincus T. DiagnosXc uncertainty and recall bias in chronic low back pain. Pain. 2014 Aug;155(8):1540-‐6. doi: 10.1016/
j.pain.2014.04.030
Los pacientes usualmente creen que…
•  La columna es vulnerable a lesiones por su forma, trabajo o lesiones

previas
•  Creen que necesitan “proteger” su columna con: reposo, ser cuidadosos o
evitar acXvidades peligrosas, fortalecer sus músculos o controlar su
postura
•  El dolor lumbar es especial en su naturaleza e impacto
Darlow B et al. Easy to Harm, Hard to Heal: PaXent Views About the Back. Spine (Phila Pa 1976). 2015 Jun 1;40(11):842-‐50
29
06-‐08-‐19
¿Qué creen los pacientes que puede

desencadenar el dolor lumbar?
Factores Físicos 84.6% Factores Psicosociales y de

35% Movs acXvos contexto 15.2%
28.1% Posturas 8% Estado Psicológico
5.3% Esfuerzo repeXdo 5% Clima
4.4% Alt biomecánica 2% Sueño
4% Comorbilidades 1.2% Dieta
1.8% Trabajo
Costa N et al. What Triggers an LBP Flare? A Content Analysis of Individuals' PerspecXves. Pain Med. 2019
Dr. Google y el dolor lumbar

•  En relación a la información psicosocial en siXos web, después de una
búsqueda en Google:
–  60% entregaban limitada info PS
–  26,7% de los siXos ninguna info PS
•  20% de los siXos entregaban información sobre ciencia del dolor
•  El 46,7% de los siXos tenía afirmaciones que implicaban que el dolor está asociado
a lesión Xsular
•  El 53,3% de los siXos discu~a la importancia de pensamientos, emociones y
comportamientos en la experiencia del dolor lumbar
Black NM et al. A biopsychosocial understanding of lower back pain: Content analysis of online informaXon. Eur J Pain. 2018,
22(4):728-‐744
30
06-‐08-‐19
Nuestras creencias afectan el tratamiento
Darlow B et al. (2012). The associaXon between health care professional a|tudes and beliefs and the a|tudes and beliefs, clinical
management, and outcomes of paXents with low back pain: a systemaXc review. Eur J Pain. 16(1):3-‐17.
Daykin AR et al. (2004). Physiotherapists' pain beliefs and their influence on the management of paXents with chronic low back
pain. Spine 29(7):783-‐95.
Agacharse y levantarse con la espalda curva es

peligroso para los kinesiólogos
Caneiro JP et al. Physiotherapists implicitly evaluate bending and li‚ing with a round back as dangerous. Musculoskelet Sci
Pract. 2019 Feb;39:107-‐114
31
06-‐08-‐19
4.  Hallazgos imagenológicos
•  En trabajadores con DL agudo el uso temprano de RM aumentó el riesgo
de duración de discapacidad y no está asociado a mejores resultados
•  RM temprana no indicada Xene fuertes efectos iatrogénicos: aumentan
los días de licencia y genera un aumento de los gastos (U$13. 000)
Graves JM et al. Early imaging for acute low back pain: one-‐year health and disability outcomes among Washington State workers.
Webster BS et al. Iatrogenic consequences of early magneXc resonance imaging in acute, work-‐related, disabling low back pain.
32
06-‐08-‐19
Leamos la letra chica de las RM
•  Disc bulge, protrusión discal, degeneración, extrusión, cambios de Modic

1 y espondilolisis son más frecuentes en adultos de 50 años o menos con
dolor lumbar
•  Hay una fuerte asociación entre disc bulges y dolor, especialmente en
sujetos menores de 30.
•  Espondilolistesis y estenosis de canal central no Xenen relación con el
dolor lumbar.
Brinjikji W et al. MRI Findings of Disc DegeneraXon are More Prevalent in Adults with Low Back Pain than in AsymptomaXc
Controls: A SystemaXc Review and Meta-‐Analysis. AJNR Am J Neuroradiol. 2015
5.  Respuesta emocional y contexto social

Factores Psicológicos Preguntas de la Entrevista
Factores emocionales (senBmientos sobre el dolor)
Respuesta emocional al dolor ¿El dolor te afecta emocionalmente?
Ansiedad ¿Te preocupas por tu dolor?
Ánimo depresivo ¿Te deprime? ¿De qué forma?
Frustración/rabia ¿El dolor te hace senXr frustrado? ¿Por qué?
Influencia de las emociones ¿Tus emociones influencian el dolor?
Miedo al daño ¿Cómo te sientes cuando te agachas y levantas cosas
pesadas?
Miedo al dolor ¿Cómo te hace senXr el dolor?
33
06-‐08-‐19
5.  Contexto social

Personas con dolor lumbar crónico usualmente Xenen poco apoyo social:
HosXlidad/críXca de la pareja, lo que genera:
•  é Dolor y ê Función
•  é Estrés
•  é Comportamientos por dolor
•  é Búsqueda de aseguramiento
•  ê Apoyo social
Burns JW et al. Spouse criXcism and hosXlity during marital interacXon: effects on pain intensity and behaviors among individuals
with chronic low back pain. Pain. 2018
5.  Contexto social

•  ¿Las personas que te rodean se dan cuenta cuando Xenes dolor?
¿Qué notan?
•  ¿Cómo reaccionan ante tu dolor?
•  ¿Qué piensan las personas que te rodean sobre tu dolor?
•  ¿Cómo reaccionaron las personas a tu alrededor cuando les dijiste
lo que dijo el médico? ¿Cómo te sientes ahora acerca de esto?
•  ¿El dolor afecta tu vida social?
•  ¿Necesitas adaptar tu trabajo / pasaXempos / deporte por tu
dolor?
Rob Oostendorp et al., “Manual Physical Therapists’ Use of Biopsychosocial History Taking in the Management of PaXents with
Back or Neck Pain in Clinical PracXce,” The ScienXfic World Journal, 2015
34
06-‐08-‐19
Topical Review
Pain as a threat to the social self:

a motivational account
Downloaded from https://journals.lww.com/pain by e6fRevh4VjyMKGuMNGlKSTn8Gd4A61NfOkeKfjXdr71dvE1MxoCyOXQ3tZtykfQDHyvrSGIDstWVOvwt6KJyXaWZTtozTisEHKlYZjR3wKGt/kUSA/k3LHWSUy7gacCCBiTcdVsatrrJV08PBoepP2EUNezI1saDHxgHKwiuep4PX4QWsIdOPw== on 06/13/2019
September 2018
· Volume 159
· Number 9
Kai Karosa,*, Amanda C. de C. Williamsb, Ann Meuldersa,c, Johan W.S. Vlaeyena,c
www.painjournalonline.com 1691
1. Introduction expression.105 Therefore, a state of illness in general and pain in

It has been proposed that the definition of pain ideally particular can place humans into a state of dependency on
recognizes not only sensory, cognitive, and emotional dimen- others.
sions, but also a social dimension. 107
Although it is widely Feelings of helplessness and uncontrollability are common
acknowledged that interpersonal context modulates pain when suffering from pain, especially when it is chronic.82
experience and communication,39,55 we still fail to understand Moreover, Western society emphasizes individual function and
why and how this modulation occurs. Drawing from evolution- autonomy, which is severely hampered by chronic illness.
ary, social, and health psychology, we argue that pain is Consequently, many people with chronic pain experience shame,
a fundamentally social and threatening human experience embarrassment, and humiliation.86 These emotions are often
because it challenges several basic needs (Fig. 1): (1) the need fueled by interpersonal worries such as being a burden or
for autonomy, (2) the need to belong, and (3) the need for justice/ whether pain is taken seriously.95 Last, pain can be the result of
fairness. Examining how pain interferes with these basic human victimization at the hand of others, such as in the cases of torture,
needs can help us better understand the dynamic interplay bullying, or physical assault.3,99 In the latter, the difference in
power and control is paramount, as it places the victim at the
between social context and pain. Here, we (1) define these
fundamental human needs, (2) outline how pain threatens these mercy of a hostile assailant.
needs, and (3) describe the consequences of such threats, Feelings of uncontrollability and helplessness have adverse
especially for pain itself. effects on physical and psychological health and pain. The
debilitating consequences of uncontrollable events have been
shown across different species and led to the “learned
2. The need for autonomy helplessness hypothesis” of depression.1 Regarding pain,
Although humans are an inherently social species, they possess experimental research has demonstrated that predictability
Figure 1. Schematic representation of the 3 fundamental interpersonal needs and controllability
at the nexus of an individual’s ofpain pain arePain
experience. majorthreatensdeterminants
these needs in of cognitive
a fundamental need for ofautonomy
a myriad andaffected
ways but is, in turn, a sense
by thwartedofneedsagency,
as well. Note that pain in this context refers to both pain appraisals (eg, pain intensity and
12,67,69,82,102
a subjective feeling unpleasantness),
of control over their own actions and their
but also pain behavior (eg, pain expression, disability, and treatmentpainadherence).
processing. Uncontrollable
Different needs may overlap and influence each other (eg, anpain stimuli are
13
experience of ostracism may be excluding but at the same time lead to perceptions perceived
of injustice as more
and helplessness). intense,
Although these harmful, and
needs are private unpleasant
to the than
outcomes. Predicting and
individual (levelcontrolling theinfluenced
1), they are inherently environment is at the
by the social context, be it the interpersonal context (level 2, ie, partner, family, and health care professionals) or the
12,61
sociocultural context (level 3, ie, groups, culture, and social norms). Conversely,controllable
thwarted interpersonalones,
needs can affect and subjective
the relationship betweenfeelings
the individual of helplessness
center of survival fitness, and the socialespecially
context as well (eg,inwithdrawal
the case ofcircles
from social aversive
or attack in the form of antisocial behavior). Finally, individual factors (eg, personality traits) might 68
experiences such asfunction pain.as17,18,98
a buffer or facilitator for the flow between these different levels.
We argue that in the context of have been associated with increased pain intensity. Losing
pain (and illness), the need for autonomy has a fundamentally control over pain is even worse than never having had control
interpersonal connotation because agency shifts from the person over pain in the first place.17 Also, feelings of helplessness,82
of behaviors, and leads to shame, guilt, and timefear of negative increasingevaluation
group co- predict pain-
with pain to others. across cultures, affects a broad variety 41,108 species and across and culture,
95not ostracized, and enhancing fitness for
From an evolutionary
serious adverse effects when thwarted.
perspective, paintocan beinconceptualized intensity
hesivenesslevels.
for those Although this research does not emphasize
Pain threatens the need belong numerous ways. First, survival,38,109 for instance, by limiting the spread of infectious
16 35 uncontrollability85 and helplessness in a social domain, pain
as a homeostatic emotion pain interferes orwithansocial
“awareness
activities such ofasaworkneed andstate”
hobbies. diseases.
People with chronic pain 106 stigmatization and in- places the individual
the need to in a state has where she/he relies on others for
that is communicated to conspecifics. experience In contrast to more
validation (ie, ignoring, rejecting, or negatively evaluating one’s support
Thwarting
consequences for physical
belong
and psychological
a host of
health
detrimental
and for pain.such as family,
solitary animal species, humans evolved as a reciprocally
14,44,77,101,104
altruistic and transferring control to others
thoughts or feelings), especially when medical Chronic deprivation of the sense of belonging has been
species, prioritizing pathology
the ability is notto confirmed. 22,78,79,81
communicatePeople needin painstates are judged
to friends, and most importantly,
associated with increased stress levels, reduced immunehealth care providers. In addition,
as less warm and less competent by pain-free individuals: doctor–patient relationships
functioning, and increased mortality.are often loneliness
Similarly, characterized is by author-
elicit help from or warn others.a derogated
effectively, This mayout-group.help to5allow for survival
More broadly, chronicinpain strongly associated with increased risk of morbidity and
6.  Comportamiento en respuesta al dolor

otherwise fatal situations.
have a signaling function,
31
conflicts withIllness
92
and functionality
anduntil
symptoms,
societal norms
theoldsame
in general,
that emphasize
age, and the dominant norm that pain
is true for facial pain
can
health, autonomy,
itarian and paternalistic physicians and problematic treatment
mortality.2,7,41 Regarding pain, social exclusion is associated
compliance, and many people
with increased pain reports and vice versa.
47
with chronic
8,28,109 pain
Social stress are dissatisfied
should be short-lived, diagnostically meaningful, and denotes with and their
pain care.
also share overlapping neural pathways, often
a fixable problem.23,72,107 interpreted as evidence that the human pain detection system
Individuals with chronic pain are more socially isolated and In been
has thecoopted
case toofdetect victimization,
and react to social consequences
threat.26,27,29,52,71 are even direr.
Victims of bullying are associated
at increased risk of developing chronic pain
•  ¿Qué haces cuándo aumenta tu dolor? Ej: te pones un guatero, tomar
33,70,74 8
Sponsorships or competing excluded
intereststhanthat healthy controls to
may be relevant across
content thearelifespan,
disclosed Social exclusion has been with increased but also
76
at the end of this article. especially when pain has no medical explanation. Although it complaints, decreased20 pain 30,97,99
reports. andPainthe tolerance
sameis is positively
true for related to
victims of torture3,11
has been argued that one of the “key objects of fear” in chronic social network size,45 and perceived 6 social isolation in individuals
una pasXlla, te vas a la cama, etc. affects the and withinterpersonal abuse. futurePain intentionally inflicted by others is
a b
Research Group of Health painPsychology, KU Leuven,64Leuven,
is threat to self-identity, this threatBelgium,
also directlyResearch low-back pain predicts disability. 46,70
In rheumatoid
Department of Clinical, Health
“social and 86
Educational
self.” IndividualsPsychology,
with chronic University College stigma perceived
pain internalize arthritis pain,as more stigmatization
perceived intense than is related to poorer pain37 and is
incidental
101
regarding calienation
London, London, United Kingdom, Department and ofdiscrimination.
Clinical Psychological The link between physical and psychological well-being. Importantly, perceptions
associated with reduced pain communication.51,73,105
•  Aunque eillsté haciendo algo
Sciences, Maastricht University, Maastricht, the Netherlands
Ostracism of members has been observed in mostm al, dthanestaca
illness and social isolation is supported by evolutionary theories.
social
*Corresponding author. Address: Department of Psychology, University of Leuven,
el social
actual size of the esfuerzo
network. por su auto-‐
of social isolation and stigmatization seem to be more important
54,77
fax: 132 (0)16 32

manejo. Ej: reposo en cama
Tiensestraat 102, Box 3726, 3000 Leuven, Belgium. Tel.: 132 (0)16 32 57 82;
Copyright ! 2018
61 44. E-mail by the
address: International Association
Kai.Karos@kuleuven.be for the Study 3.
(K. Karos). TheUnauthorized
of Pain. need to belong
reproduction of this article is prohibited.
•  ¿Qué haces cuando Xenes que hHumans

acer atuasn msome
ovimiento doloroso y ninterper-
o
PAIN 159 (2018) 1690–1695 social animals have a pervasive drive to form and
© 2018 International Association for the Study of Pain maintain least lasting, positive, and significant
7
puedes evitarlo?
http://dx.doi.org/10.1097/j.pain.0000000000001257 sonal relationships. This motivation has been demonstrated
1690
·
K. Karos et al. 159 (2018) 1690–1695 PAIN®
Copyright ! 2018 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
35
06-‐08-‐19
7.  AcBvidades importantes dolorosas, evitadas, temidas, etc.

•  ¿Qué dejaste de hacer por tu dolor?
•  ¿Has cambiado alguna acXvidad de tu vida diaria por tu dolor?
•  ¿Hay alguna acXvidad que tengas miedo de realizar? ¿Qué crees que
te podría ocurrir si la haces?

Vida sexual
•  Es un aspecto fundamental de la funcionalidad humana
•  Se ve afectado por el dolor
•  Es usualmente obviado por los profesionales de la salud
•  Los pacientes sienten miedo de “volver a senXr dolor” o de “no cumplir su
rol de pareja”
•  Quieren saber cuándo pueden volver a retomar su vida sexual
36
06-‐08-‐19
8.  Niveles globales de salud

•  ¿Cómo describirías tu salud en general? ¿muy buena, buena, regular,
mala, muy mala?
•  Sueño
•  Estrés
•  Nutrición
•  Nivel de acXvidad xsica
•  Tabaco/alcohol/drogas
37
06-‐08-‐19
9.  Metas personales importantes
•  Medio ambiente
•  Familia
•  Trabajo
•  Vida sana
•  Deporte
•  Vida integral
•  Etc, etc, etc..
Si como kinesiólogos no tomamos el

desaxo de esXmular a nuestros
usuarios a adquirir un esXlo de vida
saludable, con la acXvidad xsica
como pilar fundamental, entonces
¿quién lo hará?
38
06-‐08-‐19
Al final de la examinación
Por úl1mo, y sólo para estar seguro que no se

me escapa nada importante ¿Hay algo más que
te gustaría agregar a todo lo que hemos
hablado?
Figure A: Framework for Case Study 1
TIP: usar un ayuda

memoria como en
la universidad
a e
en.sepulveda.lopez@gmail.com
hmp://www.pain-‐ed.com/blog/2018/05/16/musculoskeletal-‐clinical-‐translaXon-‐framework-‐from-‐knowing-‐
to-‐doing/
39
06-‐08-‐19
CASO CLINICO
•  Patricia, género femenino, 48 años, DX: discopa~a degeneraXva lumbar (no sabe lo que
significa).
•  Mientras estaba en su trabajo, en una bodega, se le caen encima unas cajas encima y con un
movimiento brusco, “mal hecho” trata de afirmarlas y siente un Xrón.
•  Hace 7 años sufre su 1er episodio de DL, después cada vez que “hacía fuerza” -‐como mover
muebles o llevar bolsas del supermercado-‐ refería dolor. Nunca tuvo alivio del todo. Sin
preguntarle manifiesta que la causa de su problema podría ser genéXco porque su mamá
tuvo múlXples problemas de huesos y también al peso.
•  Cuando le duele se pone guatero, y trata de caminar los más derecha posible. Por
recomendación de la Dra. evita agacharse y le duele barrer y lavar la loza pero Xene que
hacerlo igual.
•  Emoción: dice que no se siente bajoneada, pero no se siente en la casa y Xene miedo de
terminar con muchos “achaques” como su mamá.
•  Act. Física: sedentaria, pero dice que “le gusta caminar”. No le gustan los abdominales.
•  Social: Dice que Xene mucho estrés en la casa, “ayer pasé una rabia y↑el dolor”. Vive con
esposo que trabaja en oficina y no ayuda en la cas y una hija (25) que estudia.
•  Trabajo: estampa poleras en una fábrica chica, dice que debe estar parada “8 horas al día”.
Al preguntarle dice que no se cumple la ley de la silla, pero que, a pesar de lo anterior, le
gusta su trabajo.
•  Salud gral: obesidad, no fuma, no bebe, Xene insulino-‐resistencia.
•  Co-‐morbilidades: osteoporosis, por lo que el médico le dijo que no podía hacer fuerza o
acXvidades de impacto.
•  Fue a kine porque la doctora le dijo que necesitaba fortalecer los músculos abdominales.
40
06-‐08-‐19
ESCALAS DE MEDICIÓN
Medidas de resultado
•  Chronic pain coping inventory (CPCI)

•  Fear-‐avoidance beliefs quesXonnaire (FABQ)
•  Pain Beliefs and percepXons inventory (PBAPI)
•  Pain anxiety symptoms scale (PASS)
•  Pain catastrophizing scale (PCS)
•  Tampa Scale for Kinesiophobia (TSK)
NO SON NECESARIAS PARA REALIZAR UNA EXAMINACIÓN O

MANEJO PSICOLÓGICAMENTE INFORMADO!!!
Flor y Turk. Chronic pain An integrated biobehavioral approach. IASP Press 2011
41
06-‐08-‐19
TABLE 3. Direction of change in SBST categories on each time point

Change 1 Change 2 Change 3
Categories of SBST changes (Baseline – 5 weeks) (5 weeks– 3 months) (3 months – 6 months)
N=148 N=146 N=145
Total Improved 81 (54.7%) 12 (8.2%) 15 (10.3%)
Medium to low 33 (22.3%) 4 (2.7%) 9 (6.1%)

High to low 32 (21.6%) 2 (1.4%) 1 (0.7%)
High to medium 16 (10.8%) 6 (4.1%) 5 (3.4%)
Total Stable 41 (27.7%) 81 (55.5%) 80 (55.4%)
Low to low 28 (18.9%) 68 (46.6%) 64 (44.1%)

Medium to medium 13 (8.8%) 13 (8.9%) 16 (11%)
Downloaded from www.jospt.org at Univ of New England on March 30, 2017. For personal use only. No other uses without permission.
Total Worsened 26 (17.6%) 53 (36.3%) 50 (34.5%)
Low to medium 3 (2%) 18 (12.3%) 7 (4.8%)

Low to high 0 (0%) 7 (4.8%) 3 (2.1%)
Medium to high 6 (4.1%) 14 (9.6%) 12 (8.3%)
High to high 17 (11.5%) 14 (9.6%) 28 (19.3%)
500 Abbreviations: N – Total number of patients; SBST – STarT Back Screening Tool. Note: patients who remained
501 in the high-risk classifications were categorized as worsened8
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
502
Medeiros
503 FC et al. Longitudinal Monitoring of PaXents With Chronic Low Back Pain During Physical Therapy Treatment Using
the STarT Back Screening Tool. J Orthop Sports Phys Ther. 2017
Journal of Orthopaedic & Sports Physical Therapy®
G Model
REHAB 1225 1–11
Annals of Physical and Rehabilitation Medicine xxx (2018) xxx–xxx
Available online at
ScienceDirect
www.sciencedirect.com
1
2 Review
3 Comparison between the STarT Back Screening Tool and the Örebro
4 Musculoskeletal Pain Screening Questionnaire: Which tool for what
5 purpose? A semi-systematic review§
6 Q1 Alexis Lheureux a,*, Anne Berquin b
7 Ann Phys Rehabil Med. 2019 May;62(3):178-‐188.
a
Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Neuro Musculo Skeletal lab, Avenue Mounier 53/B1.53.07, 1200 Brussels,
8 Belgium
9 b
Department of Physical and Rehabilitation Medicine, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10/1650, 1200 Brussels, Belgium 25
A R T I C L E I N F O
El OMPSQ parece mejor que la SBST para predecir los resultados de A B S T R A C T
"dolor” y "trabajo” Questionnaires

en el largo
have p lazo, la Sincluding
BST ptheuede ser Tool
mejor
(SBST) p ara
the lÖrebro
os
Article history: Background: Prevention of chronicization of low back pain requires accurate detection of at-risk patients.
Received 22 February 2018 been validated, STarT Back and
Accepted 15 September 2018 Musculoskeletal Pain Screening Questionnaire (OMPSQ). This review aims to compare these
Keywords:
resultados de "función".
questionnaires in terms of predictive value and in terms of aims, to guide the choice in clinical practice.
Methods: This study is a semi-systematic literature review. Studies evaluating at least one of the
STarT Back Screening Tool (SBST)
Örebro Musculoskeletal Pain Screening •  OMPSQ se elaboró con el objeXvo de crear una herramienta de pronósXco
questionnaires and written between 1997 and October 10th 2017 were selected from Pubmed database.
Inclusion criteria were pain duration < 3 months, outcomes including pain, function and/or global
•  SBST se diseñó como una herramienta de asignación de tratamiento y es más
Questionnaire (OMPSQ)
Low back pain
recovery. For work outcomes, inclusion criteria were extended to chronic patients. Studies had to
Predicting questionnaires provide information on sensitivity, specificity and area under the ROC Curve (AUC).
fácil de usar en la Results:

p rácXca clínica
Twenty-eight studies met our inclusion criteria (7 SBST, 21 original OMPSQ, 3 short OMPSQ). The
OMPSQ best predicted a Pain NRS ! 3 at 3 months (AUC = 0.64 (0.50–0.78)) and at 6 months (AUC
between 0.70 (no confidence interval provided) and 0.84 (0.71–0.97)). The SBST and the OMPSQ are
comparable to predict an Oswestry Disability Index ! 30% at 6 months. A single study showed no
difference between the SBST and the OMPSQ to predict absenteeism ! 30 days at 6 months. The two
questionnaires cannot be compared for ‘‘global recovery’’ outcomes.
Conclusion: The OMPSQ seems better than the SBST for predicting ‘‘pain’’ and ‘‘work’’ outcomes, the SBST
may be better for ‘‘function’’ outcomes. These results should be taken with caution because of the high
heterogeneity between studies. It should be noted that the OMPSQ was elaborated with the aim of
creating a prognostic tool while the SBST was devised as a treatmentallocating tool and is easier to use in
clinical practice. This should guide the choice of using one questionnaire rather than the other.
C 2018 Published by Elsevier Masson SAS.
"
10
11 1. Introduction industrialised countries [2,3]. About 90% of patients with acute 14
LBP appear to show much improvement [4] or heal within 6 weeks 15
12 Spinal pain is the most frequent musculoskeletal pathology [1], [2,3] to 3 months [5]. However, the financial aspect of acute, 16
13 with a 70% lifetime prevalence of low back pain (LBP) in subacute and chronic LBP is substantial, with massive direct but 17
mostly indirect costs (e.g., sickness absenteeism) [6,7]. Chronic LBP 18
§
This semi-systematic review compared 2 prognostic questionnaires about back
accounts for most of the costs associated with LBP [8,9].
Therefore, the challenge for health professionals is to avoid the
19
20 42
pain (STarT Back Screening Tool and Örebro Musculoskeletal Pain Screening chronicization of acute/subacute LBP and its consequences 21
Questionnaire) in terms of prognostic power and clinical aims, to guide the
[10,11]. It seems important to detect at-risk patients within 22
healthcare provider in choosing a questionnaire. By its large inclusion criteria, our
study is the broadest on the topic. Although the 2 questionnaires present good and 8 weeks after the onset of pain [12]. To this end, factors favoring the 23
equivalent predictive power, we highlight important differences between them in persistence of LBP have been studied and are often described as 24
clinical objectives and usefulness, which may be the most important to consider ‘‘yellow’’, ‘‘orange’’, ‘‘blue’’ and ‘‘black’’ flags [13]. Yellow flags are 25
Q1 when deciding which tool to use.. defined as inappropriate beliefs and attitudes about LBP [13]: the 26
* Corresponding author. Avenue Mounier 53/B1.53.07, 1200 Woluwe-Saint-Lambert,
belief that LBP indicates the existence of danger, the development 27
06-‐08-‐19
Scand J Pain 2019; aop
Clinical pain research
Martin Rabey*, Anne Smith, Peter Kent, Darren Beales, Helen Slater and Peter O’Sullivan
Chronic low back pain is highly individualised:

patterns of classification across three
unidimensional subgrouping analyses
https://doi.org/10.1515/sjpain-2019-0073 Implications: For clinicians this study highlights the high
Received May 8, 2019; accepted June 12, 2019 variability of presentations of people with CLBP at the
Abstract level of the individual. For example, clinician’s should
not assume that those with high levels of pain sensitivity
•  294 personas con DLC
Background and aims: Chronic low back pain (CLBP) is will also have high psychological distress and have pain
a complex disorder where central and peripheral noci- summation following repeated spinal bending. A more
•  Sensibilidad al dolor, perfil psicológico, respuesta del dolor
ceptive processes are influenced by factors from multi- flexible, multidimensional, clinically-reasoned approach
durante flexión anterior de tronco.
ple dimensions associated with CLBP (e.g. movement, to profile patient complexity may be required to inform
pain sensitivity, psychological). To date, outcomes for individualised, patient-centred care. Such individualised
•  De los 27 posibles patrones entre estas dimensiones, los
treatments matched to unidimensional subgroups (e.g. care might improve treatment efficacy. This study also
psychologically-based) have been poor. Therefore, uni- has implications for researchers; highlighting the inad-
pacientes correspondían a 26
dimensional subgrouping may not reflect the complexity equacy of unidimensional subgrouping processes and
of CLBP presentations at an individual level. The aim of methodological difficulties in deriving subgroups across

this study was therefore to explore patterns of classifi- multidimensional data.
cation at an individual level across the three previously-
Keywords: low back pain; subgrouping; biopsychosocial;
published, data-driven, within-dimension subgrouping
pain sensitivity; movement.
studies.
Methods: Cross-sectional, multidimensional data was
collected in 294 people with CLBP. Statistical derivation
of subgroups within each of three clinically-important
1 Introduction
dimensions (pain sensitivity, psychological profile, pain
Treatment outcomes for people with chronic low back pain
responses following repeated spinal bending) was briefly
(CLBP) are modest at best and no intervention appears
reviewed. Patterns of classification membership were sub-
consistently superior to another [1]. Lack of treatment
sequently tabulated across the three dimensions.
specificity, secondary to assumed sample homogeneity,
Results: Of 27 possible patterns across these dimensions,
has been proposed to underpin such modest outcomes [2].
26 were represented across the cohort.
For this reason, identification of subgroups of people with
Conclusions: This result highlights that while unidimen-
CLBP, to whom specific treatments may be targeted, has
sional subgrouping has been thought useful to guide treat-
been a research priority for decades [3].
ment, it is unlikely to capture the full complexity of CLBP.
We have previously published three studies involv-
The amount of complexity important for best patient out-
ing the same 294 participants with CLBP [4–6]. In each
comes is currently untested.
study data-driven [7] unidimensional subgroups were
“Test” de Kieran O’Sullivan

derived based upon: (1) pain sensitivity data, (2) psycho-
logical questionnaire scores, (3) pain responses following
*Corresponding author: Martin Rabey, PT, PhD, School of repeated forward and backward spinal bending. These
Physiotherapy and Exercise Science, Curtin University, Bentley, dimensions were chosen as clinically-modifiable and
Western Australia, Phone: +447781168108, important dimensions within presentations of people with
E-mail: martinrabey@gmail.com.
CLBP, with potential to facilitate targeted interventions.
https://orcid.org/0000-0003-3814-909X
Anne Smith, Peter Kent, Darren Beales, Helen Slater and Peter
However, CLBP is a complex disorder where central
O’Sullivan: School of Physiotherapy and Exercise Science, Curtin and peripheral nociceptive processes are influenced by
University, Bentley, Western Australia factors from multiple dimensions associated with CLBP
“¿cómo le explicarías tus
© 2019 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.
Brought to you by | Universitat de Barcelona
hallazgos de examinación a tu

Authenticated
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familia?...”
43
06-‐08-‐19
EVALUACIÓN PSICOLÓGICAMENTE
INFORMADA
Formulación de objetivos
•  Los objeXvos pueden ayudarnos a concentrarnos en lo que es importante
y le da a las acXvidades un propósito.
•  Permiten cambiar la conversación desde los síntomas a la función/
acXvidad
Gardner T, Refshauge K, McAuley J, Goodall S, Hübscher M, Smith L. Goal se|ng pracXce in CLBP. What is current pracXce and is
it affected by beliefs and a|tudes? Physiotherapy Theory and PracXce 2018
44
06-‐08-‐19
Características de los objetivos
•  Importantes (saXsfacción personal y calidad de vida)

•  Realistas y realizables
•  Dividibles en partes más pequeñas (baby steps)
Estrategias cuando un paciente dice “quiero tener

menos dolor”
•  ”Si yo te estuviera mirando ¿cómo podría saber que estás con menos
dolor? ¿Qué te vería hacer disXnto?
•  “Si tuvieras una varita mágica y pudieras controlar completamente tu

dolor ¿Qué te vería haciendo disXnto?”
•  Describe qué harías en un día perfecto para X

…¿Y si dice “yo hago de todo”?
45
06-‐08-‐19
Formulación de objetivos
•  El paciente puede llevarse sus objeXvos escritos en una hoja o sacarle una
foto con su celular.
•  Otra forma de generar ideas para objeXvos es preguntar por los valores
del paciente (ej: familia, mascotas, medio ambiente, deporte, etc.)
•  Si Xenes Xempo en la sesión inicial puedes enfocarte en uno de los
objeXvos del paciente sobre su condición xsica, de modo que lo
transformes en un objeXvo “SMART” (specific, measurable, achievable,
realis1c, 1med).
Formulación de objetivos: SMART

Specificic -‐ Específicos

Measurable -‐ Medibles

Achievable -‐ Realizables

Relevant -‐ Importantes

Timely -‐ Oportunos
46
06-‐08-‐19
Formulación de objetivos: ME RIO

Medibles

Específicos

Realizables

Importantes

Oportunos (se refiere a un plazo concreto
de Xempo)

“que el paciente tenga cero dolor no es el
objeXvo. La reducción del sufrimiento sí lo es – y
eso es mucho más complejo que sólo la analgesia”

Lee TH. Zero Pain Is Not the Goal. JAMA. 2016;315(15):1575–1577. doi:10.1001/jama.2016.1912
Ballantyne JC, Sullivan MD. Intensity of Chronic Pain-‐-‐The Wrong Metric? N Engl J Med. 2015 Nov 26;373(22):2098-‐9.
47
06-‐08-‐19
Establecer la condición física basal

•  La base es la canXdad de acXvidad xsica que un individuo puede manejar
con facilidad.
•  Para ayudar a los pacientes, usa el objeXvo (relacionado a la condición
xsica) como ejemplo.
•  Si el paciente quiere volver a hacer algo que dejaron de hacer, el
kinesiólogo debe sugerir un punto de parXda (TIP de Louis Gifford: “start
easy, build slow”).
•  Un buen Xp es comenzar un poco más abajo que el promedio de acXvidad
•  Preguntarle al paciente ¿de 1 a 7 cuan confiado te sientes en que podrás
realizar………. por el Xempo/repeXciones que establecimos?
Establecer la condición basal

•  Se pueden uXlizar mediciones estandarizadas (tests xsicos sencillos) en
caso de que se alineen con los objeXvos del paciente
•  Con frecuencia, los pacientes sobreesXman cuánto pueden hacer al
regresar a una acXvidad que no han hecho durante mucho Xempo
•  Por ejemplo, si a un paciente quiere reiniciar el tenis después de varios
años de no jugar, es posible que deba sugerir que comiencen con el giro
de una raqueta durante 2-‐3 minutos.
•  El paciente es quien decide en úlXmo término en qué nivel de dificultad
empezará los ejercicios

48
06-‐08-‐19
INTERVENCIÓN
PSICOLÓGICAMENTE INFORMADA
¿Qué quieren los pacientes?
Necesidad de información de alta calidad

•  Quieren información confiable de especialistas… no creen en médicos
generales estén “actualizados” (Briggs 2012)
•  Info de kinesiólogos y otros profesionales con frecuencia era
“conflicXva” (McIntosh 2003)
•  “Tienes signos de espondilolistesis” pero cuando vi al especialista me dice
“no, tu columna está bien” …a quién le creo? (Toye 2009)
Yuan Z Lim et cols. People with low back pain want clear, consistent and personalised informaXon on prognosis, treatment opXons
and self-‐management strategies: a systemaXc review, Journal of Physiotherapy, 2019
49
06-‐08-‐19
Necesidad que la información sea entregada en un tono

adecuado y un lenguaje entendible
•  Comunicación abierta y clara con foco en circunstancias personales (Briggs
2012)
•  “Te tratan como si no entendieras de lo que hablan”, “me gustaría que me
hablaran a mi nivel”. Fallan en reconocer los senXmientos del que sufre.
(Farin 2013)
Fuentes de información

•  Necesito saber dónde buscar ayuda (Laerum 2006)
•  Fuentes alternaXvas de información llevan a consejos conflicXvos. Cuando
el médico general no entrega información, los pacientes buscan fuentes
alternaXvas de información de otros profesionales y de familia y amigos
(McIntosh 2003)
50
06-‐08-‐19
Educación terapéutica
El objeXvo no es que las

personas “aprendan más
de dolor” el objeXvo es
que enXendan mejor su
propia experiencia y
disminuyan la amenaza
que significa el dolor
“Si vamos a aceptar el inmenso privilegio de

ayudar a las personas a entender su dolor y
cómo recuperarse de él, entonces estamos
absolutamente obligados a saber sobre qué
estamos hablando y si eso requiere algo de
trabajo serio, entonces que así sea”

Mick Thacker, Fisioterapeuta
51
06-‐08-‐19
Educación terapéutica
•  Educación centrada en el paciente
•  PosiXva
•  No amenazadora
•  Reforzando comportamientos saludables
•  EsXmular auto-‐eficacia
La evidencia apoya el uso de la Edu en dolor en desordenes MSK:
•  Reduce el dolor
•  Aumenta el conocimiento del paciente
•  Mejora la función
•  Disminuye la discapacidad
52
06-‐08-‐19
PUNTOS CLAVE:
Ø  Se recomienda el uso de PNE en pacientes con dolor crónico
Ø  Si se trabaja en grupos, buscar la forma de “personalizar la
educación”
Ø  Los pacientes quieren entender SU dolor no EL dolor
Educación en dolor 2.0
¿Cuál es tu

currículum?
•  Conceptos clave
•  Contenido
•  Recursos didácXcos
•  Medición de resultados
David Butler
•  Plan B
53
06-‐08-‐19
”El paciente que aprendió de su

terapeuta que su dolor realmente
no significaba nada, que de
repente se levantó de la silla, fue a
su casa y salió a andar en bicicleta
por primera vez en 5 años…
simplemente no existe!”
Louis Gifford,
Fisioterapeuta
(1953-‐2014)

Conocimiento de la neurofisiología del dolor, no predijo el éxito
clínico. Factores psicosociales podrían proponerse como elementos
para asegurar la efecXvidad de la END

54
06-‐08-‐19
“…la PNE no fue superior a la

educación biomédica en el
procesamiento nocicepXvo
central, la discapacidad o las
variables psicológicas en
pacientes con fibromialgia"
Educación
neurofisiológica del
dolor tuvo los
mismos resultados
que el placebo …

¿Cuál era el grupo
placebo?
55
06-‐08-‐19
Educando sobre dolor lumbar
•  Sentarse durante largas horas,

estrés y depresión son
desencadenantes de brotes en
personas con dolor agudo de
espalda.
•  A pesar de la creencia popular, el
levantamiento de pesas, la
acXvidad xsica y los deportes NO
se encontraron como factores
desencadenantes.
•  Ver a un kinesiólogo reducía el
riesgo de un brote.
Greg Lehman
56
06-‐08-‐19
DESCANSO
SUEÑO EN CAMA
McDonalds
PASEAR PERRO
SEDENTARISMO
W
ENTRETE DEPRESION
EJERCICIO
57
06-‐08-‐19
Evitar el ejercicio estereoXpado… “pero me ha

resultado en el pasado”
Freburger, J. Exercise PrescripXon for Chronic Back or Neck Pain: Who Prescribes It? Who Gets It? What is Prescribed?
ArthriXs Rheum. 2009 Feb 15; 61(2): 192–200.

EJERCICIOS
DEPENDIENDO DE
LOS OBJETIVOS,
NECESIDADES,
EXPECTATIVAS,
GANAS, ETC DEL
PACIENTE
Cañeiro JP, NG L, Burnem A, Campell A, O’Sullivan P. CogniXve FuncXonal Therapy for the Management of Low Back Pain in an
Adolescent Male Rower: A Case Report. JOSPT 2013, 43(8).
58
06-‐08-‐19
Exposición graduada + control

•  Exposición guiada a acXvidades dolorosas, temidas y/o evitadas
•  Concentrarse en controlar la respuesta (cogniXva, emocional y
movimiento) al dolor
•  Respiración diafragmáXca, relajación corporal, concienXzación y control
SPORTS REHABILITATION
Caneiro JP et cols. Process of Change in Pain-‐Related Fear: Clinical Insights From a Single Case Report of Persistent Back Pain
Managed With CogniXve FuncXonal Therapy. JOSPT. 2017
4a 4b 4c 4d
5a 5b 5c 5d
Mitchell, O’Sullivan & Burnem. ASPETAR SMJ 2015
Figure 4: Usual and corrected sitting and squatting postures for active extension control impairment.
Figure 5: Usual and corrected stepping and lifting postures for active extension control impairment.
* Lines have been added to indicate the level of pelvis in each component of the figure. This helps to visualise the attainment of a relatively
neutral posture.
• Teaching the athlete to adopt adaptive targeted strategies to normalise their

59
coping behaviours by providing postural and movement patterns as
strategies for optimal spinal loading quickly as possible in order to achieve pain The functional
•
and pain control.
Develop adaptive pacing strategies for
control. This involves three stages: specific
movement training, functional integration
component of
graduating training loads. and targeted conditioning. Specific focus CB-CFT provides
06-‐08-‐19
¡ así! esta es terapia

sigue
acXva centrada en el pero si no tengo miedo a
paciente.. superaremos tu moverme y no me gusta el
miedo!! gimnasio poh!!
Integración Funcional
60
06-‐08-‐19
HAY QUE DARLE

MÁS
IMPORTANCIA
A LO QUE
OCURRE EN LA
CASA!
hmps://www.medbridgeeducaXon.com/
Planeando el retorno gradual a una acBvidad

•  Hacer una lista con las acXvidades más importantes a realizar.
•  Dar un orden para hacer las cosas (de más fácil a más dixcil)
•  Ayudar a cambiar el movimiento/intensidad de las acXvidades (Ej: barrer
más corto y con menos fuerza, apoyar un pie al lavar los platos, etc)
61
06-‐08-‐19
Planeando el retorno gradual a una acBvidad

Nivel de tolerancia
•  Por cada acXvidad debemos buscar un nivel máximo de tolerancia
Evaluar
•  Después de varios días siguiendo este plan, debemos re-‐evaluar si
debemos hacer alguna modificación
Actividad graduada
•  Si después de varios días siguiendo el plan (1 semana) ha habido una
buena tolerancia (sin crisis), podemos subir la dificultad.
•  Este principio también se puede aplicar a los ejercicios.
•  La idea es dejar de seguir el principio de "no hay dolor, no hay ganancia"
de hacer ejercicio o de detenerse tan pronto como el paciente siente
dolor
•  La idea es que puedan hacer sus ejercicios primero con la guía del
kinesiólogo, después por si mismos en la clínica y después por su cuenta
en la casa (disminuir la frecuencia de las sesiones)
62
06-‐08-‐19
Actividad graduada
•  Recomendar mantener el nivel de acXvidad en los días buenos y malos, es
decir, no deben senXrse tentados a hacer más en un buen día.
•  Si han logrado alcanzar su línea de base en la mayoría de los días durante
un período de una o dos semanas, entonces pueden aumentar su
acXvidad de línea de base en un 10-‐20%.
Ejemplo
•  Si un paciente ha logrado una caminata de 10’ varias veces a la semana
durante 1-‐2 semanas, podría aumentar esto en un 10-‐20%. Entonces,
apuntarían a caminar durante 11 o 12 minutos varias veces a la semana,
durante 1-‐2 semanas más.
Actividad graduada
•  La acXvidad de referencia solo debe aumentarse en una pequeña canXdad
para que el cuerpo tenga Xempo para volverse más fuerte / flexible.
¿Y si el paciente Bene una crisis de dolor?

•  Volver al nivel anterior y permanecer allí por un Xempo más antes de
aumentar, o pueden aumentar la acXvidad en una canXdad menor.
63
06-‐08-‐19
Pacing
•  Es un enfoque sistemáXco e incremental para cambiar la acXvidad de una
persona.
•  Implica equilibrar la acXvidad, de modo que el día se divide en períodos de
descanso y acXvidad relaXva.
•  Se de be realizar la acXvidad, con o sin dolor, no hacer demasiado y no
hacer demasiado poco. El objeXvo es mantener un nivel de acXvidad
uniforme durante el día y la semana.
•  La esXmulación hace que las acXvidades o los comportamientos dependan
del Xempo o la cuota determinada (junto al kine) en lugar de los síntomas.
Estimular la auto-eficacia
•  Siempre que sea posible, debe alentar a los parXcipantes a resolver los
problemas por sí mismos
•  Un enfoque de "pruebe y vea" puede ayudar a los pacientes a converXrse
en invesXgadores o experimentadores acXvos y es clave para el
autocontrol y la autoeficacia.
•  No los retes si intentaron y “fallaron”, mejor analizar junto a ellos en qué
se equivocaron y esXmule que vuelvan a intentarlo
•  EsXmule que los pacientes prueben acXvidades y ejercicios nuevos
siempre que sea posible.
64
06-‐08-‐19
¿A quienes no les funciona?
•  Mantuvieron las creencias biomédicas

•  “Sé que hay algo más ahí”
Mala Respuesta
•  “El kine se rió y me dijo relájate, no
puedo”
•  Aceptaron el modelo BPS

Buena
•  Aumentan autoeficacia
Respuesta
•  “Entendí que me movía muy rígido”
Bunzli S. PaXent PerspecXves on ParXcipaXon in CogniXve FuncXonal Therapy for Chronic Low Back Pain. Phys Ther. 2016
Efectividad en los Programas de Auto-Manejo
Hay evidencia de

moderada calidad
que los PAM Xenen
un pequeño efecto
sobre el dolor y
discapacidad
Oliveira VC et al. EffecXveness of self-‐management of low back pain: systemaXc review with meta-‐analysis. ArthriXs Care Res
(Hoboken). 2012
65
06-‐08-‐19
Review
What Works and Does Not Work in a
Self-Management Intervention for
People With Chronic Pain?
Qualitative Systematic Review and
Meta-Synthesis
Downloaded from https://academic.oup.com/ptj/article-abstract/98/5/381/4925494 by guest on 21 July 2019

Hemakumar Devan, Leigh Hale, Dagmar Hempel, Barbara Saipe, Meredith A. Perry
Phys Ther. 2018 May 1;98(5):381-‐397. H. Devan, PhD, Centre for Health,
Activity and Rehabilitation Research
Background. Self-management interventions fostering self-efficacy improve the (CHARR), School of Physiotherapy,
well-being of people with chronic pain. University of Otago, Wellington, New
Zealand. Address all correspondence
•  Auto-‐manejo puede ser muy cansador

Purpose. The purpose of this study was to synthesize the enablers (what works)
and barriers (what does not) of incorporating self-management strategies for people in
to Dr Devan at: hemakumar.devan@
otago.ac.nz.
•  Proveer esXmulo en sesiones grupales o individuales esporádicas

everyday life after completion of a pain self-management intervention. L. Hale, PhD, Centre for Health,
Activity, and Rehabilitation Research
(CHARR), School of Physiotherapy, Uni-
Data Sources. Major electronic databases (MEDLINE, AMED, PsycINFO, Cochrane
Cuidado
•  PubMed,
Library, CINAHL,cScopus,
entrado en Scholar)
and Google la pwere
ersona
searchedy resolución
from inception to guiada de problemas es
versity of Otago.
D. Hempel, PGDipRehab, Pain Man-
July 2016.
esencial para facilitar el auto-‐manejo agement Service, Capital and Coast
District Health Board (CCDHB),
Study Selection. Study selection included qualitative and mixed-method studies that Wellington, New Zealand.
explored the perceptions of individuals with chronic pain after completion of a self- B. Saipe, B Phty, Pain Management
management intervention. Service, Capital and Coast District
Health Board (CCDHB).
Data Extraction. A thematic analysis approach was used to synthesize the review M. A. Perry, PhD, Centre for Health,
Activity, and Rehabilitation Research
findings, and a Confidence in the Evidence from Reviews of Qualitative Research (CER-
(CHARR), School of Physiotherapy,
Qual) Approach was used to assess the level of confidence.
University of Otago.
[Devan H, Hale L, Hempel D, et al.
Data Synthesis. Thirty-three studies with 512 participants were included. Enablers What works and does not work in
to self-management included self-discovery—the ability to distinguish self (ie, body, a self-management intervention for
thoughts, and feelings) from pain; feeling empowered by incorporating self-management people with chronic pain? Qualitative
strategies into practice; and supportive ambience via collaborative relationships with clini- systematic review and meta-synthesis.
cians and support from family and friends. Barriers to self-management included difficulty Phys Ther. 2018;98:381–397.]
with sustaining motivation for pain self-management; distress experienced from ongoing © 2018 American Physical Therapy
pain, anxiety, and depression; and unsupportive relationships with clinicians, family, and Association
friends. Accepted: February 13, 2018
Submitted: March 14, 2017
Limitations. This review only included interventions that involved at least 4 self-
management skills; thus, informative studies may have been missed. The follow-up period
varied from immediately after the intervention to 72 months following the intervention;
therefore, it is uncertain which of the key enablers and barriers were most influential long
term. Only articles published in the English language were included; studies conducted in
low- and middle-income countries could not be located.
Ejemplo
Conclusions. The sustained effort to self-manage chronic pain could be exhausting,
and motivation could wane over time following intervention. Providing intermittent
support in the form of booster sessions and peer support groups may be important.
Person-centered care via shared decision making and guided problem solving is essential
to facilitating ongoing self-management.
Priorizar
Post a comment for this
article at:
https://academic.oup.com/ptj
•  Limpia el living primero porque invitaste

May 2018 Volume 98 a migos
Number a cTherapy
5 Physical omer
! 381
Plan
•  ¿Podrías pasar la aspiradora durante 2 días, en lugar de hacer toda la casa
en un día? ¿Podrías barrer la cocina, ya que es más liviana que la
aspiradora y tus amigos no entrarán ahí?
Nivel de tolerancia
•  Encuentra el término medio entre lo que harías en un buen día y lo que
harías en un mal día
Evaluar
•  Si no te complicó aspirar una pieza, ¿podrías intentar hacer dos
habitaciones la próxima vez para ver si lo toleras bien?

66
06-‐08-‐19
Journal of Physiotherapy 62 (2016) 215–221
Journal of
PHYSIOTHERAPY
journal homepage: www.elsevier.com/locate/jphys
Research
Physiotherapists report improved understanding of and attitude toward the

cognitive, psychological and social dimensions of chronic low back pain after
Cognitive Functional Therapy training: a qualitative study
Aoife Synnott a, Mary O’Keeffe a, Samantha Bunzli b, Wim Dankaerts c, Peter O’Sullivan d,
Katie Robinson a, Kieran O’Sullivan a
a
Department of Clinical Therapies, University of Limerick, Limerick, Ireland; b Department of Surgery, University of Melbourne, Melbourne, Australia; c Department of Rehabilitation
Sciences, University of Leuven, Leuven, Belgium; d School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
K E Y W O R D S A B S T R A C T IdenXficar y
Qualitative é Confianza
Physical therapy
manejar factores
Question: What are physiotherapists’ perspectives on managing the cognitive, psychological and social
dimensions of chronic low back pain after intensive biopsychosocial training? Design: Qualitative study
cogniXvos,
Biopsychosocial design using semi-structured interviews to explore physiotherapists’ perceptions of their identification
é Habilidades
Low back pain
and treatment of the biopsychosocial dimensions of chronic low back pain after intensive Cognitive
Treatment
psicológicos y
Training
Functional Therapy (CFT) training. Participants: Thirteen qualified physiotherapists from four countries
who had received specific CFT training. The training involved supervised implementation of CFT in
clinical practice with patients. Interviews were audio-recorded and transcribed verbatim. An interpretive
sociales
descriptive analysis was performed using a qualitative software package. Results: Four main themes
emerged from the data: self-reported changes in understanding and attitudes; self-reported changes in
professional practice; altered scope of practice; and increased confidence and satisfaction. Participants
described increased understanding of the nature of pain, the role of patient beliefs, and a new
appreciation of the therapeutic alliance. Changes in practice included use of new assessments, changes in
communication, and adoption of a functional approach. Since undertaking CFT training, participants
described a greater awareness of their role and scope of practice as clinicians in identifying and
addressing these factors. Conclusion: Physiotherapists expressed confidence in their capacity and skill
set to manage the biopsychosocial dimensions of chronic low back pain after CFT training, and identified a
clear role for including these skills within the physiotherapy profession. Despite this, further clinical trials
are needed to justify the time and cost of training, so that intensive CFT training may be made more
readily accessible to clinicians, which to date has not been the case. [Synnott A, O’Keeffe M, Bunzli S,
Dankaerts W, O’Sullivan P, Robinson K, O’Sullivan K (2016) Physiotherapists report improved
understanding of and attitude toward the cognitive, psychological and social dimensions of chronic
low back pain after Cognitive Functional Therapy training: a qualitative study. Journal of
Physiotherapy 62: 215–221]
! 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction factors.5 Whilst the presence of cognitive, psychological and social

factors are regarded as predictors of poor prognosis, when targeted
Chronic low back pain is a costly and debilitating musculoskel- effectively, these factors are considered important mediators for
etal disorder that imposes a significant burden on both the person improved patient outcomes.6–8 This is on the basis of trials showing
and society.1,2 The societal and other costs of chronic low back pain that successful outcomes, even after a purely physical intervention,
are such that establishing an efficacious management approach to are often mediated by changes in cognitive and psychological factors
chronic low back pain is a healthcare priority.3,4 (eg, fear, catastrophising, self-efficacy, beliefs), not changes in
Chronic low back pain is no longer considered a purely structural, physical factors (eg, posture, muscle thickness), which are often the
anatomical or biomechanical disorder of the lumbar spine. Instead, main targets for treatment.9,10
there is strong evidence that chronic low back pain is associated Consequently, chronic low back pain treatment guidelines11,12
with a complex interaction of factors across the biopsychosocial generally acknowledge a shift toward a biopsychosocial manage-
spectrum. These not only involve structural or biomechanical ment approach. In this approach, the cognitive, psychological and
factors, but also cognitive (eg, unhelpful beliefs, catastrophising, social dimensions of chronic low back pain are considered in
maladaptive coping strategies, low self-efficacy), psychological (eg, addition to the physical and pathoanatomical dimensions of
fear, anxiety, depression) and social (eg, work and family issues) pain.13,14
http://dx.doi.org/10.1016/j.jphys.2016.08.002
1836-9553/! 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Dudas, sugerencias
en.sepulveda.lopez@gmail.com
+56987211949
67

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06-­‐08-­‐19

• Analizar el modelo biopsicosocial en el contexto clínico

0 years on. Which way is the be interpreted as interventional models.4

endulum swinging? WHICH WAY IS THE PENDULUM

spondence to Professor Gwendolen Jull,

spondence to Professor Gwendolen Jull, Paciente 1 Paciente 1 Paciente 1

¿Qué dicen las guías clínicas?

¿Qué dicen las Guías Clínicas en DL?

¿Qué dicen las Guías Clínicas en DL?

¿Tiene alguna ventaja seguir las guías?

• La mayoría de los estudios

Adherencia de los kinesiólogos a las Guías

Adherencia de los kinesiólogos a las Guías

Adherencia completa 5-24%

OK, reconocemos las banderas.. ¿y ahora

1 112 4 Moderate 25.4

OK, reconocemos las banderas.. ¿y ahora

EXAMINACIÓN DE FACTORES

“Sugerimos que es apropiado que los kinesiólogos

Los Factores Psicosociales cambian el resultado

Mediciones que inﬂuencian el resultado

Mediciones que inﬂuencian la relación entre

Transición de dolor lumbar agudo a crónico

¿Qué son los factores Psicosociales?

“Se describen como la combinación del estado cogniXvo,

¿Qué son los factores Psicosociales?

La Organización mundial de la salud los deﬁne como cualquier

Conceptos erróneos en relación a los PSC

Conceptos erróneos en relación a los PSC

Conceptos erróneos en relación a los PSC

¿Qué son las Banderas Amarillas?

• No son sinónimo de “factores psicosociales”

• Creencia que el dolor es dañino

¿Qué factores influencian la relación terapeuta-

Un abordaje biopsicosocial necesita la transformación de la

Antes de abrir la boca, pensemos..

Palabras a evitar AlternaBvas posibles

“Las palabras del profesional de la salud pueden

La entrevista y el contacto inicial

• Siéntate frente a tu paciente

Realizar preguntas abiertas

• En promedio un médico interrumpe a su paciente a los 11’’

Acentuar lo posiXvo

Resumir la historia al ﬁnal

Cognitive and affective reassurance and patient outcomes in primary

• Aseguramiento cogniXvo (explicaciones claras sobre la eXología,

e el pronósXco, el plan de tratamiento, etc.) mejora los resultados

a corto y largo plazo

• Aseguramiento afecXvo (cambio respuesta emocional del

no 1ene nada para enfrentar su problema”

1. Introduction such uncertainty, the consultation can be challenging for practitio-

Testimonio real de una paciente

cuanto te duele.

• é Percepción del efecto del tratamiento

AL: IF + AT DISMINUIDA

Dimensiones que debemos preguntar

Dimensiones que debemos preguntar

Experiencia de la persona con dolor

06-‐08-‐19

•  Analizar el modelo biopsicosocial en el contexto clínico

•  La mayoría de los estudios

•  No son sinónimo de “factores psicosociales”

•  Creencia que el dolor es dañino

•  Siéntate frente a tu paciente

•  En promedio un médico interrumpe a su paciente a los 11’’

•  Aseguramiento cogniXvo (explicaciones claras sobre la eXología,

•  Aseguramiento afecXvo (cambio respuesta emocional del

•  é Percepción del efecto del tratamiento

2.  Factores/posturas/movimientos agravantes y atenuantes

3.  Creencias del paciente.

3.  Creencias del paciente.

•  La columna es vulnerable a lesiones por su forma, trabajo o lesiones

•  El dolor lumbar es especial en su naturaleza e impacto

4.  Hallazgos imagenológicos

•  Disc bulge, protrusión discal, degeneración, extrusión, cambios de Modic

5.  Respuesta emocional y contexto social

5.  Contexto social

5.  Contexto social

6.  Comportamiento en respuesta al dolor

•  ¿Qué haces cuando Xenes que hHumans

7.  AcBvidades importantes dolorosas, evitadas, temidas, etc.

8.  Niveles globales de salud

9.  Metas personales importantes

•  Chronic pain coping inventory (CPCI)

•  Importantes (saXsfacción personal y calidad de vida)

•  “Si tuvieras una varita mágica y pudieras controlar completamente tu

•  Describe qué harías en un día perfecto para X