A brief introduction to what Keele's Stratified care for low back pain: Subgrouping and targeting treatment for low back pain in primary care (STarT Back).
The STarT Back approach uses a simple tool to match patients suggesting with back pain to treatment packages appropriate for them. This has been shown to decrease disability from back pain, reduce time off work, and save money by making better use of health resources.
Assessment and management of complex pain conditionsSaurab Sharma
This was a presentation made at NITTE University during their first Physiotherapy Conference where I was invited as a Speaker. I am posting this thinking if this will be useful revision for those who attended and may be of some use to those who could not listen.
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
Evidence based management of osteoarthritis in primary care - Dr Jonathan Quickepcsciences
Dr Jonathan Quicke is an NIHR Academic Clinical Lecturer in Physiotherapy (Keele University). Dr Quicke presented at the 2017 Musculoskeletal Education Day, where he discussed how we can ensure that best practice can be implemented within general practice for patients suffering with osteoarthritis
Diagnosis of inflammatory arthritis - Dr Louise Warburtonpcsciences
Co-host of the 2017 Musculoskeletal Education Day, Dr Louise Warburton helps healthcare professionals understand the difficulties in diagnosing inflammatory arthritis
There research on the effectiveness of Physical Therapy for back pain is not compelling. This presentation overviews the current evidence base and discusses the potential for classification of back pain to demonstrate stronger support for Physical Therapy.
The Specific Treatment of Problems of the Spine (STOPS) trial protocol is then presented. This study was recently completed showing moderate to strong effect sizes favouring Physical Therapy over evidence-based advice.
Note that the clinical protocol details in the presentation are examples only. For the full clinical protocol visit Physical Therapy Reviews
A brief introduction to what Keele's Stratified care for low back pain: Subgrouping and targeting treatment for low back pain in primary care (STarT Back).
The STarT Back approach uses a simple tool to match patients suggesting with back pain to treatment packages appropriate for them. This has been shown to decrease disability from back pain, reduce time off work, and save money by making better use of health resources.
Assessment and management of complex pain conditionsSaurab Sharma
This was a presentation made at NITTE University during their first Physiotherapy Conference where I was invited as a Speaker. I am posting this thinking if this will be useful revision for those who attended and may be of some use to those who could not listen.
PMR and GCA: A GP Update - Dr Toby Helliwell pcsciences
Dr Toby Helliwell is a practising GP and Researcher at the Research Institute for Primary Care and Health Sciences. As part of the 2017 Musculoskeletal Education Day, he provides an update of the diagnosis on treatment of Polymyalgia Rheumatica and Giant cell Arteritis from a GP's perspective
Evidence based management of osteoarthritis in primary care - Dr Jonathan Quickepcsciences
Dr Jonathan Quicke is an NIHR Academic Clinical Lecturer in Physiotherapy (Keele University). Dr Quicke presented at the 2017 Musculoskeletal Education Day, where he discussed how we can ensure that best practice can be implemented within general practice for patients suffering with osteoarthritis
Diagnosis of inflammatory arthritis - Dr Louise Warburtonpcsciences
Co-host of the 2017 Musculoskeletal Education Day, Dr Louise Warburton helps healthcare professionals understand the difficulties in diagnosing inflammatory arthritis
There research on the effectiveness of Physical Therapy for back pain is not compelling. This presentation overviews the current evidence base and discusses the potential for classification of back pain to demonstrate stronger support for Physical Therapy.
The Specific Treatment of Problems of the Spine (STOPS) trial protocol is then presented. This study was recently completed showing moderate to strong effect sizes favouring Physical Therapy over evidence-based advice.
Note that the clinical protocol details in the presentation are examples only. For the full clinical protocol visit Physical Therapy Reviews
Gout - what should I be doing in Primary Care?pcsciences
Dr Ed Roddy, Reader in Rheumatology (Keele University) and Consultant Rheumatologist (Haywood Hospital) presented at this year's 'Musculoskeletal Education Day'. Here Ed advises what health care professionals should be be doing when dealing with patients suffering with gout based on recent research findings.
Efficacy of classification-based_cft_in_nsclbpMeziat
Artigo (6) importante para a preparação para o curso de dor lombar crônica. "Eficácia da Terapia Cognitiva Funcional em pacientes com dor lombar crônica inespecífica: ensaio clínico randomizado controlado."
Gout - what should I be doing in Primary Care?pcsciences
Dr Ed Roddy, Reader in Rheumatology (Keele University) and Consultant Rheumatologist (Haywood Hospital) presented at this year's 'Musculoskeletal Education Day'. Here Ed advises what health care professionals should be be doing when dealing with patients suffering with gout based on recent research findings.
Efficacy of classification-based_cft_in_nsclbpMeziat
Artigo (6) importante para a preparação para o curso de dor lombar crônica. "Eficácia da Terapia Cognitiva Funcional em pacientes com dor lombar crônica inespecífica: ensaio clínico randomizado controlado."
Laura Mann Center Integrative Lecture Series: Fall 2014Cara Feldman-Hunt
A Success Story: Incorporating Integrative Medicine into the Hospital and Outpatient Care
Courtney Jordan Baechler, MD, MS, Chief Wellness Officer Vice President, Penny George Institute for Health and Healing, Allina Health
Whole Health is part of collaborative effort by the Pacific Institute for Research and Evaluation, VA Office of Patient Care and Cultural Transformation, and University of Wisconsin Integrative Health Program to transform healthcare and help people live healthier, happier lives, and more purpose-driven lives.
Learn more: https://wholehealth.wisc.edu/courses-training/whole-health-for-pain-and-suffering/
Penny George™ Institute for Health and Healing: Meeting Patients Where They AreAllina Health
By Courtney Baechler, MD. A discussion about the Penny George Institute and its goal to empower patients using the mind-body-spirit approach to health, encouraging a philosophy of wellness at any stage of care. The Penny George Institute has become a national leader in holistic health care and is an important component of Allina Health efforts to achieve health care transformation through the Triple Aim.
It's a Pain in the Neck (and Back too!)Summit Health
Thank you to the Montclair Public Library for hosting SMG's Joanne Owsiak, MD, Interventional Pain Management specialist, for a community lecture on Neck and Back Pain. Eighty-five percent of people experience low back pain during their lifetime, and back pain has become the fifth most common reason for all physician visits. Dr. Owsiak shared with the audience the many causes of neck and back pain and the pain management options available for treating all types.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
1. BACK PAIN TREATMENT
GUIDELINES
• DR. KRISHNA PODDAR
• DIRECTOR KOLKATA PAIN CLINIC
• SENIOR PAIN SPECIALIST
• FORTIS HOSPITAL
• ASSOCIATE PROFESSOR
• VIMS WBHU INDIA
• www.kolkatapainrelief.com
2. Have you had low back pain?
1. How many of you have
ever had back pain?
2. How many of you seek
help for your back pain?
3. Low Back Pain
• Low back pain is the most common musculoskeletal
disorder
• Experienced by nearly everyone at some point in his
or her life.
• The annual prevalence of chronic back pain ranges
from 15% to 45%, with a point prevalence of 30%
• Lifetime prevalence-24% in men; 30% in women
• The average age related prevalence is 15% in adults
and 27% in the elderly
• In United States the total direct costs ($65 billion)
• Indirect costs ($106 billion)
(Manchikanti, Pain Physician Vol. 3, No. 2, 2000
5. Other Causes
• Trauma
• Infections
• Rheumatoid arthritis
• Aankylosing spondylitis
• Cancers
• Referred Pain like
Endometriosis,Pancreatitis or Renal
pathology
6. Types of Back Pain
• Acute back pain is defined as lasting less
than 4 weeks,
• Subacute back pain lasts 4 to 12 weeks,
and chronic
• Chronic back pain lasts more than 12
weeks
6
7. Treatment of Low Back pain
• Non-pharmacological treatment
• Pharmacological treatment
• Interventional Pain management
1. Gilron I et al. Can Med Assoc J 2006;175:265-275.
2. Bennett MI, Closs SJ. Pain Clinical Updates 2010;18:1-6.
11. Clinical Practice Guidelines
• To describe appropriate care based
on the best available scientific
evidence and broad consensus
• To provide or promote:
a rational basis for referral
• focus for continuing education
• promote efficient use of resources
• focus for quality control
•suggest appropriate future research
?
12. THE CHALLENGES
• Recommendations for diagnosis and
treatment should be the same, are they?
• The guidelines are measured by the same
instrument?
• All Recommendation from Guidelines are
Evidence Based?
• The individuals on the guideline committees
are similar from one committee to the next?
12
14. • 1. Australia, National Health and Medical Research Council (2003)
• 2. Austria, Center for Excellence for Orthopaedic Pain Management
Speising (2007)
• 3. Canada, Clinic on Low back Pain in Interdisciplinary Practice (2007)
• 4. Europe, COST B13 Working Group on Guidelines for the Management of
Acute Low Back Pain in Primary Care 1 (2004)
• 5. Europe, COST B13 Working Group on Guidelines for the Management of
Chronic Low Back Pain in Primary Care (2004)
• 6. France, Agence Nationale d’Accreditation et d’Evaluation en Sante (2000)
• 7. Germany, Drug Committee of the German Medical Society (2007)
• 8. Italy, Italian Scientific Spine Institute (2006)
• 9. New Zealand, New Zealand Guidelines Group (2004)
• 10. Norway, Formi & Sosial‐og helsedirectorated (2007)
• 11. Spain, the Spanish Back Pain Research Network (2005)
• 12. The Netherlands, The Dutch Institute for Healthcare Improvement (CBO)
(2003)
• 14. United Kingdom, National Health Service (2008)
• 15. United States, American College of Physicians and the American Pain
Society (2007)
14
16. What makes a good guideline?
• Methodological quality – certain rules
regarding how guideline is developed and
written
• Analogy: RCT quality
– Randomised allocation
– Blinding
– Follow‐up rates
– Appopriate statistics and reporting
16
17. ACP GUIDELINES
• Ann Intern Med. 2017;166:514-530.
doi:10.7326/M16-2367 Annals.org
• These guidelines are based on 2 background evidence
reviews and a systematic review sponsored by the
Agency for Healthcare Research and Quality(AHRQ)
• Reviewers searched several databases for studies
published in English from January 2008 through April
2015 and updated the search through November 2016.
17
18. Quality of
Evidence
Benefits Clearly
Outweigh Risks
and Burden
Risks and Burden
Clearly Outweigh
Benefits
High Strong Weak
Moderate Strong Weak
Low Strong Weak
Insufficient evidence to
determine net benefits or
risks
18
19. PHARMACOLOGICAL
Acute/Subacute Chronic Back Pain RADICULAR
ACETAMINOPHEN LOW INSUFFICIENT
NSAID VS PLACEBO
NSAID VS NSAID
MODERATE
LOW-NO
MODERATE
LOW-NO
BENZODIAGEPALMS LOW-NO LOW-NO LOW-NO
SMRs MODERATE LOW
SMRs VS SMRs
SMRs+NSAIDS VS NSAIDS
NO
NO
NO
CORTICOSTEROIDS LOW INSUFFICIENT MODERATE-NO
ANTIDEPRESSANTS
DULOXETINE
NO NO
SMALL EFFECT
NO
ANTICONVULSANTS NO INSUFFICIENT
OPIOIDS VS NSAIDS
STRONG OPIOIDS
BUPRENORPHINE PATCH
TRAMADOL
NO
STRONG
LOW
MODERATE
NO
21. Acute low back pain
Non Pharmacologic
Non pharmacologic
• Heat wrap: improved pain and function (moderate
effect)
• Massage: improved pain and function (at 1 but not 5
wk) (small to moderate effect)
• Acupuncture: improved pain (small effect)
• Spinal manipulation: improved function (small effect)
21
22. CHRONIC-Non pharmacologic
• Exercise: improved pain and function (small effect)
• Motor control exercise: improved pain (moderate
effect) and function (small effect)
• Tai chi: improved pain (moderate effect) and function
(small effect)
• Mindfulness- improved pain and function (small effect)
• Yoga: improved pain and function (small to moderate
effect, )
• Progressive relaxation: improved pain and function
(moderate effect)
22
23. • Multidisciplinary rehabilitation: improved pain
(moderate effect) and function (no to small effect)
• Acupuncture: improved pain (moderate effect) and
function (no to moderate effect,
• LLLT: improved pain and function (small effect)
• Electromyography biofeedback: improved pain
(moderate effect)
• Operant therapy: improved pain (small effect)
• Cognitive behavioral therapy: improved pain
(moderate effect)
• Spinal manipulation: improved pain (small effect)
23
24. Recommendation
1- Most patients with acute or subacute low back pain
improve over time regardless of treatment
2- Nonpharmacologic treatment with superficial heat
massage, acupuncture, or spinal manipulation
3-Reassurance and activity advice,self‐care
4-pharmacologic treatment -nonsteroidal anti-
inflammatory drugs or skeletal muscle relaxants
24
25. Recommendation
• Chronic low back pain pharmacologic treatment with
nonsteroidal anti-inflammatory drugs as first-line therapy
• Tramadol or duloxetine as second-line therapy.
• Opioids as an option in patients who have failed the
aforementioned treatments and only if the potential benefits
outweigh the risks for individual patients and after a discussion
of known risks and realistic benefits with patients
• Avoid long-term opioids, tricyclic antidepressants and SSNRI
• Exercise- supervised for chronic back pain
• Don’ts– Routine x‐ray, bedrest, electrotherapies lumbar
supports
• Unclear– Massage, traction
25
26. Interventional Techniques:
Evidence-based Practice Guidelines in the
Management of Chronic Spinal Pain
Mark V. Boswell et al
Pain Physician 2007; 10:7-111 • ISSN 1533-3159
American Society of Interventional Pain Physicians
(ASIPP) guidelines
27. Definitions:
Level I
Conclusive: Research-based evidence with multiple relevant and
high-quality scientific studies or consistent reviews of meta-
analyses
Level II
Strong: Research-based evidence from at least one properly
designed randomized, controlled trial; or research-based evidence
from multiple properly designed studies of smaller size; or multiple
low quality trials
Level III
Moderate: a) Evidence obtained from well-designed
pseudorandomized controlled trials; b) evidence obtained from
comparative studies with concurrent controls and allocation not
Level IV
Limited: Evidence from well-designed nonexperimental studies
from more than one center or research group
Level V
Indeterminate: Opinions of respected authorities, based on
clinical evidence,
28. Epidural Steroid Injection (ESI)
-Transforaminal Epidural Injections or Selective Nerve Route
Blocks
moderate for preoperative evaluation of patients with negative or
inconclusive imaging studies and clinical findings of nerve root
irritation
•Caudal epidural steroid injections is strong for short-term relief
and moderate for long-term relief, in managing chronic low back
and radicular pain.
• in post-lumbar laminectomy syndrome and spinal stenosis is
limited.
29. Interlaminar Epidural Steroid
Injection (ESI)
The evidence for lumbar radiculopathy is strong for
short-term relief and limited for long-term relief.
For cervical radiculopathy, the evidence is moderate for
short-term and long-term relief.
Indeterminate in the management of neck pain, low back
pain, and lumbar spinal stenosis.
Intralaminar
30. Sacroiliac Joint Blocks
• The evidence for the accuracy of sacroiliac
joint diagnostic injections is moderate for
the diagnosis of sacroiliac joint pain
31. Facet or Zygapophysial Joint Diagnostic
Blocks
• The accuracy of facet joint nerve blocks is
strong in the diagnosis of lumbar and
cervical facet joint pain, whereas it is
moderate in the diagnosis of thoracic facet
joint pain.
32. Therapeutic Facet Joint Interventions
• Intraarticular Blocks -moderate evidence for short and long-
term improvement in managing low back pain and the
evidence is limited for short and long-term relief in the
management of neck pain
• Medial Branch Blocks. The evidence for lumbar, cervical, and
thoracic medial branch blocks in managing chronic low back,
neck, mid back and upper back pain is moderate for short-
term and long-term pain relief.
33. RF Ablation
•Medial Branch Neurotomy. Evidence for radiofrequency
neurotomy of medial branch of cervical spine, is strong for short
and long-term relief
•lumbar region, the evidence for radiofrequency neurotomy of
medial branches is strong for short-term and moderate for long-
term relief
• Evidence for cryo denervation, and pulsed radiofrequency is
indeterminate.
34. Provocation Discography
• The evidence for lumbar discography is strong for
discogenic pain
• There is no evidence to support discography without
other non-invasive or less invasive modalities of
treatments or other precision diagnostic injections
• The evidence for cervical and thoracic discography is
limited.
35. Radiofrequency posterior annuloplasty &
Intradiscal electrothermal therapy
The evidence for radiofrequency posterior annuloplasty
was limited for short-term improvement, and
indeterminate for long-term improvement in managing
chronic discogenic low back pain.
The evidence for intradiscal electrothermal therapy is
moderate in managing chronic discogenic low back
pain.
36. Percutaneous Adhesiolysis
• The number of procedures are preferably limited
to:
– With a 3-day protocol, 2 interventions per year
– With a 1-day protocol, 4 interventions per year
• Spinal Endoscopic Adhesiolysis
• The procedures are preferably limited to a
maximum of 2 per year provided the relief was
>50% for >4 months.
Contrast injection after adhesiolysis
37. • The level of evidence for vertebroplasty is
moderate
• The level of evidence for kyphoplasty is
moderate
Vertebroplasty & kyphoplasty
38. Implantable intrathecal infusion
systems
The evidence for implantable intrathecal infusion
systems is strong for short-term improvement in
pain of malignancy or neuropathic pain.
The evidence is moderate for long-term
management of chronic pain.
39. Spinal cord stimulation
strong for failed back surgery syndrome and
complex regional pain syndrome for short-
term relief and moderate for long-term
relief.
40. Chronic neck pain
Based on clinical evaluation
Facet Joint Blocks Epidural Injections
Positive Positive NegativeNegative
Epidural Injections
Positive Negative
Stop process
OR
Provocative Discography*
Facet Joint Blocks
Positive Negative
Stop process
OR
Provocative Discography*
Positive
Positive
Negative
Negative
Mark V. Boswell et al, Interventional Techniques: Evidence-based Practice Guidelines in the Management
of Chronic Spinal Pain :Pain Physician 2007; 10:7-111 • ISSN 1533-3159
41. Chronic low back pain
Somatic pain Radicular pain
i. Facet Joint Pain
Intraarticular
Facet joint blocks /
Medial branch blocks or
Radiofrequency
ii. SI Joint Pain
SI joint blocks
iii. Discogenic Pain Intradiscal
therapy
i. No Surgery/ Post Surgery/ Spinal Stenosis
Step I: Caudal / Interlaminar
or Transforaminal epidural
ii. No Surgery
Step II: Discography and
Intradiscal therapy
iii. Post Surgery
Step IV: Spinal Endoscopic
Adhesiolysis
Step V: Implantable therapy
management of chronic low back pain
Mark V. Boswell et al, Interventional Techniques: Evidence-based Practice Guidelines in the Managemen
Chronic Spinal Pain :Pain Physician 2007; 10:7-111 • ISSN 1533-3159