This document provides an overview of failed back surgery syndrome (FBSS), including its diagnosis, evaluation, and treatment. It defines FBSS as continued back and/or extremity pain following one or more spinal surgeries. Common causes of FBSS include deconditioning, psychosocial factors, and surgical complications. The evaluation of FBSS involves a detailed pain history, physical exam, imaging, and may include diagnostic blocks. Treatment is multidisciplinary and aims to improve function through physical therapy, psychological treatments, and pain management with medications, injections, or devices.
Failed Back and Neck Surgery Syndromes happen when a surgery to correct pain completely fails to alleviate the pain and in some cases makes the pain worse.
There are many reasons why a surgery could fail to provide results, both related to the patient and the surgeon.
How is it that a patient could cause a surgery to fail. A great example of this would be that a patient has undergone a spinal fusion to correct spinal instability in the lower back. The surgeon has advised the patient that smoking cigarettes which could severely reduce the healing chances and effect the fusion process. The patient ignores the doctor and continues to smoke and the fusion doesn’t heal. This is an example of the patient being at fault.
In what ways could a surgeon be at fault? There are many times that there is fault before the surgery is even performed. If there is an inaccurate diagnoses the surgery will be performed in the wrong area, and possibly the wrong surgery will be done. It is important to seek a second opinion of a specialist before proceeding with surgery of any kind. If two heads can agree on what and where the problem is, it is likely that there will be an accurate diagnosis.
One of the most common reasons for Failed Back and Neck Surgery Syndrome is that the surgeon is just not experienced enough in the technique being performed and he/she doesn’t perform it properly. This is why it is important to ask the right questions to the surgeon before moving forward with the surgery. How long have you been performing back surgeries? How long have you been performing this specific surgical procedure? and how many times a year do you perform this surgery.
Back and neck surgeries are procedures meant to be a permanent fix for a specific problem and correcting failed back or neck surgery is difficult.
Human spine is a complex structure that provides both mobility (so to bend and twist) and stability (so to remain upright). The normal curvature of spine has an “s”- like curve when looked at from the side. This curvature allows even distribution of weight and with stand stress.
IN CONCLUSION:
CRPS is a chronic debilitating painful condition
There has been significant advances in our understanding of its Pathophysiology
Early diagnosis and management – is essential to help patients and reduce suffering
The Budapest Criteria should help while excluding others
A Multidisciplinary Approach to Management has been shown to be beneficial
With particular emphasis on Patient Education and Support
Interventional pain management by dr rajeev harsheRajeev Harshe
This is a brief presentation on how pain can be managed in a better way. Dr Rajeev Harshe is senior pain management consultant in western India. He is attached to Apollo Hospitals and has his private consulting room as well.Email: dr.harshe@gmail.com. If you are anaesthesiologist and if you wish to learn pain management,contact him.
Different descriptions of Pain, Pain Pathways, Specific Types of pains and their management, Pharmacological treatment of pain and non-pharmacological maneuvers to relieve pain, WHO ladder of pain, Chronic Pain management Goals
Failed Back and Neck Surgery Syndromes happen when a surgery to correct pain completely fails to alleviate the pain and in some cases makes the pain worse.
There are many reasons why a surgery could fail to provide results, both related to the patient and the surgeon.
How is it that a patient could cause a surgery to fail. A great example of this would be that a patient has undergone a spinal fusion to correct spinal instability in the lower back. The surgeon has advised the patient that smoking cigarettes which could severely reduce the healing chances and effect the fusion process. The patient ignores the doctor and continues to smoke and the fusion doesn’t heal. This is an example of the patient being at fault.
In what ways could a surgeon be at fault? There are many times that there is fault before the surgery is even performed. If there is an inaccurate diagnoses the surgery will be performed in the wrong area, and possibly the wrong surgery will be done. It is important to seek a second opinion of a specialist before proceeding with surgery of any kind. If two heads can agree on what and where the problem is, it is likely that there will be an accurate diagnosis.
One of the most common reasons for Failed Back and Neck Surgery Syndrome is that the surgeon is just not experienced enough in the technique being performed and he/she doesn’t perform it properly. This is why it is important to ask the right questions to the surgeon before moving forward with the surgery. How long have you been performing back surgeries? How long have you been performing this specific surgical procedure? and how many times a year do you perform this surgery.
Back and neck surgeries are procedures meant to be a permanent fix for a specific problem and correcting failed back or neck surgery is difficult.
Human spine is a complex structure that provides both mobility (so to bend and twist) and stability (so to remain upright). The normal curvature of spine has an “s”- like curve when looked at from the side. This curvature allows even distribution of weight and with stand stress.
IN CONCLUSION:
CRPS is a chronic debilitating painful condition
There has been significant advances in our understanding of its Pathophysiology
Early diagnosis and management – is essential to help patients and reduce suffering
The Budapest Criteria should help while excluding others
A Multidisciplinary Approach to Management has been shown to be beneficial
With particular emphasis on Patient Education and Support
Interventional pain management by dr rajeev harsheRajeev Harshe
This is a brief presentation on how pain can be managed in a better way. Dr Rajeev Harshe is senior pain management consultant in western India. He is attached to Apollo Hospitals and has his private consulting room as well.Email: dr.harshe@gmail.com. If you are anaesthesiologist and if you wish to learn pain management,contact him.
Different descriptions of Pain, Pain Pathways, Specific Types of pains and their management, Pharmacological treatment of pain and non-pharmacological maneuvers to relieve pain, WHO ladder of pain, Chronic Pain management Goals
The evaluation of back pain can be a pain in the neck or a back-breaking exercise, so to speak. However, the diagnosis hinges always on a focused History and Physical Exam and not really on labs or imaging. Knowing what to ask and where to look can make the evaluation of this all-too-common condition manageable for the internist.
This lecture focuses on the evaluation of low back pain and will guide the reader on the key points in the Hx and PE and prevent unnecessary testing/imaging. It also presents 3 "unusual" cases of low back pain which may be disabling if not recognized immediately.
Pain management: An Interdisciplinary Approach | VITAS HealthcareVITAS Healthcare
Pain management is first and foremost in a hospice patient’s plan of care. Hospice provides comfort and quality of life near the end of life, and hospice providers are experts at managing pain. The goal of this webinar is to help healthcare professionals understand all aspects of a patient’s pain as a symptom near the end of life, and how to utilize an interdisciplinary approach to provide the most effective pain management.
Austin Pain & Relief is an open access, peer reviewed, scholarly journal dedicated to publish articles covering all areas of Pain & Relief.
The journal aims to promote research communications and provide a forum for doctors, researchers, physicians and healthcare professionals to find most recent advances in all areas of Pain & Relief. Austin Pain & Relief accepts original research articles, reviews, mini reviews, case reports and rapid communication covering all aspects of pain and relief.
Austin Pain & Relief strongly supports the scientific up gradation and fortification in related scientific research community by enhancing access to peer reviewed scientific literary works. Austin Publishing Group also brings universally peer reviewed journals under one roof thereby promoting knowledge sharing, mutual promotion of multidisciplinary science.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
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
DISSERTATION on NEW DRUG DISCOVERY AND DEVELOPMENT STAGES OF DRUG DISCOVERYNEHA GUPTA
The process of drug discovery and development is a complex and multi-step endeavor aimed at bringing new pharmaceutical drugs to market. It begins with identifying and validating a biological target, such as a protein, gene, or RNA, that is associated with a disease. This step involves understanding the target's role in the disease and confirming that modulating it can have therapeutic effects. The next stage, hit identification, employs high-throughput screening (HTS) and other methods to find compounds that interact with the target. Computational techniques may also be used to identify potential hits from large compound libraries.
Following hit identification, the hits are optimized to improve their efficacy, selectivity, and pharmacokinetic properties, resulting in lead compounds. These leads undergo further refinement to enhance their potency, reduce toxicity, and improve drug-like characteristics, creating drug candidates suitable for preclinical testing. In the preclinical development phase, drug candidates are tested in vitro (in cell cultures) and in vivo (in animal models) to evaluate their safety, efficacy, pharmacokinetics, and pharmacodynamics. Toxicology studies are conducted to assess potential risks.
Before clinical trials can begin, an Investigational New Drug (IND) application must be submitted to regulatory authorities. This application includes data from preclinical studies and plans for clinical trials. Clinical development involves human trials in three phases: Phase I tests the drug's safety and dosage in a small group of healthy volunteers, Phase II assesses the drug's efficacy and side effects in a larger group of patients with the target disease, and Phase III confirms the drug's efficacy and monitors adverse reactions in a large population, often compared to existing treatments.
After successful clinical trials, a New Drug Application (NDA) is submitted to regulatory authorities for approval, including all data from preclinical and clinical studies, as well as proposed labeling and manufacturing information. Regulatory authorities then review the NDA to ensure the drug is safe, effective, and of high quality, potentially requiring additional studies. Finally, after a drug is approved and marketed, it undergoes post-marketing surveillance, which includes continuous monitoring for long-term safety and effectiveness, pharmacovigilance, and reporting of any adverse effects.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
1. Failed Back Surgery
Syndrome – Part 1
Diagnosis and Evaluation
Richard K. Osenbach, M.D.
Division of Neurosurgery
Duke University Medical Center Brought to you by
2. Chronic Pain – Scope of the Problem
9% – 28% of the population suffers from moderate to severe
chronic non-cancer pain
American Pain Society (2002); Chronic pain in
America: roadblocks to relief
86 million Americans suffer from chronic pain
66 million Americans partially/totally disabled
8 million disabled by LBP
65,000 cases of permanent disability diagnosed annually
100 billion dollars in annual economic losses
40 million physician visits per year
515 million lost workdays annually
Business Week (1999)
Brought to you by
3. Pain Types
NOCICEPTIVE PAIN
results from ongoing activation of mechanical,
thermal, or chemical nociceptors
typically opioid-responsive
eg. pain related to mechanical instability
NEUROPATHIC PAIN
spontaneous or evoked pain that occurs in the
absence of ongoing tissue damage
typically opioid-resistant***
eg. pain secondary to nerve root injury Brought to you by
4. Neuropathic Pain
Pain in absence of ongoing tissue damage
Pain in an area of sensory loss
Paroxysmal or spontaneous pain
Characteristics of pain: burning, pulsing, stabbing
Allodynia, hyperalgesia, or dysesthesias
Delay in onset following injury
Presence of major neurological deficit
Poor response to opioids
Brought to you by
6. Failed Back Surgery Syndrome
FBSS is a term applied to a heterogeneous group of
individuals who share only one characteristic - continued
back and/or extremity pain following one or more spinal
operations
15% of patients will experience persistent or recurrent
symptoms
Spectrum of abnormalities ranging from purely organic
to purely psychological, but in most cases consists of a
physiological abnormality complicated by psychological
factors
FBSS is perhaps the prototypical example of chronic
pain as a biopsychosocial disorder
Brought to you by
7. Failed Back Patient Profile
Pain and suffering often disproportionate to any
identifiable disease process
Depression
Physical deconditioning
Inappropriate use of physician-prescribed medications
Superstitious beliefs about bodily functions
Failure to work or perform expected physical and
cognitive activities
No active medical problems that can be remediated with
the expectation of relief of pain
Brought to you by
8. The “Ds” of FBSS
Disuse
Deconditioning
Drug misuse
Dependence
Depression
Disability Brought to you by
9. Post-operative Causes of Back Pain
Deconditioning Trauma
Muscle spasm Wrong level fused
Myofascial pain Insufficient levels fused
Spinal instability Pseudomeningocele
Diskogenic pain Graft donor site pain
Facet arthropathy Psychosocial factors
Infection
Pseudarthrosis
Loose hardware
Arachnoiditis
Brought to you by
10. Post-operative Causes of Leg Pain
Retained disk fragment Arachnoiditis
Recurrent HNP Synovial cyst
Far lateral disk Root sleeve meningocele
Lateral recess stenosis Loose hardware
Inadequate decompression Facet fracture
Wrong level decompressed Psychosocial factors
Nerve root injury
Retained foreign body
Epidural fibrosis Brought to you by
11. Goals of Chronic Pain Management
in Patients with FBSS
Functional improvement
Functional improvement
Functional improvement!!!
Improvement in physical activities and exercise tolerance
Reduction in narcotic use
Reduction in healthcare consumption
Return to work
Pain reduction
Brought to you by
12. Principles of Chronic Pain Management
1. “Single most important ingredient is the existence
of health care providers who are willing to work
together as a team.”
2. Providers must take an interest in chronic disease
and not be overly focused on acute illness as is
fostered by the biomedical model
3. Commitment of the provider to the patient
Brought to you by
13. Principles of Chronic Pain Management
4. Patient must be motivated to change their lives and must be
willing to do the therapeutic work
5. Treatment represents the beginning of a journey to reclaim
one’s life from the pain problem; long-term support is
required to maintain success
6. Patient selection is a key to success. Attempting to treat
the untreatable results in demoralization of the treatment
team
Brought to you by
14. Multidisciplinary Pain Management
Collaborative efforts of a group of providers
Physicians
Nurses
Psychologists
Physical Therapists
Vocational counselors
Social workers
Support staff
Team work is essential
Extensive interactions between team members
Adequate space Brought to you by
15. Multidisciplinary Pain Programs
No single accepted format
Generic concept and plan common to all
programs of this type
Based on biopsychosocial model of pain
Complaint of pain generated by a combination of
events in any particular patient
Simultaneously address all issues
Present patient with a single treatment program
that encompasses all the TREATABLE issues
Brought to you by
16. Common Features of
Multidisciplinary Pain Management
Physical therapy and rehabilitation
Medication management
Patient education about pain and body function
Psychological treatments
Coping skills training
Vocational assessment
Therapies targeted toward improving the likelihood of
return to work
Surgical interventions for selected patients Brought to you by
17. Multidisciplinary Pain Clinic Personnel
Physicians
Neurosurgeon
Orthopedic surgeon
Anesthesiologist
Neurologist
Physiatrist
Internal medicine
Psychiatrist
Addictionologist
Nurses
Psychologists
Physical Therapist
Occupational Therapist
Vocational counselor
Social worker
Dietician
Recreational staff
Administrative support staff
Brought to you by
18. Failed Back Surgery Syndrome
Surgical Complications
Disk space infection
Iatrogenic instability
Nerve root injury
Retained disk fragment
Recurrent disk herniation
Inadequate decompression
Complications of fusion and instrumentation
Adhesive arachnoiditis
Brought to you by
19. Failed Back Surgery Syndrome
Physician Decision Making
Poor patient selection
Poor patient selection
Poor patient selection
Poor patient selection
Poor patient selection
Poor patient selection
Poor patient selection Brought to you by
20. The most common cause of failed back syndrome is
poor judgment on the part of the physician.
Surgery prescribed as a last resort, with a hope
and a prayer that it might alleviate the pain.
Brought to you by
21. When in doubt, it’s a good idea to take a
history and examine the patient
Brought to you by
22. Evaluation of the Patient with FBSS
Detailed pain history including prior treatments and
MOST IMPORTANTLY the outcome of each
Obtain appropriate imaging studies (including those
on which surgical decisions were based)
Attempt to establish the underlying cause of the
pain; however……….
Brought to you by
23. DO NOT get caught up in an endless search for
THE PAIN GENERATOR
Brought to you by
25. Pain History
Where is it located?
Does the pain radiate?
When did it start and under what circumstances?
What is the quality of the pain?
What is the severity of the pain (VAS scores)
What factors make it worse?
What factors make it better?
Are there associated symptoms?
Brought to you by
26. Pain History
Effect of pain on sleep
Medications taken for pain
Health professionals consulted
Patient’s beliefs concerning the cause of pain
Expectations of outcome of treatment
Family expectations
Pain reduction required for “reasonable activities
Brought to you by
27. Treatment History
What therapies have been tried and what were the
outcomes?
Physical therapy
Injections
Epidural steroids, nerve root blocks, facet blocks,
etc
Medication history
What drugs?
Dose?
How long?
Effect?
Brought to you by
28. Physical Examination
Rarely diagnostic
Principally serves to establish the current level of
physical impairment
Lack of physical abnormality should not be used to deny
a patient evaluation and therapy if indicated
Brought to you by
29. Examination of the Lumbar Spine
Inspection, palpation, and evaluation of ROM
Abnormalities of muscle tone
Local tenderness
Reduced ROM
Neurological exam
Muscle strength
Sensation
Reflexes
Nerve root tension signs
Sciatic and femoral stretch test
Brought to you by
30. Imaging Studies
Static plain radiographs
Spinal alignment
Flexion/extension views
Instability
Computed tomography (CT)
Bony surgical defects
Hardware placement
Fusion mass
Magnetic resonance imaging (MRI)
Soft tissue and neural structures
Radionuclide imaging
Technetium99 bone scan
Indium111 WBC scan
Brought to you by
33. Electrophysiological Studies
EMG is likely of greater utility in FBSS than
in primary low back pain and sciatica
Greatest use is for establishing the presence
of a peripheral neuropathy
May be helpful for defining a feigned
neurological deficit
Rarely using in decision-making regarding
treatment
Brought to you by
34. Diagnostic Blockade
Rationale is straightforward
In practice, it is much more
complicated
Specificity may be low
Single blocks (positive or negative)
have a high error rate
Placebo controls provide the most
accurate information
Multiple blocks using different
agents
BLOCKS ARE ADJUNCTS AND SHOULD NEVER BE
SUBSTITUTED FOR SOUND CLINICAL JUDGEMENT !
Brought to you by
35. Sensitivity and Specificity of
Diagnostic Blocks
Differences in pain processing
Technical aspects
Incorrect needle placement
Large volumes of anesthetic
Effects local anesthetics
Psychological issues
Environmental cues, expectations, anxiety, etc.
Placebo response
Brought to you by
36. Facet Block
Blockade of the innervation of the facet joint will relieve
pain in some patients with facet disease
Brought to you by
37. Facet Block
Rarely useful in patient with
FBSS
Transitional facet disease
above a fused level
Anatomy obliterated and
accurate block not possible
Blockade of pseudarthrosis may
sometimes be useful Brought to you by
38. Selective Nerve Root Block
Must be done accurately to provide any useful
information
One root at a time
Small volume of local anesthetic without
steroids
Confirm the presence of an adequate block
Confirm findings on repetitive blocks
Brought to you by
39. Therapeutic Heat
Increases muscle temperature, decrease spindle sensitivity,
increases blood flow
Pain relief, increase in tissue extensibility, reduction of muscle
spasm
Superficial heat
Greatest effect 0.5cm from skin
Deep heat
Ultrasound diathermy
Heat up to 5cm deep to skin
Treatment of deep soft tissues
Hydrotherapy
Buoyancy minimizes stress to joints Brought to you by
40. Cold Therapy
Affects muscle spindle and may modulate
neurotransmitters
Provides longer pain relief than heat
Ice and gel packs, vapocoolant sprays, cold baths
Particularly useful for trigger points,
Treatment of choice for acute injuries
Brought to you by
41. TENS
Electrical energy transmitted from skin surface
Rationale based on “Gate Theory” of pain
Most effective at high-frequency, low-intensity
“Acupuncture TENS” – high-intensity, low-frequency
Questionable benefit for chronic back pain
Brought to you by
42. Therapeutic Exercise and Massage
Essential for restoration of function
“Hurt” vs. “Harm”
Stretching exercises
Strengthening exercises
Aerobic exercises
Therapeutic massage
Brought to you by
44. Anticonvulsant Agents (AEDS)
Similarities in pathophysiology of neuropathic pain and
epilepsy
All AEDS ultimately act on ion channels
Efficacy of AEDS most clearly established for neuropathic
conditions characterized by episodic lancinating pain
Most clinical studies have focused on DPN and PHN
Use of AEDS in patients with FBSS is nearly entirely empiric Brought to you by
45. Antidepressant Analgesics
Relieves all components of neuropathic pain
Clear separation of analgesic and antidepressant effects
Although other agents (eg anti-epileptics)) may be
regarded as 1st
line therapy over antidepressants, there is
no good evidence for this practice
More selective agents are either less effective or not useful
(serotonergic, noradrenergic)
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46. Guidelines for Use of
Antidepressants in Pain Management
Eliminate all other ineffective analgesics
Start low and titrate slowly to effect or toxicity
Nortriptyline or amitriptyline for initial treatment
Move to agents with more noradrenergic effects
Consider trazodone in patients with poor sleep pattern
Try more selective agents if mixed agents ineffective
Do NOT prescribe monoamine oxidase inhibitors
Tolerance to anti-muscarinic side effects usually takes
weeks to develop
Withdraw therapy gradually to avoid withdrawal syndrome
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47. Antidepressants for LBP-RCT
Author Agent No. Effect Comments
Jenkins et al., 1976 Imipramine 50mg
4 weeks
44/59 No Parallel design
Alcott et al., 1982 Imipramine 150mg
8 weeks
41/50 No Parellel design; poss
role for pain
Godkin et al., 1990 Trazadone 200mg 42 No Parellel design
Serotonergic agent
Usha et al., 1996 Fluoxetine 20mg
Elavil 25mg
Placebo
4 weeks
59 Yes Parallel design
Fluoxetine more
effective with fewer SE
Atkinson et al., 1998 Nortriptyline 100mg
Inert placebo
57/78 Yes Parallel design
Non-depressed pts
Dickens et al., 2000 Paroxetine 20mg 61/92 No Parellel design
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48. Opioid Therapy - RCT
Pain Type Study Control Results
Nociceptive Arner & Meyerson, 1988 Placebo Pos
Kjaersgaard-Anderson, 1990 Paracetamol Pos***
Neuropathic Arner & Meyerson, 1988 Placebo Neg
Dellemijn & Vanneste, 1997 Placebo/Valium Pos
Kupers, et al., 1991 Placebo Pos
Rowbotham et al., 1991 Placebo Pos
Idiopathic Arner & Meyerson, 1988 Placebo Neg
Kupers, et al., 1991 Placebo Neg
Moulin et al., 1996 Benztropine Pos***
Unspecified Arkinstall et al., 1995 Placebo Pos***
Mays et al., 1987 Placebo/Bupiv Pos
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49. Opioid Therapy – Prospective
Uncontrolled Studies
Pain Type Reference Results
Nociceptive McQuay et al., 1992 Pos
Neuropathic Fenollosa et al., 1992 Pos
McQuay et al., 1992 Mixed
Urban et al., 1986 Pos
Idiopathic McQuay et al., 1992 Neg
Mixed/Unspecified Auld et al. 1985 Pos
Gilmann & Lichtigfeld, 1981 Pos
Penn and Paice, 1987 Pos
Plummer et al., 1991 Mixed
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51. NSAIDS for Chronic LBP
One systematic reviews of 2 studies within
framework of Cochrane Collaboration
NSAID vs. Placebo
Better short-term pain relief
NSAID vs. Acetominophen (N=4)
No difference in short-term pain relief
Better overall improvement
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52. Corticosteroids
Useful in the short term for treatment of radicular pain
Limited role in the long-term treatment of FBSS
Epidural or transforaminal steroids for selected patients
Cochrane Review (Nelemans, et al., 2002)
Most trials included patients with radicular pain
No significant difference in pain relief after 6 weeks or
6 months between ESI and placebo
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53. Topical Treatments
Aspirin preparations
Eg. aspirin in chloroform
Local anesthetics
Topical 5% lidocaine patch
EMLA
Eutectic mixture of local anesthetics
Capsaicin Brought to you by
55. Cannabinoids
Strong laboratory data supporting an analgesic effect of cannabinoids
Efficacy of cannabinoids in human has been modest at best
Effectiveness hampered by unfavorable therapeutic index
Campbell (2001) – systematic review of 9 clinical trials of
cannabinoids
Cancer pain (5), Chronic non-cancer pain (2), acute pain
(2)
Analgesic effect estimated equivalent to 50-120mg
codeine
Adverse effects reported in all studies
RCT have shown modest benefits when compared with placebo
Increased incidence of psychiatric illness and cognitive dysfunction
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57. Multidisciplinary Treatment Outcomes
Decrease in pain self-rating by about 30%
Opioid consumption reduced by about 60%
Pain-related physician visits decrease by 60%
Physical activities increase by 300%
Gainful employment occurs in 60%
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58. Comprehensive Pain Management
Pain Reduction
0
10
20
30
40
50
60
70
80
90
100
Discharge 3 Month 1 Year
Rosomoff Comprehensive Pain Center, 1999-2005
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59. Comprehensive Pain Management
Functional Improvement
0
10
20
30
40
50
60
70
80
90
100
Discharge 3 Months 1 Year
Rosomoff Comprehensive Pain Center, 1999-2005
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61. Comprehensive Pain Management
Employed/Work Ready
0
10
20
30
40
50
60
70
80
90
100
Discharge 3 Months 1 Year
Rosomoff Comprehensive Pain Center, 1999-2005
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62. Comprehensive Pain Management
Opioid Usage
0
10
20
30
40
50
60
70
80
90
100
Discharge 3 Months 1 Year
Rosomoff Comprehensive Pain Center, 1999-2005
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63. Comprehensive Pain Management
Patient Satisfaction
0
10
20
30
40
50
60
70
80
90
100
Discharge 3 Months 1 Year
Rosomoff Comprehensive Pain Center, 1999-2005
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64. Treatment Outcomes
Flor et. al., Pain 1992
Metanalysis of 65 studies with 3,089 patients
Average pain reduction 20% (0-60%)
Return to work 67%
Standard treatments (24%)
Dramatic reductions in health care consumption and
additional surgery
Steig et al (Pain 1986) - $280,000 savings in health care
expenses up to retirement
Okifuji et al (1998) – 280 million saving per year if
patients receiving standard medical/surgical treatments
were treated in a multidisciplinary clinic Brought to you by
65. So What’s The Problem?
It is difficult to obtain funding
and reimbursement for this
type of healthcare , despite the
fact that more outcome data
are available than for any other
type of chronic pain treatment
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66. “The only antidote
for mental suffering
is physical pain”
“That’s the most
ridiculous thing I’ve ever
heard.”
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67. This platform has been started by Parveen
Kumar Chadha with the vision that nobody
should suffer the way he has suffered because
of lack and improper healthcare facilities in
India. We need lots of funds manpower etc.
to make this vision a reality please contact us.
Join us as a member for a noble cause.
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68. Our views have increased the
mark of the 10,000
Thank you viewers
Looking forward for franchise,
collaboration, partners.
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