- Abdulaziz is a 27-year-old man who presented with 7 days of lower back pain after lifting a heavy object. On examination, he had tenderness over the paraspinous muscles and limited forward flexion, but no neurological deficits or red flags.
- For patients with nonspecific lower back pain like Abdulaziz without red flags, imaging and other diagnostic tests are not routinely recommended. His history and examination findings are consistent with a diagnosis of back strain.
- The goal of evaluation for lower back pain is to identify red flags indicating serious underlying conditions that require further evaluation or emergent treatment, while Abdulaziz showed no signs of these on history or examination
Introduction to low back pain
Reasons for low back pain
Epidemiology of LBP
Causes of LBP
Risk factors of LBP
Diagnosis of LBP
Treatment for LBP
Occupational therapy interventions for LBP
Introduction to low back pain
Reasons for low back pain
Epidemiology of LBP
Causes of LBP
Risk factors of LBP
Diagnosis of LBP
Treatment for LBP
Occupational therapy interventions for LBP
This presentation is a comprehensive summary about all aspects of back pain. Back pain is one of the most common orthopaedic morbidity or orthopedic disability. Sciatica and lumbar disc diseases are common cause of spinal disability. Back pain are divided into Red flags, green flags and yellow flags for quick clinical screening. both treatment, prevention aspects are covered. Spinal anatomy and Biomechanics are covered. Epidemiology and role of various types of spine surgery, microdiscectomy, endoscopic spine surgery are also described.
This presentation is meant for educating people about Low Back Pain, its symptoms & causes, home remedy tips and physiotherapy management of low back pain.
Detailed history and its evaluation , examination of spine in general and local with special tests in cervical , thoracic outlet syndrome , lumbar spine and SI joint with diagrams, neurological examination both sensory and motor.
As part of a class presentation, we attempted to make this to briefly explain what Torticollis meas, the Types of presentation of Torticollis, and Management strategies for a Physiotherapist for Congenital Torticollis especially.
I hope this helps. :)
The pictures and information had been taken from internet, complied to make a brief presentation for the purpose of class presentation.
I do not own any content.
Musculoskeletal Health Concerns of the Aging PopulationAllan Corpuz
A lecture on low back pain, osteoarthritis and soft tissue rheumatisms delivered to nurses, nursing attendants and institutional workers at the the Philippine General Hospital
This presentation is a comprehensive summary about all aspects of back pain. Back pain is one of the most common orthopaedic morbidity or orthopedic disability. Sciatica and lumbar disc diseases are common cause of spinal disability. Back pain are divided into Red flags, green flags and yellow flags for quick clinical screening. both treatment, prevention aspects are covered. Spinal anatomy and Biomechanics are covered. Epidemiology and role of various types of spine surgery, microdiscectomy, endoscopic spine surgery are also described.
This presentation is meant for educating people about Low Back Pain, its symptoms & causes, home remedy tips and physiotherapy management of low back pain.
Detailed history and its evaluation , examination of spine in general and local with special tests in cervical , thoracic outlet syndrome , lumbar spine and SI joint with diagrams, neurological examination both sensory and motor.
As part of a class presentation, we attempted to make this to briefly explain what Torticollis meas, the Types of presentation of Torticollis, and Management strategies for a Physiotherapist for Congenital Torticollis especially.
I hope this helps. :)
The pictures and information had been taken from internet, complied to make a brief presentation for the purpose of class presentation.
I do not own any content.
Musculoskeletal Health Concerns of the Aging PopulationAllan Corpuz
A lecture on low back pain, osteoarthritis and soft tissue rheumatisms delivered to nurses, nursing attendants and institutional workers at the the Philippine General Hospital
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.
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
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
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.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of 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 leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
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. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
4. Introduction
• 84 % of adults have low back pain at some time in their lives
• Most of them are self-limited.
4
5. Epidemiology of Low Back Pain in Saudi Arabia
• A computer based literature search
• A total of Twelve articles was used for this study
• From March 2014-2015.
• Seven studies were cross sectional and found a prevalence ranging
from 53.2% to 79.17%.
Awaji, M. (2016). Epidemiology of low back pain in Saudi Arabia. Journal of Advances in Medical and Pharmaceutical Sciences, 6(4),
1-9.
6. Definition
Low back pain (LBP)
Musculoskeletal pain or stiffness of lower back and lumbar
spine.
• LBP by duration
Acute LBP → < 6 weeks
Subacute LBP→ between 6 weeks and 3 months
Chronic LBP → > 3 months
6
8. Terminology (1)
• Spondylosis: Arthritis of the spine
• Spondylolysis: A fracture in the pars interarticularis where the vertebral body and the
posterior elements protecting the nerves are joined.
• Spondylolisthesis : If left untreated, spondylolysis can weaken the vertebra so the fractured
pars interarticularis separates, allowing the injured vertebra to shift or slip forward on the
vertebra directly below it.
• Spinal stenosis: Narrowing of the vertebral canal by bone or soft tissue elements.
• Radiculopathy: Impairment of a nerve root, usually causing radiating pain, numbness,
tingling, or muscle weakness .
8
10. Terminology (2)
• Sciatica
– Pain radiating down posterior or lateral leg below the knee
– The most common cause for sciatica is lumbar disk herniation
– Symptoms that increase the specificity of sciatica:
1. Pain that is worse in the leg than in the back
2. Typical dermatomal distribution of neurologic symptoms
3. Pain that is worse with the Valsalva maneuver
10
13. Terminology (4)
• Kyphotic curves : outward curve of the thoracic spine
• Lordotic curves : inward curve of the lumbar spine.
• Scoliotic curving : sideways curvature of the spine and is always abnormal.
• A small degree of both kyphotic and lordotic curvature is normal
13
14. MCQ1
What is the specific
diagnosis of this pt’s LBP?
A. Nonspecific LBP
B. Spinal stenosis
C. Spondylolisthesis
D. Malignancy
14
15. MCQ1
2. What is the specific
diagnosis of this pt’s LBP?
A. Nonspecific LBP
B. Spinal stenosis
C. Spondylolisthesis
D. Malignancy
15
16. MCQ2
A 62-year-old man presents with complaints of leg pain. He notes that the pain is
primarily in his buttocks and thighs. It is worse when he is walking but improved when
he sits. On examination his vital signs are normal, he has no peripheral edema, and his
pedal pulses are intact. The most likely diagnosis to explain his symptoms is which one
of the following?
A) A dissecting aortic aneurysm
B) An incarcerated inguinal hernia
C) Intermittent claudication
D) Myasthenia gravis
E) Spinal stenosis
16
21. MCQ3
3. Which of the following is not indicative of inflammatory back pain
such as ankylosing spondylitis?
A. Insidious onset
B. Onset before 40 years of age
C. Pain for more than 3 months
D. Morning stiffness
E. Aggravation of pain with activity
21
22. Goal of evaluation
To identify features that discriminate between “benign” cases and
“serious pathologies” which need immediate further evaluation
23. DD of LBP by Severity
23
Other etiologiesLess serious, specific
etiologies ( Less than 10 %)
Serious systemic etiologies
(less than 1 % )
Nonspecific back pain (>85
%)
Ankylosing spondylitis :
features suggesting an
inflammatory etiology
(morning stiffness,
improvement with
exercise, pain at night)
Compression fracture :
commonly by osteoporosis
Cauda Equina Syndrome :
by herniation or disk
Back pain in the absence of
a specific underlying
condition that can be
identified
OsteoarthritisRadiculopathy : from
degenerative changes in
the vertebrae, disc
protrusion
Metastatic cancer (breast,
prostate, lung, thyroid, and
kidney,MM)
Mostly musculoskeletal
pain
Scoliosis and
hyperkyphosis
Spinal stenosisSpinal infection :
• Spinal epidural abscess
• Vertebral osteomyelitis
Psychological distress
26. Case
• Abdulaziz is a 27 year old.
• Came to PHC complaining of lower back pain.
How to approach this patient ?
26
27. Analysis of the pain:
1- Site.
2- Onset.
3- Duration.
4- Character.
5- Radiation.
6- Aggravating factors.
7- Intensity.
8- Relieving factors.
9- Ass. Symptom.
• Screening for Red flags.
• Systemic review.
• Medical & surgical history.
• Medication.
• Family history.
• Social history.
• Psychosocial stressors at home
or work
• ICEE
History (1)
29. History (2)
29
• Red flags for cauda equina syndrome (CES):
Motor or sensory deficit
Saddle anesthesia
Bilateral sciatica or leg weakness
Difficulty urinating and retention
Fecal incontinence
Additional indicators of nerve root problems
• Unilateral leg pain
• Pain radiates to foot or toes
• Numbness and paresthesia
• Straight leg raising test positive
30. History (3)
• Other Red flags:
Onset at age < 20 or > 55
Pain which is:
Unrelated to time or
activity (nonmechanical)
Thoracic
Widespread neurologic
symptoms
Spinal deformity
Unexplained weight loss
Fever
Significant trauma
IV drug use
Previous hx of steroid use
Previous history of:
Osteoporosis; cancer;
immunosuppression
Failure to improve after 4-6
weeks of conservative
therapy
30
31. -Fecal incontinence -Saddle anesthesia
-Urinary retention
-Immunosuppression -Intravenous drug use
-Unexplained fever
-Osteoporosis
-Significant trauma at any age
-Chronic steroid use
-History of cancer
-Unexplained weight loss
-Focal neurologic deficit
-No improvement after six weeks of conservative
management
Cauda equina
syndrome
Infection
Fracture
Neoplasm
Any of the
above
33. MCQ4
It is recommended that all patients with low back pain be risk-
stratified with an initial assessment to identify red flags. All of the
following signs and symptoms are considered red flags in this
situation, except which one?
A) Fever
B) History of cancer
C) Onset after heavy lifting
D) Onset after a fall
E) Urinary retention
33
34. Physical Exam (1)
34
• General: posture, pain behavior
• General inspection of lower back
Deformities, symmetry, redness, swelling
• General palpation of lower back
Tenderness, deformities, warmth, tone
• Gait
• Range of motion (ROM) testing
35. Physical Exam (2)
35
• Neurologic exam
Evaluate sensation, strength, and reflexes
• Provocative tests
Straight-leg-raise test (SLR)
if (+) may indicate neurologic involvement
36. Physical Exam (3)
36
Straight-leg-raise test (SLR)
• Positive test
– Sciatic pain at 30-70 degree
– Aggravation of pain dorsiflexion of the foot
– Relief of pain by knee flexion
- if positive indicates lumber nerve root compromise.
- not specific, but SLR is the most sensitive test→ negative result helps rule it out
Crossed SLR
- Examiner observes for radiating pain in affected leg while lifting patient’s opposite
uninvolved leg
A positive crossed SLR test is more specific for lumbar disk herniation, and it complements
the sensitive uncrossed SLR test
37. Physical Exam (4)
37
• Red flags by examination:
Saddle anesthesia
Loss of anal sphincter tone
Weakness in lower extremities
Fever
Vertebral tenderness
Limited spinal ROM
Neurologic abnormality
38. Back to the case
• History
o Abdulaziz is a 27 year old.
o Came to PHC complaining of lower back pain since 7 days
o Diffusing dull aching pain, started after lifting heavy object at home, relieved by
Ibuprofen
o Prolong sitting or moderate activity aggravate the pain
o No radiation , numbness or leg pain
o No fever , weight loss , or hx of trauma
o No urinary or fecal incontinence
o Not on steroids or any medication
o No abdominal pain , nausea or vomiting
o No hx of surgeries
38
39. Back to the case
• On examination
o Uncomfortable, prefer to stand.
o Has full ROM except for limited forward flexion of the back
o Tenderness on paraspinous muscles.
o SLR & crossed SLR test are negetive.
o Lower limb neurological exam: Normal tone, power , reflexes, and sensation.
39
41. LBP testing
• Do not routinely obtain imaging studies or other diagnostic
tests in patients with nonspecific LBP
(ACP Strong recommendation, Moderate-quality evidence)
41
43. Imaging
• Perform diagnostic imaging in LBP if severe or progressive
neurologic deficits or serious underlying conditions suspected.
(ACP Strong recommendation, Moderate-quality evidence)
• MRI (preferred) or CT recommended if :
• Neurologic deficits
• Suspected serious condition (cauda equina syndrome, cancer)
• X-ray not routinely recommended but may be considered if :
• Suspicion for cancer or vertebral compression fracture
• Suspicion for ankylosing spondylitis (bamboo sign)
43
49. MCQ5
A 41-year-old sedentary man with frequent flare-ups of back pain presented to you 6
weeks ago with the acute onset of low back pain radiating to the left leg. His neurologic
examination at the time was normal, but he did not respond to conservative therapy. X-
rays are normal. Which of the following is the most appropriate next step?
a. Flexion and extension radiographs
b. Magnetic resonance imaging (MRI)
c. Electromyelography
d. Bone scan
e. A complete blood count (CBC) and erythrocyte sedimentation rate (ESR)
49
50. Explanation 5
The answer is b. (Mengel, pp 300-306.) MRI is indicated for people
whose pain persists for more than 6 weeks despite normal radiographs and
with no response to conservative therapy. Flexion/extension films would
not be helpful in identifying more concerning causes of pain. EMG is not
indicated without neurologic involvement. A bone scan and/or ESR should
be considered in those with symptoms consistent with cancer or infection.
50
53. • Patient Education
1st line treatment: maintain overall activity.
• Pharmacological
NSAIDS, paracetamol, muscle relaxants
• Non-pharmacological
Heat , exercise, massage, lumber support, acupuncture ,manipulation, traction and
Cupping (Hijama)
• Surgery
Referral for red flags
severe ± treatment failure
53
Management principles
54. • Remain active
Advice to stay active recommended and associated with improved
pain and functional status compared to bed rest in patients with acute
low back pain (LBP)
(Strong recommendation, Moderate-quality evidence; level 2 [mid-level] evidence)
• Further education
Benign nature of LBP
Provoking/aggravating factors
If posture → correct, lifting techniques, etc.
54
Patient Education (1)
56. Pharmacotherapy (1)
1. NSAIDS
Initial therapy (1st line) — a trial of short-term (two to four weeks)
• Beware of GI and renal toxicity→ long-term use; at risk pt’s
• Try start taper by end of wk1, stop by end wk2 for most pts
o Ibuprofen (400 to 600 mg four times daily)
o Diclofenac (50-100mg bid )
o Naproxen (250 to 500 mg bid)
2. Paracetamol
1 gram tid-qid (max 4g/day in pt’s without liver disease)
High-quality evidence that acetaminophen showed no benefit compared with placebo in
acute low back pain
56
57. Pharmacotherapy (2)
3. Muscle relaxants
Second-line therapy — For patients with pain refractory to initial pharmacotherapy
Efficacy – Muscle relaxants provide symptomatic relief with acute low back pain
Beware of ADE: drowsiness, dizziness
o Chlorzoxazone 250 mg and paracetamol 300 mg (Relaxon) TID
o Cyclobenzaprine 5-10mg po q8hr
o Baclofen 5mg po q8hr
57
58. Pharmacotherapy (3)
4. Opioids or Tramadol
• 3–5 days course may be given for severe pain not relieved by NSAID.
• Effective for neuropathic pain
• Do not routinely offer opioids for managing acute low back pain
• Side effects : risk of dependence , drowsiness , nausea and constipation.
o E.g. Hydrocodone/acetaminophen: 5/500 mg PO q4–6h
o Oxycodone/acetaminophen: 5/500 mg PO q4–6h
• Tramadol
is an opioid agonist
similarly to opioids limiting use for a few days.
58
59. Pharmacotherapy (4)
5. Systemic glucocorticoids
In acute nonspecific back pain :
No evidence to support the use of systemic glucocorticoids
In acute lumbosacral radiculopathy who do not respond well to
analgesics and activity modification :
May provide partial pain relief
A course of oral prednisone (60 to 80 mg daily) for 5-7 days, followed by
discontinuation over 7 to 14 days.
6. Topical agents
No evidence to support the use of lidocaine patches in LBP.
59
61. 1. Heat therapy
Associated with short-term pain reduction in patients with acute or
subacute LBP
(level 2 [mid-level] evidence)
No such benefit seen with ice therapy
61
Non-pharmacological (1)
63. 2.Exercise-based therapy for low back pain
For acute LBP
Acute low back pain (LBP) (<4 weeks) has a very good prognosis.
Exercise has not been shown to be more beneficial for acute LBP when compared with other
conservative treatments.
Patients should be advised to avoid bedrest and stay as active as possible.
For subacute and chronic LBP
Systematic reviews have concluded that exercise may have modest benefits for pain relief and
improved function in patients with subacute and chronic LBP
Physical therapy
In general, No need to refer patients with acute low back pain for physical therapy.
Early referral to a physical therapist may benefit patients with acute back pain who are at higher
risk of developing chronic back pain (eg, poor functional or health status, psychiatric
comorbidities).
63
Non-pharmacological (2)
65. 3. Massage
Safe and may be relaxing for some patients
For acute LBP
Insufficient evidence
For subacute and chronic LBP
Evidence of short-term improvement in symptoms for subacute and chronic LBP, but no long-
term benefits
65
Non-pharmacological (3)
67. 3. Lumbar supports
o The role of corsets (lumbosacral orthoses, braces, back supports and abdominal binders)
in the treatment of patients with low back pain is controversial
In acute LBP
No evidence to suggest that lumbar supports have therapeutic value
In chronic LBP :
Not routinely recommended, may provide some benefit for patients with subacute LBP
who are actively engaged in recommended therapies.
67
Non-pharmacological (3)
69. 4. Acupuncture
o Recommendations from guidelines, some recommending against acupuncture,
and some not making a recommendation for or against acupuncture
ACP guideline (2017) : recommends non-pharmacologic therapies including acupuncture as
initial therapy for patients with chronic low back pain
NICE guideline (2016) : does not recommend acupuncture for management of low back pain
In acute LBP
Limited and inconclusive evidence to support acupuncture for acute LBP.
In chronic LBP :
Reduces chronic low back pain compared to no acupuncture.
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Non-pharmacological (4)
71. 5. Spinal manipulation
o A form of manual therapy that involves the movement of a joint beyond its usual end range
of motion, but not past its anatomic range of motion , high-velocity movement of the joint is
frequently accompanied by an audible cracking or popping sound.
In acute LBP
May reduce pain and disability, but evidenced inconsistent
(level 2 [mid-level] evidence)
In chronic LBP
May slightly improve pain and function at 6 months in patients with chronic LBP.
(level 2 [mid-level] evidence; ACP Strong recommendation, Low-quality evidence)
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Non-pharmacological (5)
73. 6. Traction
o Is a form of decompression therapy that relieves pressure on the spine, can be performed
manually or mechanically.
In acute LBP
May provide short-term pain relief in patients with low back pain with or without sciatica.
(level 2 [mid-level] evidence)
In chronic LBP
mechanical traction is not recommended for use in chronic low back pain.
(APS Good-quality evidence)
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Non-pharmacological (6)
76. 7. Cupping (Hijama)
o From Sunnah, used for all conditions, especially musculoskeletal pain
Dry pulsatile cupping and minimal cupping may each reduce short term pain in patients with nonspecific
chronic low back pain
(level 2 [mid-level] evidence)
o Based on randomized trial, 110 adults (mean age 49 years) with nonspecific chronic low back pain were
randomized to 1 of 3 interventions for 4 weeks and followed for 12 weeks.
o Result : pulsatile dry cupping and minimal cupping each associated with improved scores on physical component
subscale of Short Form-36 quality-of-life questionnaire compared to control at 4 and 12 weeks.
http://www.dynamed.com/topics/dmp~AN~T906249/Acupuncture-and-related-therapies-for-chronic-low-back-pain#sec-Cupping
76
Non-pharmacological (7)
77. 7. Cupping (Hijama)
Cupping might slightly reduce pain in patients with chronic low back pain
(level 2 [mid-level] evidence)
o Based on systematic review of low-to-moderate quality trials
o 6 trials assessed effect of cupping on patients with low back pain (median treatment duration 3 weeks)
o All trials had ≥ 1 methodologic limitation including unclear randomization, unclear allocation concealment, unclear
blinding of patients and providers, and unclear reporting of dropout rate
o Result :
Cupping associated with slight reduction in pain compared to medication use in analysis of 4 studies with 430
patients
Cupping associated with reduction in pain compared to usual care at 3-month follow-up (in 1 trial with 98 patients
http://www.dynamed.com/topics/dmp~AN~T906249/Acupuncture-and-related-therapies-for-chronic-low-back-pain#sec-Cupping
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Non-pharmacological (7)
79. MCQ6
You are seeing a 34-year-old special education teacher, who complains of
pain in her lower back following an injury at school, where she hurt her back
after lifting some therapy mats to store them for the night. Which one of the
following has not been shown to be useful in the prevention of back pain?
A) Attending a formal “Back Education” school
B) Modifying the work site to minimize the risk of injury
C) Staying active with regular physical activity
D) Utilizing a back belt when lifting
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80. What are the indications of referral for LBP
patients ?
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81. 1. Not improving in 4 to 6 weeks
2. Loss of bladder and/or bowel function
3. Red flag suggesting fracture, tumor ,infection
Urgent
• Cauda equina syndrome
• Infection ( osteomyelitis , epidural abscess)
Elective
• Disc herniation
82. Take Home Massage (1)
• Clinicians should conduct a focused history and physical examination to help
categorizing patients with low back pain. (strong recommendation)
• The history should include assessment of psychosocial risk factors, which
predict risk for chronic disabling back pain.
(strong recommendation)
83. • Clinicians should not routinely obtain imaging or other diagnostic tests in
patients with nonspecific low back pain.
(strong recommendation)
• Advise patients to remain active, and provide information about effective self-
care options.
(strong recommendation)
• Clinicians should perform diagnostic imaging and testing when severe or
progressive neurologic deficits are present or when serious underlying
conditions are suspected.
(strong recommendation)
Take Home Massage (2)
84. MCQ7
1. Which of the following statements is true regarding the pathogenesis of
LBP?
A. the anatomic structures causing LBP are identified clearly
B. approximately 10% of patients with acute LBP will eventually require
surgery
C. in up to 90% of cases of LBP, a definite anatomic or pathophysiologic
diagnosis cannot be made
D. patients with acute LBP and no previous surgical procedures have a 20% to
25% chance of recovering after 6 weeks, regardless of the treatment used
E. none of the above statements is true
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85. MCQ8
The presence of a “bamboo spine” on spine radiographs, elevated
ESR, and a positive test for HLA-B27 supports the diagnosis of
which one of the following conditions?
A) Ankylosing spondylitis
B) Multiple myeloma
C) Pott disease
D) Reiter syndrome
E) RA
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86. MCQ9
You are seeing a 40-year-old woman who reports the gradual onset
of low back pain over several months. The pain is associated with morning
stiffness that improves throughout the day. On examination, there are no
neurologic deficits. Which of the following is the most likely cause?
a. Back strain
b. Inflammatory arthropathy
c. Disk herniation
d. Compression fracture
e. Neoplasm
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87. Explanation 9
The answer is b. (Mengel, pp 300-306.) Inflammatory conditions
(rheumatoid arthritis, ankylosing spondylitis, Reiter syndrome) which
cause back pain are rare, but have characteristics that are helpful in differentiating
them from other causes of pain. Inflammatory conditions generally
produce greater pain and stiffness in the morning, while mechanical
disorders tend to worsen throughout the day with activity. A disk herniation
might be associated with radiation and neurologic symptoms. A compression
fracture would begin suddenly, and a neoplasm is unlikely to get
better throughout the day.
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88. MCQ10
A 30-year-old woman with frequent back problems was putting her groceries into her
trunk and had a recurrence of low back pain. She has tried acetaminophen for 2 days
without relief. On examination, her range of motion is limited, and she has tenderness to
palpation of the lumbar paraspinal muscles. Which of the following treatment options is
best?
a. NSAIDs and return to normal activity
b. Opiate analgesia and limited activities
c. Oral corticosteroids
d. Bed rest for 3 to 5 days
e. Spinal traction
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89. Explanation 10
The answer is a. (Mengel, pp 300-306.) It is recommended that
patients with low back pain maintain usual activities, as dictated by pain.
Neither prolonged bed rest nor traction has been shown to be effective in
returning people to their usual activities sooner. NSAIDs are effective for
short-term symptomatic pain relief. Muscle relaxants appear to be effective
as well. Opioids may be indicated in pain relief for those who have failed
NSAIDs, but are significantly sedating. Steroids can be considered in those
who have failed NSAID therapy.
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