This document discusses age-related health problems like low back pain and osteoarthritis that are on the rise due to an aging global population living longer lives. It focuses on low back pain, providing details on epidemiology, risk factors, anatomy, clinical evaluation through history, physical exam, imaging tests and diagnostic considerations. Case examples are presented to illustrate lumbar spondylosis, sciatica due to disc herniation, and degenerative spondylolisthesis diagnoses. The summary highlights the rising prevalence of age-related health issues, evaluation of low back pain, and examples of lumbar spine diagnoses.
Common Musculoskeletal (orthopedic) disorders in elderlyBhaskarBorgohain4
elderly and geriatric old age people tend to suffer many orthopedic disability due to common functional limitations and mobility issues as a result of pain from osteoarthritis, osteoporotic fractures, low back pain and degenerative spinal disorders like lumbar spondylosis and vitamin D and nutritional deficiencies. early diagnosis , prevention, timely surgical interventions and optimum rehabilitation are paramount to bring elderly to pre-injury state of functional independence.
PHYSIOLOGY OF AGING PROCESS, CONCEPTS OF AGING PROBLEMS WITH NORMAL AGING, AGEING PROCESS PHYSIOLOGY OF AGING, PROBLEMS IN OLD AGE, USUAL TO SUCCESSFUL AGING
Multiple sclerosis a devastating progressive condition cased due to demyelination and gliotic changes in CNS. Physiotherapy managemnet options available for most of the clinical features are enumerated
Common Musculoskeletal (orthopedic) disorders in elderlyBhaskarBorgohain4
elderly and geriatric old age people tend to suffer many orthopedic disability due to common functional limitations and mobility issues as a result of pain from osteoarthritis, osteoporotic fractures, low back pain and degenerative spinal disorders like lumbar spondylosis and vitamin D and nutritional deficiencies. early diagnosis , prevention, timely surgical interventions and optimum rehabilitation are paramount to bring elderly to pre-injury state of functional independence.
PHYSIOLOGY OF AGING PROCESS, CONCEPTS OF AGING PROBLEMS WITH NORMAL AGING, AGEING PROCESS PHYSIOLOGY OF AGING, PROBLEMS IN OLD AGE, USUAL TO SUCCESSFUL AGING
Multiple sclerosis a devastating progressive condition cased due to demyelination and gliotic changes in CNS. Physiotherapy managemnet options available for most of the clinical features are enumerated
Author: Brent C. Williams, M.D., M.P.H., 2009
License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution – Share Alike 3.0 License:
http://creativecommons.org/licenses/by-sa/3.0/
Health promotion is the process of enabling people to increase control over & improve their health by developing their resources to maintain or enhance well being.
Hospital Acquired Deconditioning in Older AdultsChris Hattersley
Evidence based information on hospital acquired deconditioning in older adults, links to any studies referenced are included in the notes section of the presentation slides.
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.
Author: Brent C. Williams, M.D., M.P.H., 2009
License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution – Share Alike 3.0 License:
http://creativecommons.org/licenses/by-sa/3.0/
Health promotion is the process of enabling people to increase control over & improve their health by developing their resources to maintain or enhance well being.
Hospital Acquired Deconditioning in Older AdultsChris Hattersley
Evidence based information on hospital acquired deconditioning in older adults, links to any studies referenced are included in the notes section of the presentation slides.
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.
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.
Evaluation of Lumbar Spine Disease starts with understanding the clinical back grounds. It starts with good history and physical examination. This is a teaching lecture given twice by Prof. Dr. Mohamed Mohi Eldin, professor of neurosurgery, in the Basic Spine Course, Egyptian Medical Syndicate, Cairo, March 2009 and in 2010.
This is a lecture focused on pelvic floor dysfunction in elite male sport especially football. It addressed the assessment and management of Pelvic pain in elite sport. Gerard Greene is a men's health physio who works in Birmingham UK ( Birmingham Men's Health Physio Clinic ) and Southampton UK ( Dr Ruth Jones ) .
Diffuse idiopathic skeletal hyperostosis (DISH) is a common skeletal process of uncertain etiology found in 12 to 18% of Indian populations above 50 years. The primary manifestations of DISH are calcification and ossification of the spinal ligaments, as well as entheseal ossification within extraspinal sites
ANA-tomy of Autoimmunity:Revisiting ANAAllan Corpuz
Autoantibodies are a hallmark of autoimmunity and, specifically, antinuclear antibodies (ANAs) together with anti-dsDNA antibodies and extractable nuclear antigens (ENAs) are the most relevant autoantibodies present in systemic autoimmune rheumatic diseases (SARDs), since they can be relevant for the classification, diagnosis, and monitoring of patients with connective tissue diseases (CTDs). We will review the past, present, and future of ANAs, showing the evolution that has taken place from aspects related to the services involved in ANA requests to the different techniques that have been developed for their determination to the role of standardization in interpretation for clinical practice.
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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
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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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
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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.
7. Epidemiology
• 65-80%: during entire lifetime
• Most prevalent chronic pain
syndrome
• Leading cause of limitation: <45 y/
o
• 2nd most frequent reason for MD
visit
• 3rd most common surgical
indication
8. Epidemiology
• Pain and function improve
substantially within 1 month
• >90% are better at 8 weeks (but
are susceptible to future brief
relapses)
• 7-10% chronic LBP
13. HISTORY
• Identify those with neural compression or
underlying systemic disease (<5%)
• Look for “Red Flags”
• Look for social or psychologic distress
– Job dissatisfaction
– Pursuit of disability compensation
– Depression
15. HISTORY
MECHANICAL
LBP
INFLAMMATORY
LBP
>95%
Less
common
Usually
seen
in
elderly
people,
postmenopausal
women
Seen
in
men
<40y/o
(sPA)
Typically
increases
with
physical
ac6vity
and
upright
posture
Marked
morning
s6ffness
>30mins
Worse
during
2nd
half
of
the
night
Alterna6ng
bu"ock
pain
Relieved
by
rest
and
recumbency
Improves
with
exercise
but
not
rest
Most
common
cause
is
degenera6ve
change
in
the
LS
Spondyloarthri6des
16. PHYSICAL
EXAMINATION
INSPECTION
Scoliosis;
Spina
bifida
occulta;
muscle
atrophy
PALPATION
Paravertebral
muscle
spasm
(loss
of
normal
lumbar
lordosis);
Fibromyalgia
(widespread
tender
points)
Spondylolisthesis
(palpable
step-‐off
b/n
adjacent
spinous
processes)
ROM:
-‐Limited
spinal
mo6on
(flexion,
extension,
lateral
bending,
rota6on):
more
useful
for
Tx
monitoring
-‐Chest
expansion
<2.5cm
(AS)
-‐Tenderness
over
greater
trochanter
of
femur
(trochanteric
bursi6s)
–Decreased
ROM
hip
(hip
OA)
PERRCUSSION
Point
tenderness
over
spine
(Sensi6ve
but
not
specific
for
Vertebral
OM
AUSCULTATION
Bruits
(AAA)
18. PHYSICAL
EXAMINATION
• Litigation or with psychologic distress
• Exaggerated symptoms
• Nonorganic signs
• Most reproducible tests*:
– Superficial tenderness
– Overreaction during examination
– Discrepancy in the SLR test done in seated and supine
positions
*Waddell
G,
McCullogh
JA,
Kummel
E,
Venner
RM:
Non-‐organic
physical
signs
in
low
back
pain,
Spine
5:117–125,
1980.
20. IMAGING
Imaging is NOT required UNLESS significant symptoms
PERSIST BEYOND 6-8 weeks
Dixit RK: Approach to the patient with low back pain. In Imboden J, Hellmann D, Stone J, editors. Current diagnosis and
treatment in rheumatology, ed 2, New York, 2007, McGraw-Hill
NEITHER MRI NOR PLAIN RADIOGRAPHS taken EARLY
in the course of LBP evaluation improves clinical
outcome, predicts recovery course, or reduces overall
cost of care
Chou R, Fu R, Carrino JA, Deyo RA: Imaging strategies for low back pain: systematic review and meta-analysis, Lancet
373:463–472, 2009.
21. IMAGING
• Weak association between imaging abnormalities
and symptoms
• Up to 85%: cannot make precise pathoanatomic Dx
with identification of the pain generator
• Reinforce suspicion of serious disease, magnify the
importance of non-specific findings, and label
patients with spurious diagnosis
Deyo
RA,
Weinstein
DO:
Low
back
pain,
N
Engl
J
Med
344(5):363–
370,
2001.
24. IMAGING: MRI
• Best initial test for LBP patients who require advanced
imaging
• Preferred for detection of spinal infection, cancers,
herniated disks, and spinal stenosis
• INDICATIONS:
– Suspicion of systemic disease
– Preop evaluation of surgical candidates on clinical grounds
– Pxs with radiculopathy or spinal stenosis who are candidates
for epidural steroids
Jarvik
JG,
Deyo
RA:
Diagnos6c
evalua6on
of
low
back
pain
with
emphasis
on
imaging,
Ann
Intern
Med
137:586–597,
2002
Chou
R,
Qaseem
A,
Snow
V,
et
al:
Diagnosis
and
treatment
of
low
back
pain:
a
joint
clinical
prac6ce
guideline
from
the
American
College
of
Physicians
and
the
American
Pain
Society,
Ann
Intern
Med
147(7):
478–491,
2007
25.
26. IMAGING: CT Scan
• Superior to MRI in evaluation of bone anatomy
• Safe in patients with ferromagnetic implants
• CT myelography is preferred in patients with
surgically placed spinal hardware
28. IMAGING: Bone Scan
• Infection, bony
metastases,
Occult fractures
• Differentiation
from
degenerative
changes
• Limited
specificity: Poor
spatial resolution
• Require
confirmatory
imaging by MRI
29. ELECTRODIAGNOSTIC
STUDIES
• LS Radiculopathy
• EMG-NCV
• Confirm nerve root compression and define the distribution
and severity of involvement
• INDICATIONS:
– Pxs with persistent disabling symptoms of radiculopathy with
discordance b/n clinical presentation and findings on imaging
– Evaluation of possible factitious weakness
• LIMITATIONS:
– delayed detection
– Persistent abnormalities
32. Chou
R,
Qaseem
A,
Snow
V,
et
al.
Diagnosis
and
treatment
of
low
back
pain:
a
joint
clinical
prac6ce
guideline
from
the
American
College
of
Physicians
and
the
American
Pain
Society.
Ann
Intern
Med.
2007;147:478-‐491.
35. CASE
• 55M, fisherman, with low back pain
• >5 years duration
• Pain radiates to buttock and anterior thigh
• Alleviated by forward flexion
• Exacerbated by bending to the right side of the body
37. Diagnosis
• LUMBAR SPONDYLOSIS (Facet Syndrome)
• Degenerative changes in facet joints
• Imaging evidence is common in the general
population, increases with age and maybe unrelated
to back symptoms
• Patients with severe mechanical LBP may have
minimal radiographic changes, and conversely,
patients with advanced changes may be
asymptomatic
38. CASE
• 35M, businessman
• Low back pain that radiates to the medial aspect foot
• Sudden onset
• Duration: 6 weeks
• Lancinating, sharp pain with numbness and tingling
• Worsened by coughing, sneezing or when he defecates
• +SLR Right
• Weak dorsiflexion of foot and great toe
40. Diagnosis
• SCIATICA secondary to INVERTERBRAL DISK
HERNIATION L4-L5
• Occurs when the NP in a degenerated disk prolapses
and pushes out the weakened annulus, usually
posterolaterally
• Seen in 27% of asymptomatic individuals
Jensen
MC,
Brandt-‐Zawadski
MN,
Obuchowski
N,
et
al:
Magne6c
resonance
imaging
of
the
lumbar
spine
in
people
without
back
pain,
N
Engl
J
Med
331:69–73,
1994
41. Diagnosis
• LS spine is susceptible to herniation because of its
mobility
• 75% of flexion-extension occurs at the LS joint (L5-
S1)
• 20% occurs at L4-5
• Therefore, 90-95% of clinically significant
compressive radiculopathies occur at these 2 levels
42. Diagnosis
• Disk herniation is rare in young individuals
• Frequency increases with age
• Peak: 44-50y/o (progressive decline in frequency
thereafter)
43. Diagnosis
• L1 radiculopathy: rare; pain, paresthesias and sensory
loss in inguinal areas
• L2-4 radiculopathies: uncommon; seen in elderly with
spinal stenosis
• Cauda equina syndrome: midline L4-5 herniation
– LBP, bilateral radicular pain, bilateral motor deficit with leg
weakness
– Urinary retention with Overflow incontinence
– Asymmetric PE
– Saddle anesthesia
– Surgical emergency!
44. Diagnosis
• Natural history is favorable (progressive
improvement in most patients)
• Regression in sequential MRI
• Partial or complete resolution in 2/3 of cases after 6
mos
• Only 10% have sufficient pain after 6 weeks of
conservative care (consider decompressive surgery))
45. CASE
• 70F, store owner
• Chronic aching low back pain
• Duration: 8 years
• Occasionally relieved by Paracetamol, Mefenamic
Acid, rest
• Normal PE
47. Diagnosis
• DEGENERATIVE SPONDYLOLISTHESIS
• Anterior displacement of a vertebra on the one
beneath it
• Two types
ISTHMIC
DEGENERATIVE
Caused
by
bilateral
spondylolyis
Caused
by
severe
degenera6ve
changes
with
subluxa6on
at
the
facet
joints
Acquired
early
in
life;
young
boys
Older
age
group
>60,
women
Most
commonly
a
defect
in
the
pars
ar6cularis
at
L5
MC
L4-‐5
Nerve
root
impingement
Spinal
stenosis
48. CASE
• 73M, carpenter
• Chronic low back pain
• >5 years
• Pain and paresthesias in buttocks, thighs
and legs
• Exacerbated by erect posture and walking
but has no problems cycling
• Relieved by sitting or flexing forward
• Unsteady gait, weakness lower
extremities
• SLR (-)
• DTRs: + on both LE
50. Diagnosis
• SPINAL STENOSIS
• Neurogenic claudication
• Simian stance; shopping cart sign
• Wide based gait (90% specific)
• 20-30% asymptomatic adults have
abnormal imaging
• Factors that favor neurogenic claudication
(vs vascular)
– Preservation of pedal pulses
– Provocation of Sxs by standing erect as
readily as walking
– Relief of symptoms by spine flexion
– Location of maximal discomfort to the
thighs rather than calves
51. Diagnosis
• Indolent, benign
• Symptoms unchanged
in 70%, improved in
15%, worsened in 15%
• Prophylactic surgical
intervention not
warranted
52. CASE
• 55M, previously diagnosed with prostate cancer, s/p
cTURP
• Persistent, progressive Low back pain for 2 months
• Not alleviated by rest
• Worse at night
• Minimal relief with Paracetamol, NSAIDs
• Weight-loss, anorexia
• Recently, acute weakness of both lower extremities
(MMT 2/5)
• Urinary retention with overflow incontinence
54. Diagnosis
• CAUDA EQUINA Syndrome 2 to Vertebral
Metastases from Prostate Ca
• Neoplasia accounts for <1% of patients with LBP
• Prior history of Ca was the most important
predictor for likelihood of underlying Ca
56. Diagnosis
• Plain radiographs less sensitive
• Metastatic lesions may be lytic (radiolucent), blastic
(radiodense) or mixed.
• Unlike infections, the disk space is usually spared
• MRI: greatest sensitivity and specificity
• Purely lytic lesion (MM) will not be detected by
bone scan
57. CASE
• 30M, kargador, IV drug user
• Fever, low back pain, weight loss
• Pain is persistent, present at rest, exacerbated by
activity
• +point tenderness: L4-L5
• Grade 3/6 systolic murmur over the 4th ICS RPSB
• Leukocytosis
• Elevated ESR, CRP
• Blood CS: Moderate growth of S. aureus
59. Diagnosis
• Vertebral OM
• Hematogenous, direct inoculation, contiguous
spread
• MC: lumbar spine
• MC: #1 S. aureus #2 E.coli
• Leukocytosis in 2/3
• CRP correlates with clinical response to Tx
• Bone Bx if Blood CS (-)
60. Diagnosis
• Plain Xray: initial imaging (late and non-specific)
– Loss of disk height and loss of cortical definition
– Bony lysis of adjacent vertebral bodies
• MRI: most sensitive and specific
– Classic finding: involvement of 2 vertebral bodies with
their intervening disk
61. CASE
• 40F, housewife
• Low back pain after lifting bag of laundry
• Duration: 3 days
• SLR (-)
• No LOM
62. Diagnosis
• Nonspecific LBP
• Lumbago, strain, sprain
• Self-limited, acute, mechanical
• Mild to severe
• Trauma, lifting, twisting injury
• Most patients are better within 1-4 weeks but
remain susceptible to similar future episodes
• <10% develop chronic non-specific LBP
64. ACUTE (Less than 3
mos)
• Excellent prognosis
• Only 1/3 seek medical care
• >90% recover within 8weeks or earlier
• Stay active; continue ordinary daily activities within limits
permitted by pain
• Discourage bedrest >1-2days
• Acetaminophen and NSAIDs: 1st line for symptom relief
• Short term opioids: for severe disabling LBP or if with CI to NSAIDS
• Muscle relaxants are moderately effective (but high prev of adverse
events
Coste
J,
Delecoeuillerie
G,
Cohen
deLara
A,
et
al:
Clinical
course
and
prognos6c
factors
in
acute
low
back
pain:
an
incep6on
cohort
study
in
primary
care
prac6ce,
BMJ
308:577,
1994.
Chou
R:
Pharmacological
management
of
low
back
pain,
Drugs
70(4):384–402,
2010.
65. ACUTE (Less than 3
mos)
• Back exercises not helpful in the acute phase
• PT referral not usually necessary in the first month
• Individually tailored exercise program
• Educational booklets strongly recommended
• Heating pads or blankets
Chou
R,
Qaseem
A,
Snow
V,
et
al:
Diagnosis
and
treatment
of
low
back
pain:
a
joint
clinical
prac6ce
guideline
from
the
American
College
of
Physicians
and
the
American
Pain
Society,
Ann
Intern
Med
147(7):478–491,
2007.
66. ACUTE (Less than 3
mos)
• INSUFFICIENT EVIDENCE
– Spinal manipulation
– Cold packs, corsets or braces
– Acupuncture, massage
– Traction
– TENS, PENS, interferential therapy, low-level laser therapy,
shortwave diathermy, ultrasound
– Injection of trigger points, ligaments, SI joints, facet joints,
intradiskal steroid injections
Clarke
JA,
van
Tulder
MW,
Blomberg
SE,
et
al:
Trac6on
for
low
back
pain
with
or
without
scia6ca,
Cochrane
Database
Syst
Rev
(23):CD003010,
2007.
Chou
R,
Qaseem
A,
Snow
V,
et
al:
Diagnosis
and
treatment
of
low
back
pain:
a
joint
clinical
prac6ce
guideline
from
the
American
College
of
Physicians
and
the
American
Pain
Society,
Ann
Intern
Med
147(7):478–491,
2007
Chou
R,
Loeser
JD,
Owens
DK,
et
al:
Interven6onal
therapies,
surgery,
and
interdisciplinary
rehabilita6on
for
low
back
pain.
An
evidence
based
clinical
prac6ce
guideline
from
the
American
Pain
Society,
Spine
34(10):1066–1077,
2009.
67. SUBACUTE (More
than 6wks)
– Injection therapy
– Epidural CCS: remarkable but unjustified popularity
– Evidence of moderate benefit compared to placebo for
short term relief of leg pain from HNP
– No significant functional benefit
– No reduction in need for surgery
Care"e
S,
Leclaire
R,
Marcouxs
S,
et
al:
Epidural
cor6costeroid
injec6ons
for
scia6ca
due
to
herniated
nucleus
pulposus,
N
Engl
J
Med
336(23):1634–1640,
1997.
70. CHRONIC (More than
3 mos)
– Overall: results of treatment are unsatisfactory
– Complete relief of pain is unrealistic for most
– High costs
– Acetaminophen and NSAIDs as first line
– Opioid analgesics for severe disabling LBP
– No evidence that long-acting RTC dose is superior to
short-acting PRN dosing
– Continuous exposure leads to tolerance and dose
escalation
Chou
R:
Pharmacological
management
of
low
back
pain,
Drugs
70(4):384–402,
2010.
71. CHRONIC (More than
3 mos)
– Muscle relaxants are not recommended for long-term
use
– Antidepressants that inhibit NE uptake: pain modulating
properties
– Low dose TCAs are an option
– No evidence for SSRIs (except for concomitant Tx of
depression)
– Duloxetine (SNRI) has marginal efficacy
– Insufficient evidence for Gabapentin and topiramate
72. CHRONIC (More than
3 mos)
– PT modalities and injection techniques: not recommended
– Lumbar supports and traction: ineffective
– Medium firm mattress or back-conforming mattress (water-
bed or foam): superior to a firm mattress
– Spinal manipulation is superior to sham manipulation but is
no more effective than conventional medical Tx
– Less evidence for massage and acupuncture
– Chemonucleolysis with chymopapain: potentially life-
threatening
– Radiofrequency denervation: lacks evidence
73. CHRONIC (More than
3 mos)
– Lack of evidence:
• Radiofrequency denervation
• Intradiskal electrothermal therapy
• Percutaneous intradiskal RF thermocoagulation
• Prolotherapy
• Spinal cord stimulation
• Instraspinal drug infusion systems (?): morphine
74. CHRONIC (More than
3 mos)
– Supportive measures
• Interdisciplinary rehabilitation
• Functional restoration (work hardening)
– Surgery
• As a general rule, the results of back surgery are disappointing when the
goal is relief of back pain rather than relief of radicular symptoms from
resulting neurologic compression
• Role of surgical treatment for chronic disabling LBP w/o neurologic
improvement in patients with degenerative disease remains controversial
• MC: spinal fusion
• For non-radicular back pain with degenerative changes, fusion is no more
effective than intensive interdisciplinary rehab but is associated with small
to moderate benefits compared with standard non-surgical care
76. NERVE ROOT COMPRESSION SYNDROMES
Disk
HerniaDon
Spinal
Stenosis
Spondylolithesis
Treat
nonsurgically
(as
in
Acute
LBP)
unless
with
serious
or
progressive
neuro
deficit
Conserva6ve
non-‐opera6ve
Tx
Surgery
if
with
serious
or
progressive
neuro
deficit
Treat
conserva6vely
Only
about
10%
have
sufficient
pain
aoer
6
weeks
of
conserva6ve
Tx
to
warrant
Surgery
Symptoms
stable
for
yrs;
may
improve
in
some
Drama6c
improvement
uncommon
Surgery:
moderate
short
term
benefits
(thru
6-‐12wks)
vs
non-‐Sx
but
outcome
differences
diminish
over
6me
and
no
longer
present
in
1-‐2
yrs
PT:
mainstay
of
mgt
Core
strengthening,
stretching,
aerobic,
loss
of
wt,
Px
educa6on;
Cycling
Lumbar
corsets
Open
diskectomy
or
microdiskectomy
Laminectomy,
par6al
fascetectomy,
excision
of
hypertrophied
LF
Epidural
CCS
injec6ons:
moderate
benefit
for
short
term
relief
but
no
func6onal
benefit
and
don’t
reduce
need
for
Surgery
Lumbar
epidural
CCS
injec6ons:
small
RCT
showed
reduc6on
in
pain
and
improvement
in
fxn
at
6
mos
but
don’t
influence
fxnal
status
and
need
for
surgeyr
at
1yr
Decompression
surgery
with
fusion
be"er
than
non-‐surgical
care
for
isthmic
spondylolisthesis
and
disabling
isolated
LBP
or
scia6ca
for
at
least
a
year
An6TNF
being
inves6gated
Titanium
interspinous
spacer
77. OUTCOME
• Natural history of acute LBP is favorable
• Improvement in pain and fxn within 1 month in the
majority of patients; >90% are better at 8weeks
• Only 1/3 of acute LBP patients seek medical care
• Rest resolves
78. OUTCOME
• Improvement is also the norm for Pxs with sciatica 2
to HNP
• 1/3 better in 2 weeks, 75% improve after 3 mos,
10% ultimately undergo surgery
• Spinal stenosis: stable in 70%, improved in 15%,
worsened in 15%
• 7-10% with chronic LBP: responsible for high costs
79. Factors that predict
chronicity
• Maladaptive coping behavior
• Presence of non-organic signs
• Functional impairment
• Poor general health status
• Psychiatric comorbidities
• Job dissatisfaction
• Disputed compensation claims
• High level of “fear avoidance”
80. SUMMARY
• History and PE are more important than Imaging
• Prognosis of acute LBP is excellent
• Prognosis of chronic LBP is unsatisfactory
• Surgery is reserved for neurologic deficits
84. Diagnosis
" Pathologically
" Radiographically
" Osteophyte
" Joint space narrowing (JSN) on Plain Xray (or MRI)
" Clinically
" Nodal changes in the hands
" Limited and painful internal rotation of the hip
" Crepitus with knee movement
SYMPTOMATIC OA = pain, aching or stiffness in a joint
with radiographic OA
86. ACR
Radiologic and Clinical Criteria
" HAND
1. Hand pain, aching, or stiffness on most days of prior
months
2. Hard tissue enlargement of >=2 of 10 selected joints*
3. Fewer than 3 swollen MCP joints
4. Hard tissue enlargement of >=2 DIP joints
5. Deformity of >=2 of 10 selected joints*
" DIAGNOSIS REQUIRES ITEMS 1-3 AND EITHER 4 OR 5
" 10 Selected Joints: DIP 2-3, PIP 2-3, and CMC 1
bilaterally
88. ACR
Radiologic and Clinical Criteria
" KNEE: Clinical
1. Knee pain for most days of prior month
2. Crepitus with active joint motion
3. Morning stiffness lasting <=30 min
4. Bony enlargement of the knee on examination
5. Age >=38 yr
" Diagnosis REQUIRES 1+2 + 4, or 1+2+3+5, or 1+4+5
89. ACR
Radiologic and Clinical Criteria
" KNEE: Clinical AND Radiographic
1. Knee pain for most days of prior month
2. Osteophytes at joint margins
3. Synovial fluid typical of OA
4. Age ≥ 40 y/o
5. Morning stiffness lasting ≤ 30min
6. Crepitus with active joint motion
" Diagnosis REQUIRES 1+2, or 1+3+5+6, or 1+4+5+6
90. ACR
Radiologic and Clinical Criteria
" HIP: Clinical AND Radiographic
1. Hip pain for most days of the prior month
2. ESR ≤20mm/hr
3. Radiographic femoral and/or acetabular
osteophytes
4. Radiographic hip joint space narrowing
Diagnosis REQUIRES 1+2+3, or 1+2+4, or 1+3+4
91. Primary vs Secondary
• Primary: absence of an injury history or other
joint disease
• Secondary: (+) of predisposing disorder
• Division currently less clear
• Genetics, Hx of injury/jt damage, mechanical
factors, psychosocial milieu à joint à end-
stage or failed joint
92. Etiologies of Secondary OA 1637CHAPTER 99 | CLINICAL FEATURES OF OSTEOARTHRITIS
Table 99-3 Etiologies of Secondary Osteoarthritis
Metabolic
Crystal-associated arthritis
Calcium pyrophosphate or apatite deposition
Acromegaly
Ochronosis
Hemochromatosis
Wilson’s disease
Hyperparathyroidism
Ehlers-Danlos
Gaucher’s disease
Diabetes
Mechanical/Local Factors
Slipped capital femoral epiphysis
Epiphyseal dysplasias
Legg-Calvé-Perthes disease
93. Etiologies of Secondary OA
Ochronosis
Hemochromatosis
Wilson’s disease
Hyperparathyroidism
Ehlers-Danlos
Gaucher’s disease
Diabetes
Mechanical/Local Factors
Slipped capital femoral epiphysis
Epiphyseal dysplasias
Legg-Calvé-Perthes disease
Congenital dislocation
Femoroacetabular impingement
Congenital hip dysplasia
Limb-length inequality
Hypermobility syndromes
Avascular necrosis/osteonecrosis
Traumatic
Joint trauma (e.g., ACL tear)
Fracture through joint
94. Etiologies of Secondary OA
Legg-Calvé-Perthes disease
Congenital dislocation
Femoroacetabular impingement
Congenital hip dysplasia
Limb-length inequality
Hypermobility syndromes
Avascular necrosis/osteonecrosis
Traumatic
Joint trauma (e.g., ACL tear)
Fracture through joint
Prior joint surgery (i.e., meniscectomy, ACL)
Charcot joint (neuropathic arthropathy)
Inflammatory
Rheumatoid arthritis or other inflammatory arthropathies
Crystalline arthropathy (gout)
History of septic arthritis
ACL, anterior cruciate ligament.
Modified from Altman R, Asch E, Bloch D, et al: Development of criteria
for the classification and reporting of osteoarthritis. Classification of osteo-
96. General Symptoms & Signs
– Knees, hands, feet, hips and spine
– Symptomatic or radiographic
– Pain in the joints that is:
• Worse with activity
• Limited morning stiffness (≤30mins)
• Pain and stiffness with rest (gelling phenomenon)
– Bony enlargements, crepitus, reduced ROM
– Soft tissue swelling or effusion
98. Knee
• Insidious onset of pain
• Gelling
• Limitation of ROM
– Walking, transferring, stair climbing
– Sense of instability or “giving out” at the knee
• Locking sensation
– Stiffness
– Loose bodies in the joint space
– Meniscal lesions
• Crepitus, bony enlargement
99. Knee
• Pain: medial or lateral joint line
• Effusions: cool, generally w/o redness
– Association with Baker’s cyst
• Pain over anserine bursa or greater trochanter: altered biomechanics
• Malalignment (mc: varus) – risk factor for progression
• Severe disease: flexion deformities or joint stability
• Risk factors: Quadriceps weakness (modifiable) à muscle atrophy
(late stage); loss of proprioception and vibratory sense
• Patellofemoral OA: pain, disability; often overlooked
100.
101. Hip
• Groin pain (specific)
• Vague: pain in the thigh, buttock, low back, or ipsilateral knee
• Consider differential Dx
– Femoral neck Fx, Avascular Necrosis
• Limitations in walking, bending, transferring, stair climbing
– Internal rotation: limited and painful (even in early dse)
– Putting on socks, tying shoes, trimming toe nails
• Visible deformity, hip flexion contracture, severe limitations of ROM à
severe dse (superior migration of the femoral head)
• Consider: Femoroacetabular impingement – young, groin pain worsened
by sitting, pain and limitation on F-IR-AD of the hip
103. Hand
• Heberden’s nodes: DIP; Bouchard’s nodes: PIP
• Erosive arthritis: episodic inflammation, pain and swelling (elderly women)
• First CMC: significant pain, limitations in fucntionality, reduced grip strength
– CMC squaring: osteophyte formation and JSN
• Bilateral involvement of multiple joints:
– Within (multiple PIPs) and across (both DIPs and PIPs)
• MCP involvement: increasing; consider inflammatory arthropathies or secondary OA
(hemochromatosis)
• DeQuervain’s tenosynovitis: mimic or aggravate symptoms
104. Spine
• Osteophytosis of the spine à older individuals; often asymptomatic
• Lumbar disk degeneration (DSN, end plate sclerosis, herniation): often seen in
association with radiographic osteophytosis (relationship controversial)
• Cervical spine:
– pain in the neck, radiation to the arms, weakness or paresthesia (osteophytic
compression)
– Dysphagia (anterior cervical spine osteophytes)
• Lumbar spine:
– Osteophytes and DSN à sciatic nerve impingement (pain, burning, numbness
and/or weakness down one or both legs)
105. Shoulder
• Symptoms are more often due to
osteophytosis and narrowing of the
acromioclavicular and/or sternoclavicular jts
rather than the glenohumeral jt itself
• DDx: Subacromial bursitis, Rotator Cuff
pathology, Adhesive capsulitis, Cervical
spine pathology
• Milwaukee shoulder syndrome
– Destructive arthropathy: glenohumeral
joint
– Large effusions
• High RBC count
• Basic Calcium crystals
106. Other Joints
• 1st MTP: pain and hallux valgus (bunion)
deformity
• Loss of function due to ankylosis
(hallux rigidus) à altered gait
• Other joints:
– TMJ
– Ankles: talonavicular, subtalar
– Elbow OA: rare
• Trauma, vibration damage,
pseudogout
107. Polyarticular OA
• Generalized OA: no universally understood or accepted
definition
• Kellgren and Moore (1952):
– Primarily: Heberden’s nodes and CMC
– With: spine, knees, hips, feet (descending frequency)
• Later studies:
– >3 or >5 joint sites affected
– Affected joint counts
– Multiple hand involvement
– Nodal hand OA with other jt involvement
– Summed scores of OA across multiple joints
120. Imaging: Advanced Modalities
• MRI:
– Exclude DDx
– Define early changes (before Xray changes occur)
– BM lesions (knee) = correlate with pain, bone
attrition, progressive cartilage damage
• Arthroscopy
– Often used as a response to MRI findings
– Overused and generally ineffective
– Cost not indicated in routine practice
• Ultrasound
– Bedside procedure
– Detect small effusions, early cartilage changes,
diff infx vs non-inflx arthropathies
– Therapeutic adjunct
121. Mortality in OA
• Increased compared to gen pop
• CV and GI causes
• Inc mortality with inc jt involvement
• Reduced survival: hand, B knees, cervical
(NOT: hip, foot, lumbar)
• Contributors:
– Reduced physical activity
– Comorbid conditions
– Adverse SE of meds
127. SUMMARY
• Aging has caused a lot of health-related disorders
• It is important to get the correct diagnosis so
appropriate treatment can be given
• Most cases of low-back pain are benign, do not need
imaging and respond to conservative therapy
• Osteoarthritis is a degenerative disease that
responds to analgesics and physical therapy
• Soft tissue rheumatisms are overuse diseases and
respond to rest and steroid injections