Natural Lower Back Pain Treatment Book

Back Pain Breakthrough

Back Pain Breakthrough is a natural program aim for those suffering from chronic back pain. These methods are such that were discovered after the creator saw a drawing done by Leonardo Da Vinci. It is such that is scheduled to be used for only ten minutes per day and can be used any time of the day. The methods were not intended to permanently heal back pain instantaneously. However, it is something that the creator is so assured of that he promised to send $100 to anyone that didn't see the result. During the period of the usage of this program, one will get the chance to carry out some exercises and read some books that will give one the right knowledge as regards the program. The product comes in various formats- The 6-Part video masterclass, which is a complete step-by-step instruction on how to treat back pain in ten minutes; Targeted Spinal Release Methods: an E-book that has a 30-day plan; Advance Healing Technique E-book. It comes with various benefits such as relief from a long time Back Pain. After using this program, the users will get relief from crippling low- back pain and sciatica as well as longtime back pain. Read more here...

Back Pain Breakthrough Summary


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Contents: 6-Part Video Masterclass, Ebook
Author: Dr. Steve Young
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My Back Pain Breakthrough Review

Highly Recommended

All of the information that the author discovered has been compiled into a downloadable ebook so that purchasers of Back Pain Breakthrough can begin putting the methods it teaches to use as soon as possible.

This ebook does what it says, and you can read all the claims at his official website. I highly recommend getting this book.

Epidural analgesia and longterm back pain

Back pain after childbirth is common. In the absence of epidural analgesia, early studies estimate that the incidence of back pain within the first six days post partum is about 38 .32 Whether or not long-term back pain is caused by epidural analgesia is controversial. In a large retrospective study, investigators surveyed patients who had delivered a baby in their institution within the previous nine years. Their results indicated that there was a strong association between epidural use and long-term back pain.33 The authors concluded that this association was probably causal. However, retrospective studies concerning peripartum back pain are subject to important inaccuracy and potential biases. In particular, women are unable to consistently recall the magnitude of their back pain near the time of childbirth, when asked about it later. In a one-year follow-up study, Macarthur et al. found that only 56 of women accurately recalled the amount of Table 6.2 Epidural analgesia and...

Chronic low back pain or chronic pain syndrome

The International Association for the Study for Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.22 Chronic low back pain is defined and distinguished from acute pain by symptom duration, treatment responses, the concept of neuroplasticity (sensitization) of the central nervous system, and the relationship of symptoms to the initial noxious stimulus. In contrast, in chronic pain syndrome, the balance between the sensation of pain and the emotional experience associated with it is far out of balance in favor of the emotional side.23 The criteria are as follows

Diagnosis of Low Back Pain

It is often difficult to pinpoint a specific anatomical diagnosis for most patients with isolated low back pain. The majority of low back pain is benign in other words, the pain is musculoskeletal in origin. A careful history and physical examination (Tables 26.1, 26.2, and 26.3) can generally rule out serious causes of low back pain. A history of pain at night, fever, history of cancer and or unexplained weight loss, loss of bowel or bladder control, and progressive neurological deficits may be associated with serious causes of low back pain and should prompt urgent evaluation of the patient (Table 26.4). It should be noted that serious causes of low back pain are rare compared to mechanical low back pain or leg pain (Table 26.5).

Anatomic Structures That Contribute to Back Pain Muscles

Anatomic structures that can contribute to back pain and innervation of the lumbar spine are outlined in Table 26.6 and Fig. 26.1, respectively (Deyo and Weinstein 2001 Bogduck Table 26.1 History for back pain. Table 26.2 Focused physical examination in a patient with back pain.

Table 86 Treatment options for back pain

The nature of the pain can simulate other disorders (e.g., trigger points in trapezius and cervical muscles can produce headache pain, and those in the paravertebral muscles can produce low back pain). Identification of trigger points is essential in diagnosing myofascial pain.

Doctor What Is Causing My Chronic Low Back Pain

The issue of finding the source of pain is an important one on several levels. First, patients expect their practitioner to find the pain source and expect to discuss it in detail. Second, aside from rare and serious underlying disease screening, clinicians need to understand that there is a lack of diagnostic tools to indeed answer this question accurately. In other words, a meticulous history and examination along with judicious use of imaging studies all fail to localize the source of pain in most cases.52,5354 There are important exceptions that need to be considered (see above under Don't be fooled by these patient populations), therefore, one must not become complacent or dismissive. Third, the astute spine care provider will do well to understand the various etiologic theories currently espoused regarding chronic low back pain The patient's mindset regarding the causes of their pain is crucial for effective counseling and education. Their mindset may be colored by contrasting...

Common Presentations of Back Pain

Once serious causes of back pain are ruled out, the next step is to determine if the patient has musculoskeletal back pain or nerve root pain. Back pain that is musculoskeletal or mechanical in nature varies with activity and presents predominantly in the lumbosacral area, buttocks, and thighs in a patient who is otherwise well or in stable health. Nerve root pain can arise from a prolapsed disk, spinal stenosis, or surgical scarring. The pain generally radiates to the foot or toes and may be associated with numbness or tingling and signs of nerve root irritation such as positive straight leg raising (Table 26.3).

Nonspecific Acute Low Back Pain

The vast majority of patients improve with conservative management which may include hot or cold packs and anti-inflammatory agents. It is unclear if these patients will benefit from muscle relaxants which often cause sedation. Patients should be encouraged to return to normal activities and should be reassured (after complete patient assessment) that there is no serious pathology. Patients may recover from non-specific back pain as quickly as within 2 weeks, although they should be warned that back pain often recurs. In view of this, physical therapy or manipulation therapy may be delayed until 3 weeks since many patients may improve on their own.

Subacute and Chronic Back Pain

If back pain has not resolved in 4-6 weeks, further workup including imaging studies may be helpful. Plain x-rays may demonstrate bone changes such as fractures. Although x-rays may show bone destruction, it may not be sensitive enough to pick this up early on. Computed tomography (CT) and especially Magnetic resonance imaging (MRI) are more sensitive than plain x-rays for the detection of soft tissue injury and disk pathology. MRI should be considered early on in patients where there is a high index of suspicion for neoplasm or an infection involving the spine. However, it should be noted that disk herniations, bulges, and degenerative changes are found just as commonly in asymptomatic patients and that such findings on an MRI may or may not be related to the patient's presenting back pain.

Chronic low back pain is a welldocumented disabling condition costly to both individuals and society Waddell 1992

Definition of Acute Low Back Pain The International Association for the Study of Pain (IASP) adopted a topographic basis for the definition of acute low back pain (Merskey and Bogduk 1994). The IASP recognises different forms of spinal pain lumbar spinal pain, sacral spinal pain, or lumbosacral pain, as constituting low back pain. These definitions explicitly locate the pain as perceived in the lumbar and or sacral regions of the spine, which collectively cover the following regions non-specific low back pain. The following are beyond the Guidelines developed by other groups were evaluated to determine whether an existing guideline could be adapted for use in the Australian context. Other countries have produced national clinical practice guidelines for low back pain. In a recent qualitative review, Koes et al. (2001) identified 11 guidelines published in English, Dutch and German (the original draft version of these Australian guidelines was included in this review). The guidelines...

Low Back Pain Syndrome

Back pain can be classified as axial (focused on the low back), referred (pain experienced in the buttock or posterior thigh), or radicular (pain radiating down the leg). Aside from the common muscle strain that can cause LBP, there are several common back pain syndromes, such as HNP, facet disease, degenerative disc disease (DDD), spinal stenosis, and compression fractures (Figure 11.3). Some conditions are the result of degenerative changes, but others can be caused by trauma, poor lifting or stretching techniques, or simply a sudden sneeze. For an HNP located in the lumbar region, diagnostic criteria includes the use of a straight leg raise, during which the back pain is reproduced when the leg is straight raised to a 90 angle. If pain is severe and there is a neurologic impairment, magnetic resonance imaging (MRI) is recommended to assist with diagnosis (Chou et al., 2007).

Acute Low Back Pain continued

Plain xrays of the lumbar spine are not routinely recommended in acute non-specific low back pain as they are of limited diagnostic value and no benefits in physical function, pain or disability are observed. Appropriate investigations are indicated in cases of acute low back pain when alerting features ('red flags') of serious conditions are present. A specific patho-anatomic diagnosis is not necessary for effective management of acute non-specific low back pain. Terms to describe acute low back pain with no identifiable pathology include 'lumbar spinal pain of unknown origin' or 'somatic lumbar spinal pain'.

Table 85 Common causes of back pain

Without a doubt, back pain results in significant morbidity and constitutes the leading cause of long-term disability in the United States (Atlas and Deyo 2001). Clinicians treating patients with back pain often are confronted with a perplexing differential diagnosis. Common causes of back pain include those listed in Table 8-5. Back pain may emanate from injury in a number of body areas (e.g., the vertebrae, facet joints, nerve roots, muscle, connective tissue). In 60 of back pain patients, there is often no direct relationship between physical findings discovered on physical examination or diagnostic testing and the patient's perceived level of pain, disability, and psychological distress (Reesor and Craig 1988). Patients whose back pain appears disproportionate to the level of pathology noted on examination have a marked propensity toward depression and maladaptive cognitive patterns compared with those with clear pathology for their pain. Such patients are particularly prone...

Chronic back pain

The disciplined investigation of chronic low back pain is predicated on the relative prevalence of various possible Another factor bears on this initial consideration. An MR image of the lumbar spine is an appropriate screening test before undertaking any invasive investigations for low back pain. Not only will it reveal any occult lesions not evident on or suspected from history, it also streamlines invasive investigations, preventing them from being undertaken arbitrarily or routinely. The MR image may show a high intensity zone (HIZ) in an annulus fibrosus. This sign should not be confused with fissure or unremarkable spots in the annulus. It consists of a bright signal, seen on carefully acquired T2-weighted images, with a brightness greater than that of the nucleus, and at least equivalent to that of the cere-brospinal fluid.138, 139 140 141 When present in patients with back pain, it implicates the affected disk as the source of the patient's pain, with a positive likelihood...

Low back pain

Tricyclic and heterocyclic antidepressants have beneficial effects on pain intensity among patients with chronic low back pain. Specific medications used in randomized placebo-controlled trials include nortriptyline,61,62 II maprotiline,63 II doxepin,64 II desipramine,65 II imi-pramine,66,67 II and amitriptyline.68 II In these trials, the dose of nortriptyline ranged from a mean of 84 to 100mg day and the dose of imipramine ranged from

Back Pain

About 60 of patients suffer from low back pain which is second only to upper respiratory symptoms for physician visits (Deyo and Weinstein 2001). Back pain is often challenging for healthcare professionals in terms of diagnosis and treatment. In addition to enormous healthcare costs, back pain is one of the leading causes of disability and work loss, incurring huge costs to society. Men and women appear equally affected with low back pain. Risk factors associated with low back pain include a history of previous back pain, history of heavy lifting, bending, twisting, whole body vibration, obesity, poor job satisfaction, lower social class, and emotional distress.

Myofascial Back Pain

Injury to muscles is a common cause of back pain. This may be related to increased activity or an acute injury. Trigger points or tender points may be palpated in the back. There are no neurological changes on examination. Muscle spasm may be noted, and tender or trigger points, which is diagnostic, palpated. Injection of trigger points, usually with local anesthetic is often helpful and may decrease discomfort and improve range of motion. For maximum benefit, it should be carried out in conjunction with physical rehabilitation.

Discogenic Back Pain

The intervertebral disks separate each vertebral body. Each disk consists of a nucleus pulposus surrounded by an annulus fibrosus. Disk degeneration can lead to small tears in the annulus fibrosus, causing back pain which is usually non-radiating. Patients may present with a work history that involves repetitive motions, such as handling heavy machinery. MRI may show a desiccated disk. Provocative discography, although a controversial study, may help identify the disk (or disks) as the source of pain.

This chapter contains information that is generic to the management of all people with acute musculoskeletal pain

It is logical that clinicians and patients should strive to understand each other, that clinicians should avoid the use of intimidating jargon and misleading diagnostic labels and that patients have a need to be supported. These elements of effective communication are based largely on concept validity and face validity, however there is some evidence for these practices contained in the literature on low back pain. Studies of the treatment of subacute low back pain have demonstrated that significant improvements in the number of patients with back pain returning to work can be achieved by providing an explanation, assurance and encouragement to remain active, with no other intervention (Indahl et al. 1995, 1998). A non-randomised study of acute low back pain found that good outcomes can be achieved by focusing on the fears of Abenheim et al. (1995) investigated the prognostic consequences of making an initial diagnosis of work-related back injury. A chart review revealed that...


Acute low back pain has many possible sources, including all diseases, injuries and other impairments that invoke nocicep-tive mechanisms in the region. Table 4.1 outlines some of the possible causes of acute low back pain, however pain does not always correlate with the presence of a particular condition. With the exception of conditions posing a serious threat to health, identification of a specific cause is not a precondition for effective management of acute low back pain (Bogduk and McGuirk 2GG2). Conditions Associated with Acute Low Back Pain Radiological Findings Table 4.2 shows the prevalence of conditions identified in patients presenting with acute low back pain based on radiological findings. Data were obtained from prospective studies of patients with acute low back pain referred for lumbar radiography from primary care (Suarez-Almazor et al. 1997 Hollingworth et al. 2GG2). The table demonstrates that the findings were 'normal' or showed degenerative changes in the vast...


There are conflicting data from studies on the natural history of acute low back pain which may be partly explained by variations in symptom duration at inclusion and length of follow up. Estimates range from 90 with complete recovery at two weeks from an episode of acute low back pain in a primary care cohort with pain for less than 72 hours at presentation (Coste and Rigby 1994) to only 27 completely better at a three month follow up among another primary care cohort with a mean pain duration of three weeks at inclusion to the study (Croft and Rigby 1994). The latter cohort was followed for a period of 12 months and while more than 90 had stopped seeking medical care for their back pain by three months, only 25 stated that they were completely re-covered (i.e. no pain and no disability) at 12 months (Croft et al. 1998). Thus, ceasing medical care does not necessarily mean the patient is symptom free or has returned to full function. Schiottz-Christensen et al. (1999) performed a...

Criteria for Treatment Success

Pain reduction The most common criterion measure of outcome in various treatment approaches for pain problem. Dvorak and colleagues studied 575 patients who were operated on lumbar disk herniation and concluded that 70 continued to complain of back pain 4-17 years after surgery (Dvorak et al. 1988). Pain reduction following treatment at MPCs ranged from 20 to 40 (Flor et al. 1992). Studies investigating the long-term maintenance of pain reduction observed at discharge tend to be maintained at follow up of up to 2 years. In a direct comparison, Gallon showed that only 17 of the surgical patients viewed themselves as improved as compared to 38 of non-surgical-treated patients.

Costs Of Chronic Pain

Most patients with chronic pain report pain that exists at some level throughout the day. The patients with low back pain may have episodes of pain in which the pain increases and then returns to a lower, more tolerable level. Along with the pain, patients can become anxious or depressed as the pain appears to be untreatable or as pain intensity increases. The uncertainty of the pain experience can lead patients to feel helpless and hopeless.

Understanding The Basic Principles Of Epidemiology

Absolute risk is the most easily interpreted risk measure. It is usually specified in terms of risk per time unit per individual. Using the cells in Table 5.2, the absolute risk in individuals exposed to a risk factor per time unit is (a) (a+c). An example for this type of analysis was conducted using the population-based (n 1387) Longitudinal Study of Aging Danish Twins. The authors assessed the influence of physical activity as a risk factor for incident low back pain among seniors aged 70-100 years. They found that active lifestyle protects against incident low back pain. Absolute risk estimates for incident low back pain among participants with below average strength score engaged in strenuous physical activity and those with below average strength score not engaged in strenuous physical activity were 10 and

Efficiency and equity

These studies are useful as reference points for subsequent economic analyses,32 but rely heavily on estimates and underlying assumptions and should be treated with caution.33 In addition, there are theoretical debates about the most appropriate method for estimating productivity and indirect costs.33 The human capital approach considers the value of potentially lost production resulting from a disease in terms of absenteeism, reduced productivity, and disability or premature death at a specific age until the age of retirement. The alternative, friction cost method, assumes that production losses are confined to the period needed to replace the sick worker.34 The differences in results can be highly significant. For example, the indirect nonmedical costs of neck pain in the Netherlands in 1996 were estimated at US 530 million, using the human capital approach and US 96 million using the friction cost method.35 Similarly, the indirect cost of back pain in the UK in 1998 was estimated...

Managing Chronic Pain Using Nonopioid Medications

Tie mainstay for treating chronic pain is medication management. Most patients expect to receive a medication prescription when they see their primary care provider with a pain complaint. However, for some conditions, such as low back pain, the current recommendations for the acute phase is acetaminophen nonsteroidal anti-inflammatory drugs (NSAIDs) and continued activity, rather than opioids and bed rest. About 15 of the patients who have acute low back pain progress to chronic low back pain. Medication management for chronic low back pain is recommended, accompanied by a plan of care that includes medications along with other therapies, such as physical therapy and counseling (D'Arcy, 2009b). Opioids are in most cases reserved for severe level pain that is impairing functionality.

Magnetic resonance imaging

In relation to pain medicine, the high sensitivity of MR imaging makes it the most useful form of medical imaging for screening purposes to rule out unexpected conditions, or ones that cannot be detected by other means. In musculoskeletal medicine, MR imaging is the best way to detect osteonecrosis.21 For this condition, MR imaging is both sensitive and specific, and is able to detect changes earlier than can plain radiography or CT. Because of its better resolution of nerves, and its ability to provide coronal and sagittal images, as well as axial images, MR imaging is the preferred means of investigating radicu-lopathy. Its ability to demonstrate the internal structure of intervertebral disks accords it a unique role in the investigation of chronic back pain. Its ability to resolve connective tissues makes it the premier means of assessing joints and periarticular structures.

Conducting an Interview

Patients appear for psychiatric evaluation with varying agendas. For example, a patient might seek out psychiatric assessment at the recommendation of a clinician who is concerned about the patient's adherence to treatment or about psychological issues that might be contributing to or exacerbating pain. On the other hand, the patient might have an agenda that is quite different from the clinician's agenda (e.g., the impact of pain on relationships, employment, and quality of life). The open-ended line of inquiry allows for exposure and examination of the more covert aspects of the patient's reasons for seeking evaluation or treatment. Ascertaining the patient's agenda can be helpful in guiding the interview and arriving at a reasonable treatment plan that reflects the patient's needs. An example A patient sought help on the recommendation of her physician, who presumed that depression was complicating her chronic back pain. During the evaluation, it became apparent that she had con...

To determine the outcome of pain conditions

For example, patients with back pain who are female, have had long or frequent previous episodes of pain, who exercise less, and who have had a poor initial response to treatment are more likely to be disabled by their pain five years later.1 Studies such as this illustrate the large number of factors that must be controlled in research involving chronic pain. The stakeholders of outcome measurement are summarized in Table 14.1.

As a guide to treatment

Very many treatments have been used in patients with chronic pain. Published studies describe techniques varying from the drug treatment of phantom limb pain with anticonvulsants,2 II to heating vertebral disks to treat back pain,3 II and from the physical exercise of yoga4 II to spiritual healing.5 II It is hardly surprising that interpretation of the results of these individual treatments is difficult for the clinician, even without the added complications of several sequential or concurrent treatments, some of which may be unknown to the treating clinician. Patients naturally demand the best, but many factors are involved in determining what is best. For example, whether the simplicity, safety, and availability of transcutaneous electrical nerve stimulation (TENS) outweighs the precise stimulation localization, but inevitable risk of complications with spinal cord stimulation (SCS) cannot be reduced to yes or no. A great deal will depend on the patient and their attitudes to risk...

Control group or lack of

In two similar studies comparing surgical and conservative management of back pain,73 II , 74 II there was no difference demonstrated. It is therefore difficult to conclude which is the best treatment for an individual patient. Noninferiority was concluded in a study of surgery versus SCS for chronic back pain,75 II and in another of surgery versus intradiscal electrothermal therapy.3 Unfortunately, without control groups, these studies cannot exclude it being better to offer no treatment at all

Guidelines and implementation

During the last decade, various clinical guidelines on the management of acute low back pain in primary care have been published 3, 61 . At present, guidelines on acute low back pain exist in at least 12 different countries Australia, Denmark, Finland, Germany, Israel, The Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the United States. However, recently the first guidelines on chronic low back pain were published 62 . To increase consistency in the management of nonspecific low back pain across countries in Europe, the European Commission has approved a program for the development of European guidelines for the management of low back pain, called COST B13. The main objectives of this COST action were developing European guidelines for the prevention, diagnosis and treatment of nonspecific low back pain. Representatives from 13 countries participated in this project that was conducted between 1999 and 2004. The experts represented all relevant health...

How to produce evidence of effectiveness in the future

A promising strategy is trying to identify relevant subgroups that may benefit more from a specific intervention. A recently published RCT found that patients with acute or subacute low back pain had significantly better functional outcomes when they received a matched treatment versus an unmatched treatment 66 The authors examined all patients before treatment and assigned them to one of three groups (manipulation, stabilization exercises, or specific exercise) thought most likely to benefit the patients. Patients were subsequently randomized irrespective of this subgroup assignment into one of the three interventions groups with the same treatments. The analyses were focused on matched versus unmatched treatment according to their baseline subgroup assignment. Previous studies also found better results of matched treatments in subgroups of patients with nonspecific low back pain. For example, one study showed that it was possible to identify a subgroup of patients likely to benefit...

Natural history of nonspecific neck pain and whiplash with factors associated with chronic disability

Nonspecific neck pain usually resolves within days or weeks, but can recur or become chronic. Once pain becomes persistent, outcome is more unpredictable, and there is little consistency in the literature regarding the duration of symptoms and factors that influence outcome. A systematic review of the clinical course and prognostic factors in nonspecific neck pain found little consensus as to outcome or relevant prognostic factors, although this was based on poor-quality studies 19 . The systematic review found evidence that in patients with chronic pain treated in secondary care or an occupational setting, 20-78 (median 54 ) of patients remained symptomatic, irrespective of the therapy given. Six of the included studies documented prognostic factors, and the severity of pain at presentation was the best predictor of a poor outcome, although previous episodes of neck pain were also important. Three subsequent studies also considered the factors at presentation which might influence...

Human Tcell lymphotropic virus type

Human T-cell lymphotropic virus type 1 (HTLV-1) infection is seen predominantly in the equatorial regions of southeastern Japan, the Caribbean, Africa, and Central and South America. Its routes of transmission are thought to be sexual, perinatal and by contact with contaminated blood.178 Most infected individuals remain asymptomatic. Affected patients present with back pain or painless progressive spastic paraparesis with constipation and urinary urgency or incontinence.179 HTLV-1 myelopathy (HAM), also know as tropical spastic paraparesis (TSP), has a highly variable disease course. Symptoms often stabilize within a few years of onset. Serum ELISA for HTLV-1 may establish the presence of the virus. CSF demonstrates elevated intrathecal synthesis of anti-HTLV-1 IgG. MRI reveals atrophy of the thoracic spinal cord and white matter lesions that can mimic those seen in multiple sclerosis. Although the exact pathogenesis is not well understood, virus particles and virus-infected T- and...

The Placebo and Clinical Trials

However, Emanuel et al. highlight several problems with the mandated use of active controls in every clinical trial. In some cases, the discomfort or harm suffered by a patient is relatively minor and an inert placebo would cause little harm, and so forcing a clinical trial using standard therapy would not be ethically necessary. For instance, the use of a sugar pill as the control instead of celecoxib in a trial exploring treatments for chronic low back pain would not cause undue and irreparable harm. Furthermore, patients receiving placebo therapy do receive clinical attention, and this may lead to clinical improvement irrespective of the efficacy of any pharmacologic intervention. Finally, they argue that clinical trials comparing an investigational drug against standard therapy require a larger number of participants than trials using placebo. This arises because the difference in clinical effect is likely larger in the placebo-controlled trial, so researchers need a fewer number...

Types Of Cam Therapies

Complementary Techniques or additional therapies that are used in conjunction with recognized mainstream medical practices for example, when music or relaxation is used with medication for low back pain. Hot and cold applications are common home remedies. Patients are comfortable with the idea of using a heating pad for back pain or applying a cold pack for a minor muscle injury. Every household has an assortment of heating pads, ice packs, and the newer versions of microwave heating pads and wraps. Most patients find more comfort in heat and prefer it over cold packs. As for research support, a Cochrane report with low back pain patients indicates the therapies have limited support (French, Cameron, Walker, Reggars, Esterman, 2006). However, additional information indicates that a heat wrap can increase functionality in patients with low back pain (French, 2006). Ice baths, cold packs, or ice massage are helpful for decreasing the pain minor injuries, low back pain, and muscle spasms...

Experimental Pain Studies And Depression

These differences in pain thresholds and tolerances suggest patients with depression may experience a differential analgesic response to opioid medications compared to patients without depression. In a randomized, cross-over, double-blind, placebo-controlled study, 60 patients with chronic low back pain were stratified into three groups based on the severity of depressive, anxiety, and neurotic symptoms.9 Subjects in each of the three groups were administered 4-6 mg of morphine intravenously and pain severity was assessed over three hours. The total analgesic response was significantly greater in the low psychopathology group compared to the high psychopathology group. Additionally, the analgesic placebo response was significantly greater in the high psy-chopathology group compared to the low group. While the mechanisms mediating the association between chronic pain, depression, and analgesia remain to be fully elucidated, alterations in emotional processing could be important...

Generalized painful symptoms of depression

Several randomized controlled trials of duloxetine for depression reported significant improvements in a variety of pain symptoms, including back pain, shoulder pain, and headache.96,97,98 II The findings from these and other similar trials have been summarized and subjected to further pooled analyses.99,100,101 I Painful physical symptoms among patients with depression was the primary outcome measure for a randomized placebo-controlled trial of duloxetine.102 In this particular study, subjects who received duloxetine 60 mg daily experienced significant improvements in pain and activity-related pain interference. These clinical improvements occurred independent of changes in depressive symptoms.

Other pain conditions

Muehlbacher et al.65 II carried out a double-blind study on the effect of topiramate 300 mg day in chronic low back patients with moderate levels of pain and disability. Up-titration was conducted over five weeks to a daily dose of 300 mg of topiramate or placebo, which was maintained for a further five weeks. There were 48 assessable patients in each group. Topiramate was modestly superior to placebo as measured using the Pain Rating Scale from McGill Pain Questionnaire, Oswestry Disability Index, and SF-36. As an interesting observation, anger reduction was also greater in the topiramate group. Topiramate was used as an add-on medication and the authors did not declare whether there were dose changes in the ongoing medication and did not discuss what other treatments the patients were receiving (e.g. physiotherapy).65 II Given the almost complete lack of pharmacotherapy available for patients with chronic low back pain who have failed to benefit from conventional analgesics, these...

Chronic nonmalignant pain

ITDD can be considered as a potential treatment in the management of some nociceptive pain, particularly mechanical back pain, cases of mixed neuropathic and nociceptive pain, and cases of widespread pain, for example back and leg pain. In a retrospective study, Raphael et al.53 III found ITDD systems appeared to confer advantage over spinal cord stimulation in failed postsurgical spine pain and chronic mechanical back pain.

The Adult With Chronic Pain

The constant demand to react and adapt to pain and its associated disabling consequences also results in emotional problems. Principal among them is the development of a pattern of pain-related fear that is itself distressing, but is also thought to be a factor in the maintenance of chronic disability.8 IV Typical targets of fear (or fear-provoking stimuli) for chronic pain patients are physical activity and movement, or even the thought of physical activity and movement. Movement is often associated with the catastrophic belief that increased pain and (re)injury will occur.9 These fears may be specific to the patient group, e.g. the fear for chronic low back pain patients that a back-stressing movement, such as lifting, will lead to disk damage.

Nociceptive musculoskeletal pain

Low back pain is common and probably the consequence of a combination of factors. Lumbar paraspinal muscle spasticity may result directly in muscular pain and also produce increased mechanical stress on nonmuscular components of the spine (such as ligaments, disks, and zygapophysial joints). Additionally, the immobilization and weakness that occurs with advancing disability may predispose to musculoskeletal spinal pain in the same way as is believed to occur in patients with chronic back pain without neurologic disease.

General considerations

Effective treatment of pain in neurologic disease is seldom, if ever, disease specific. Burning central neuropathic pain is probably as likely to respond to a tricyclic antidepressant whether the disorder responsible is syringomyelia, multiple sclerosis, or spinal cord injury. Conversely, an antiepileptic drug that successfully treats trigeminal neuralgia in a patient with MS may be completely ineffective for lumbar back pain in the same patient. Rational management of pain in any patient with neurologic disease must start with an attempt to identify the nature of the likely pathophysiology giving rise to the pain (or pains).

Psychologic treatment

Second, physical disability in many painful neurologic diseases may be directly attributable to motor sensory deficit or dysfunction, in contrast with, for example, the patient with musculoskeletal back pain without neurologic disease whose disability is pain contingent. This may limit the capacity for improving physical function with a cognitive-behavioral management approach.

Factors to Be Addressed in Psychotherapy

The experience and expression of anger may have an impact on chronic pain. Higher levels of anger (as well as depression and anxiety) are found among patients with chronic low back pain than are found among asymptomatic control subjects (Feuerstein 1986). Poorly managed anger adversely affects pain levels. In one study, patients with chronic tension headache differed from control subjects in their experience and expression of anger (Hatch et al. 1991). Headache patients were prone to hostility (i.e., feelings of resentment, suspicion, and mistrust), anger arousal (i.e., perceiving situations as annoying or frustrating and aroused to anger frequently), and anger suppression (i.e., being more likely to suppress angry feelings once aroused). However, once overtly angry, headache patients tended to expend less control over the expression of anger than control subjects. Taken together, these studies suggest that modulation of anger and hostility might be a major determinant of the...

Regional Anesthesia and Other Interventions

Traumatic brain injury (TBI) is another common cause of chronic pain and disability, affecting nearly 1.5 million Americans per year. The prevalence of pain following TBI varies dramatically, ranging from 18 to over 90 depending on the surveillance method, severity, and associated trauma (Cohen et al. 2004). The most common pain complaints in patients with mild TBI (Glasgow Coma Scale 13-15, loss of consciousness

Other Indicators of Functionality

Sara Stone, who is a 45-year-old patient, tells you she has had LBP for about 6 weeks. She says the back pain started when she was moving and she lifted a series of heavy boxes. She has tried a variety of treatments with little effect. She lists the things that she has tried as heat and cold, analgesic balms (Icy Hot), acetaminophen, over-the-counter ibuprofen, and a pain pill from an old surgery she had several years ago. Nothing seems to work, and the pain is very intense at night when she gets into bed. She can only tolerate the lying position for several hours, and then she gets up and sleeps the rest of the night in a recliner chair. She has an appointment with a chiropractor but thought she would see her primary care provider before she went and had an adjustment.

Special Techniques in Pain Management

It should be noted that highly invasive procedures, although useful, are not a panacea. For example, back pain patients randomly assigned to lumbar fusion surgery or noninvasive educational exercise programs did not differ significantly at 1-year follow-up on measures of perceived disability, subjective pain ratings, use of analgesics, and general life satisfaction (Brox et al. 2003).

Implications Of The Complexity Of Mechanisms

The complexity also has implications for clinical practice. The extent of the changes in the nervous system suggests that pharmacological, psychological, and behavioral therapies may be more beneficial to patients than invasive treatments. Simplistic notions about treatment, for example simple nerve blocks, or further surgery are unlikely to help, and may well do harm, by causing further damage. If surgery has the potential to cause chronic pain, then caution is needed before embarking on operations. This is of particular relevance for cosmetic surgery, or for other procedures that are performed out of choice rather than need. It also raises important questions about surgery in conditions where the evidence for efficacy is lacking, for example some types of surgery for back pain, producing the post laminectomy syndrome.76

Botulinum Toxin Botox Injection

Botulinum toxin (both A and B types) has been invoked in the treatment of cervical dystonia, migraine headache, tension headache, temporomandibular joint disorders, and chronic back pain (Argoff2005). Multiple series of injections may be required to achieve maximal analgesia. Contraindications include pregnancy, concurrent aminoglycoside antibiotic use (e.g., gentamicin, tobramycin), myasthenia gravis, Eaton-Lambert syndrome, and known sensitivity to toxins. Clinical resistance brought on by development of antibodies to toxins may reduce clinical efficacy after repeated administrations.

Why Are They Coming To See

The office evaluation of the CLBP patient should include, at a minimum, the assessment of pain severity, functional disability, and screening for underlying serious disease.15 However, most of these issues carry little importance to the chronic low back pain patients as their reasons for seeking care may be entirely different. Perhaps the most common reason for seeking care is to find the source of the back pain.16 However, many other reasons exist (Box 37.1). Simply continuing to probe into the patient's reasons for seeking an evaluation will allow more meaningful counsel and is less time-consuming.10 This can lead to improved outcomes of not only patient satisfaction, but compliance of treatment, self-rated improvement, and decreased desire for ordering further testing.17In addition, to the patient's reasons for seeking care for the CLBP, referring physicians have additional interests. They may hold some of the same expectations as their patients.18 For example, low back pain myths...

Dont be fooled by these patient populations

The chronic low back pain patient, who has presented on numerous occasions, can subsequently develop a life-threatening reason for their pain. They may only complain of worsening symptoms over time or an additional area of pain, when indeed they are harboring a new cancer, infection, or fracture. The patient with psychological overlay or the possibility of chronic pain syndrome similarly can have a serious underlying reason for their pain.

Effective screening for red flag and yellow flag issues

Screening for serious underlying pathology includes screening for malignancy and or benign tumor, infection, fracture, inflammatory arthropathy, and neurologic disease, such as radiculopathy, spinal stenosis, or the rare but serious cauda equina syndrome.25 In all of these cases, with the exception of neurologic disorders, the examination is nonspecific.32,33 There is often very little difference in the appearance of someone with gardening-variety low back pain on examination and those with cancer, infection, or fracture. Therefore, the history is relied upon heavily to assess risk (Table 37.1).

Physical examination

The examination of a patient's chronic low back pain is best performed with the patient wearing garments that allow viewing of the spine, buttock region, and extremities. The examination is also geared towards screening for serious underlying disease processes. It is most heavily weighted towards neurologic conditions, most commonly radiculopathy or other diseases, involving the cauda Typically abrupt onset of back pain with pain in one or both legs weakness, sensory changes, saddle distribution sensory changes, urinary retention or incontinence without warning, occasionally rectal sphincter dysfunction as well (a surgical emergency)

Cauda Equina Syndrome

Cauda equina syndrome (CES) is the new onset of sacral nerve dysfunction manifested by initial urinary retention, then overflow incontinence, and unilateral or bilateral saddle distribution sensory loss with the possibility of rectal sphincter dysfunction. This is all in the context of typically abrupt onset of back pain and unilateral or bilateral leg pain, weakness, or paresthesias. While this is classically a bilateral leg problem different from radicu-lopathy, occasional patients will present with what otherwise looks like radiculopathy but have the sacral segment symptoms (incontinence) that make this

Lumbar Radiculopathy And Spinal Stenosis Patients

Patients with radiculopathy are approached with the same treatment tools in mind as the patient with only CLBP with some important additional considerations. First, the back pain and radicular leg pain component are approached as two different problems since they can act and respond to treatments in very different ways. For instance, the back pain component does not usually respond to the treatments that are helpful for the radicular component. Treatments, such as surgical disc-ectomy, epidural steroid injections, or neuropathic drugs, can eliminate radicular leg pain, but have not shown efficacy for treating axial pain.140 Most of these patients will have a discogenic or bony hypertrophic etiology for their radicular pain. Occasionally, the radicular pain comes from a synovial cyst, but serious underlying spine disease as a source of radiculopathy is extremely rare32 and only investigated if the usual low back screening red flags are positive. Patients with classical spinal stenosis...

First patient on longterm hemoperfusion

She was bedridden in the hospital, with a BUN of 186 mg dl,creatinine of 24 mg dl,and a 24 h creatinine excretion of 80 mg. She was placed on peritoneal dialysis but this resulted in massive intra-abdominal bleeding and severeshock. Hemodialysis treatment resulted in hypotension. She was referred to this author since there was no other way to treat her condition. At that time, because of lack of facilities, patients of her age were not generally accepted into long-term hemodialysis program. Thus, I first had the assurance of the dialysis unit that if she improved on the hemoperfusion program, the dialysis unit would accept her on the standard dialysis program. For the next 50 days, she underwent hemoperfusion procedures, each lasting for 2 h. During this 50 days, she received only one hemodialysis for the removal of water and electrolytes. After that, she continued for a total of eight months on hemoperfusion combined with hemodialysis. The...

Other visceral cancers

Sources of pain can be visceral due to the primary tumor or somatic neuropathic due to local involvement and metastases. Cancer treatments themselves may be pain-producing. All of these sources of pain are similar to those described above under Pancreatic cancer (Box 40.2). Patterns of tumor spread differ between types of tumors and so general patterns of symptomatology related to metastases also differ. Gastrointestinal tumors tend to spread through the lymphatics towards the liver and may present with diffuse abdominal complaints. In contrast, prostatic tumors frequently spread relatively early to involve the lumbar spine and so may present as back pain. Pain treatment options for all cancers are similar to that described for pancreatic cancer (Box 40.3). Treatment of the cancer (surgery, chemotherapy, radiotherapy) may be curative or palliative. Neuroablation is an option with the particular site of treatment determined by the site of the symptomatic cancer (see Figure 035.1 in...

Antiarrhythmic agents

In another study patients with CPDN, posther-petic neuralgia and low back pain, who had partial response to gabapentin-containing analgesic regimens, were enrolled 77 . Eligible patients were included in this open-label, nonrandomized, prospective, 2-week study in which the lidocaine patch 5 was applied to the area of maximal pain, using no more than a total of four patches changed every 24 hours whilst patients were maintained on their other analgesic regimens. In the combined patient population (n 77), 2 weeks of treatment with the lidocaine patch 5 significantly improved all four composite measures on the Neuropathic Pain Scale (P 0.01). Overall, eight patients (10 ) experienced mild to moderate treatment-related adverse effects 77 .

Polycystic kidney disease

This disorder is an autosomal-dominant genetic disease that eventually leads to kidney failure. Cyst formation, rupture, infection, and secondary compression traction of neighboring structures may produce low back pain, abdominal pain, headache, chest pain, flank pain, and or leg pain.134 Renal stone formation and liver cyst formation are both common comorbidities and so reports of pain may require an assessment of those etiologies. Bajwa et al.135 have proposed a general progression from non-pharmacological methods to non-narcotic analgesics and minimally invasive procedures to progressively more invasive procedures and use of opioids. Procedures unique to polycystic kidney disease include surgical or percutaneous drainage of the cysts with marsupialization to avoid fluid reaccumulation.136

Local anesthetic nerve blocks

An example of a specific nerve block that can be highly effective in reducing muscle spasm is an accessory nerve block. This nerve supplies the accessory muscle and the anterior portion of the sternomastoid muscle. It has no sensory distribution. It passes close to the skin about one-third of the way down the anterior border of the sternomastoid muscle between the mastoid process and medial end of the clavicle. Deposition of local anesthetic and corticosteroid around the anterior border of the sternomastoid muscle at this location can be a very effective treatment of torticollis. A further example of use of a local anesthetic in the treatment of muscle spasm would be a lumbar epidural injection where the local anesthetic blocks nerves to para-vertebral muscles and also to many of the structures which may have initiated the low back pain and caused the muscles to become spasmodic.

Interleukin2 receptor IL2R targeting DAB389IL2 Ontak denileukin diftitox

The response rate in CTCL was recently confirmed in a phase III trial in 71 CTCL patients in which 7 CRs and 14 PRs were observed, and most of the patients had objective improvements in skin lesions 21 . The phase III trial was designed to test two dose levels below the MTD, including 9 and 18 g kg QD X 5. At total of 16, 10, 19, 11 and 15 patients had stage Ib, IIa, IIb III and IVa CTCL, respectively, with similar numbers in each of the two treatment groups. At the lower dose level, 6 of 14 (43 ) stage Ib-IIa patients versus only 2 of 21 (10 ) stage IIb-IVa patients responded. In contrast, at the higher dose level 4 of 12 (33 ) stage Ib-IIa patients versus 9 of 24 (38 ) stage IIb-IVa patients responded. Thus, while overall response rates (23-36 ) and median durations of response (6.8-6.9 months) were not statistically different between the 2 dose levels, the results did suggest the higher dose as being advantageous for patients with higher disease burden. The most common type of...

Infusion related reaction and other nonhematologic toxicity

All pts who were enlisted in Table 2 were accessed for safety. Major non-hematologic toxicity was summarized in Table 3 with dose and number of pts. Reactions to infusion were observed on first exposure to the drug in 10 pts. Early reactions to infusion developed between 5 to 20 minutes after the start of infusion and were characterized by flushing, chest discomfort, lumbago or itching. All symptoms disappeared shortly with no treatment or

Fibromyalgia syndrome

Rheumatism, myalgia, interstitial fibrositis, myofascitis, and myofascial pain. In 1977, Smythe and Moldofsky3 applied the term fibrositis to patients with localized or generalized musculoskeletal pain associated with tender points. This is a misnomer since the term implies an inflammatory process in fibrous tissue which has never been demonstrated by biopsy. The diagnosis of FMS has been problematic in the absence of an objective test. In 1990, Wolfe et al.4 defined the American College of Rheumatology (ACR) classification criteria, which are currently the standard used to diagnose this syndrome in clinical and therapeutic research. They state that patients must have a history of widespread pain lasting more than three months, defined as pain in both sides of the body, pain above and below the waist. In addition, axial skeletal pain (cervical spine, anterior chest, thoracic spine, or low back) must be present. Low back pain is considered lower segment pain. They must also have pain...

Neuroendocrine Alterations

In patients with FMS, a reduced hypothalamic-pituitary-adrenal (HPA) axis response to stress has been demonstrated.41,42,43 The neuroendocrine response acts normally under baseline conditions, but not when subjected to stress or even normal activities of daily living. However, this deficit might have more impact on depression, a common associated feature of FMS as well as chronic pain. Patients with FMS often report experiencing previous stressful or traumatic events. A reduced HPA axis response to stress can contribute to FMS development or worsening of FMS. The HPA axis is also linked to the autonomic nervous system, which is involved in modulating sleep, mood, pain, and cardiovascular activities (including microcirculation of muscles). This could explain many clinical features and the association of FMS with sympathetic nerve system over activity, although more detailed mechanistic studies will be needed to confirm a causative relationship. Abnormal HPA axis activity has also been...

Generalized anxiety disorder

CBT has been shown to be effective in chronic painful conditions.34 I This treatment is also used in GAD associated with pain.35 It has been shown that in patients with low back pain who have pain-related anxiety receiving CBT combined with physical therapy, that improvement in anxiety was more important than changes in physical capacity in predicting outcome.36 Similar benefits when reducing anxiety in patients with back pain were shown in a Finnish study.37 In a recent World Health Organization (WHO) survey, people with back and neck pain were over 2.5 times more likely to have GAD than controls without this condition.38 This survey was not able to show the temporal relationship between pain and anxiety, but other studies have strongly suggested that anxiety sensitivity is a feature in this population.27'36

Central pain in multiple sclerosis

In addition to central pain, nociceptive pain conditions (including spasm-related pain and low back pain) and pain associated with optic neuritis are frequently seen in this population of patients. It may be difficult to differentiate between nociceptive pain conditions and central pain.

Physiological Influences

Investigated, but the findings to date in the elderly suggest genetic factors are not important. A study looking at the development of neck pain in the elderly failed to demonstrate a significant influence of genetic factors.11 IV Similar work on back pain in the over 70 age group suggests a small genetic effect in men but not women. Significant predictors for back pain found in this latter study included previous or current diagnosis of osteoporosis, arthritic or lumbar disk disease, as well as environmental effects.12 IV

Epidemiology of chronic pelvic and vulvalperineal pain in women

In the setting of UK primary care consultations, data from 284,162 women aged 12-70 years who had a general practice contact in 1991 were analyzed to identify subsequent contacts over the following 5 years 23 . The monthly prevalence rate was 21.5 1000 and the monthly incidence rate was 1.58 1000. The authors highlighted the burden of disease represented by these data, pointing out the comparability with migraine, back pain and asthma in primary care. Older women had higher monthly prevalence rates for example, the rate was 18.2 1000 in the 15-20 year age group and 27.6 1000 in women over 60 years of age. This association was thought to be due to persistence of symptoms in older women, the median duration of symptoms being 13.7 months in 13-20 year olds and 20.2 months in women over 60 years 24 .

Epidemiology of nonspecific neck pain

About two-thirds of the population will experience neck pain at some time in their lives 7, 8 , with the condition being most common in middle age, and in women 9 . The reported prevalence of neck pain varies widely between studies, but has a mean point prevalence of 7.6 (range 5.9-38.7 ) and a mean lifetime prevalence of 48.5 (range 14.2-71 ) 9 . A UK survey found that 18 of 7669 adults had neck pain at the time of the survey, but when symptomatic people were re-questioned 1 year later (58 responded), half were still symptomatic 10 . A Norwegian survey of 10,000 adults also reported that 34 of responders had experienced neck pain in the previous year 11 . Neck pain is second only to back pain in frequency of musculoskeletal consultation in primary care.

Hypogastric Plexus Block

Complaint after the procedure is back pain. A thorough patient history and physical examination will differentiate between back pain from needle placement or hematoma. CT scan is essential to rule out hematoma. Another common complaint is back pain which can be differentiated from back pain due to hematoma by the severity of pain and by performing serial exams. CT scan is diagnostic.

Pharmacologically Resistant Psychologically Conditioned Pain

Hypochondriasis, somatization disorder, depression, and malingering or compensatory behavior. These terms are used in a general fashion, without the specificity that a psychiatrist or psychologist would apply. The general practitioner may call the back pain and its manifestations functional overIay or of psychogenic origin, that is, conditions for which no organic origin can be found. Current evidence suggests that the majority of these patients really do perceive disabling pain. Thus, somatoforme pain, is not only seen in the head, the heart, the gastro-intestinal and the genital area, but more frequently in patients with neck and back pain. Patients regularly displace such psychosomatic interconnection, which is very difficult to treat. The patient refuses to acknowledge such cause and demands newer and more extensive medical examinations. Although any premature psychosomatic diagnosis is dangerous, because it impairs the diagnostic assessment and results in a displeased and angry...

The Malingering Patient With Compensatory Pain Behavior

Malingering Patient

The malingering patient is motivated by a conscious secondary gain that may be tangible or intangible. It is important to remember that a malingerer may be uninterested in financial rewards and may instead be seeking other forms of reinforcement from employers, coworkers, or family. In contrast, the compensatory patient is interested only in monetary gain. The patient may have been injured at work or may be involved in litigation related to an automobile accident. The possibility of large financial settlements motivates many victims, some with quite minor injuries, to file lawsuits claiming extensive and even ridiculous disabilities. These patients usually give a vague story and try to confuse the examiner by avoiding specific details of their problem or their pain distribution. A bizarre gait, inconsistent with physical findings, is typical (Figure I-59). After bending forward, the patient returns to the erect position in a cogwheel fashion, groaning and complaining of increased...

Painful bladder syndrome interstitial cystitis

Abdomen, pelvis, groin and or perineum 60 . The onset of the disease may follow an event but is notable for a rapid progression of symptomatology. Depression and anxiety are frequent co-morbidities. In one analysis, Clemens and associates reported that 25 of patients with IC also carried an International Statistical Classification of Diseases (ICD)-9 diagnosis of depressive disorder and 19 carried a diagnosis of anxiety. In this study, compared to controls, patients with IC were also more likely to suffer from fibro-myalgia, gastritis, headaches, esophageal reflux and back pain, and were more likely to have a history of child abuse 63 . Suprapubic tenderness to palpation may accompany a diagnosis of IC. Although a history of frequent urinary tract infections is twice as common in IC patients as in non-IC patients, most report infrequent urinary tract infections (

Opioid Tolerance And Opioidinduced Hyperalgesia

OT OIH may develop within hours of starting opioid therapy, as demonstrated by increased postoperative pain and hyperalgesia following remifentanil-based anesthe-sia.121 A recent clinical experiment using cold pressor testing found that OT OIH developed within one month of commencing oral morphine for chronic low back pain.122 It has long been recognized that former heroin addicts on long-term methadone maintenance therapy exhibit lower thresholds to cold pressor testing and are cross-tolerant to high doses of morphine.123 Some authorities suggest that the presence of pain in some way reduces the development of OT OIH in clinical pain, compared with addiction or animal models.124 The rate of opioid dose escalation (possibly reflecting reduced OT

Pain after amputation

Pain after limb amputation was undoubtedly the first of all the postsurgical pain syndromes to be recognized. Silas Weir Mitchell described phantom limbs and pain syndromes caused by gunshot wounds following the American Civil War.36 Pain following limb amputation falls into two broad categories, phantom pain and stump pain (also called residual limb pain). Many lower limb amputees also report back pain.37 For a detailed review of phantom pain, see the excellent article by Nikolajsen and Jensen, and Chapter 31, Postamputation pain.38

Pain Intensity Difference Versus Pain Relief

There now seems to be reasonable consensus from a variety of sources that a change in pain intensity of 30-60 percent, or two to four points on an 11-point scale, represents a clinically useful reduction in chronic pain.50' 83'84'85'86 Percentage pain reduction correlates better with patient global impression of change than does pain intensity difference, particularly when the initial pain report is high. Patients may view an 80 percent reduction in both pain and disability as desirable, but will consider 25 and 35 percent, respectively, to be worthwhile.87 Levels of depression and disability appear to modify expectations of outcome of treatment.88 The minimum clinically important change (MCIC) has been reported for back pain and associated disability smaller improvements are more valuable in chronic pain states than in acute ones.89 Meanwhile, satisfaction with care may be rated as more important than satisfaction with improvement in pain Outcome success may be specifically defined...

Risk factors for chronicity

It is important to identify early those low back pain patients at risk for long-term disability and sick leave, because early and specific interventions may be developed and used in this subgroup of patients. As stated before, most patients are likely to recover within a couple of days or weeks, but recovery for those who develop chronic low back pain and disability becomes increasingly less likely the longer the problems continue. The small group of patients with long-term severe low back pain also account for substantial healthcare utilization and sick leave, and associated costs. Evidence suggests that psychosocial factors are important in the transition from acute to chronic low back pain and disability 19 . A systematic review of prospective cohort studies found that some psychologic factors (distress, depressive mood, and somatization) are associated with an increased risk of chronic low back pain 22 . Individual and workplace factors, such as job dissatisfaction, low...

Plasmacytomas and multiple myeloma

Solitary plasmacytomas of bone (SPB) account for 5 of malignant plasma cell disorders.2 The spine is a frequent site of involvement, representing 25-60 of all SPB.1,3,4 A high incidence of SCC is reported in SPB, ranging between 43 and 71 of the cases.1,5,6 In contrast, in multiple myeloma, where spinal involvement is always present, the reported incidence of SCC varies between 10 and 16 .1,7,8 In many cases, SCC is the presenting manifestation of the disease, although the majority of spinal lesions are asymptomatic. Back pain and radicular pain usually precede signs of SCC by several weeks to months in about 80 of patients. The pain may be related to bone destruction, nerve root compression or dural impingement. Neurologic signs relate to the level of the lesion(s). The most affected spinal area is the thoracic spine, followed by the lumbar, while cervical involvement is uncommon.1

Sreekumar Kunnumpurath Mbbs Md Fcarcsi Frca Ffpmrca

Andrew is 75-year-old man who has been very active until about a year ago. He used to play golf twice a week. One year ago, he slowly started to get persistent lower back pain which gradually began to worsen. A few months later he noted that he was getting pain in his thigh and to his dismay his neck was becoming painful too. Finally, he had to stop playing golf altogether. He was seen by his PCP who after a careful examination made a diagnosis of non-specific back pain. Andrew was started on acetaminophen and ibuprofen, which reduced his back pain to such an extent that he could play some golf again. However, a few months later during a routine checkup his PCP noticed edema of his ankles. On further investigation, he was found to have elevated blood urea and crea-tinine. Ibuprofen was promptly stopped with resulting recurrence of back and neck pain. Andrew was then prescribed regular codeine phosphate and diazepam before bedtime for Majority of back pain cases have a benign etiology....

Social psychology and pain collective experience

Psychologists are interested in the beliefs that people hold about their pain, and their negotiation, because these beliefs are implicated in patient behavior. For example, those who believe that back pain is caused by a medical condition will resist treatment attempts aimed at movement despite pain and a therapeutic focus on stress-related factors. Similarly, those who cannot accept that a valuable life can be led without analgesia will not benefit from attempts to teach self-management, without addressing those beliefs. Matching belief to adaptive behavior is a socially mediated process. For a recent example, worrying thoughts and beliefs about the meaning of pain can lead people to seek medical support, which when appropriate is adaptive. However, when a medical cure is pursued in opposition to unhelpful, unchanged beliefs about the cause of pain, this pursuit can fuel anxiety, depression and disability 6 .

Adjunctive Interventions

Relaxation and imagery (R&I) has been employed in both acute and chronic pain and has been successfully implemented in the treatment of tension headache, migraine headache, temporomandibular joint pain, chronic back pain, and myofascial pain syndrome (Turner and Chapman 1982a). Progressive muscle relaxation (PMR) is the most common approach used. In PMR, the patient is instructed to tense muscles in a region of the body or a limb and then subsequently relax those muscles. The tension and subsequent relaxation of muscle groups is conducted in a logical and sequential manner, generally from head to foot or the reverse. For some patients (e.g., those with myofascial pain and fibromyalgia), the process of tensing sequential muscle groups could prove to be too difficult or fatiguing. Consequently, alternative measures can be employed (e.g., guided imagery or deep breathing exercises). Current conceptualizations view hypnosis as a form of focused attention that is useful in managing acute...

Shu Ming Wang MSci MD Janet S Jedlicka PhD Otrl Anne M Haskins PhD OTRL and Jan E Stube PhD OTrl

Harris is a 45-year-old, otherwise healthy man suffering from lower back pain. He over exerted himself lifting a heavy box from the floor. He did not experience immediate pain until the following morning. He complained that his pain was very severe and had significantly affected his movement. He stated that he experienced sharp pain associated with every movement. The pain radiated downward over the buttocks and both legs. He had no other symptoms, and an MRI of his back was normal. The patient received several sessions of massage, but his symptoms and pain did not subside. As a result, he is here to receive acupuncture treatment. Compare the pathological interpretation of low back pain in Chinese medicine to modern medicine Chinese medicine and modern medicine have radically different concepts regarding the etiology of back pain Chinese concept of pathological changes is as follows. The local muscles of the lower back were injured followed by overexertion. Consequently, the...

Sickle Cell Related Pain

Pain, back pain, or extremity pain, especially of the legs. Any one or combination of these regions may be affected during a vaso-occlusive crisis (VOC) (Wethers 2000, Serjeant and Serjeant 2004). Shapiro in the 1990s described the event as a painful episode to de-emphasize the emotional component in an effort to improve coping (Shapiro et al. 1995). Despite an attempt to control the behavioral facet by de-emphasizing the anxiety, it has been shown that many patients objectively test positive for anxiety and a sense of helplessness that may be a co-morbidity for this life-threatening disease. The unpredictability of onset and severity of pain coupled with the uncertainty of sequelae and shortened lifespan can be likened to living in a mine field.

The Response to Placebo

In his landmark paper on the power of the placebo, Beecher found that the number of patients who responded to a placebo varied between 15 and 53 (Beecher 1955). Other investigators examining such various diseases as headaches, low back pain, and angina have even reported response rates higher than 50 . The oft-cited statement that the response rate to placebo is 30 likely derives from the average of Beecher's original observations.

Perceived Effects and True Effects from Placebo Agents

The increased efficacy seen in the perceived placebo effect compared to that measured in the true placebo effect results from several factors. First, the symptoms of a disease may change over time, so the natural history of the disease itself may contribute to the perceived placebo effect. For instance, it is well known that acute episodes of low back pain often significantly resolve within 4-6 weeks. A clinical trial comparing an active agent against a placebo during this time period would demonstrate a large perceived placebo effect, when in fact the improvement in clinical symptoms would likely be expected from understanding that acute low back pain is usually self-resolving.

Risk factors for occurrence

Although results of epidemiological studies are not necessarily consistent, factors that have been reported to be associated with low back pain are age, physical fitness, and strength of back and abdominal muscles. There seems to be no association between low back pain and other individual factors such as gender, length, weight, Body Mass Index, flexibility mobility and structural deformities of the spine. Recent systematic reviews found that smoking and body weight should be considered weak risk indicators and not causes of low back pain 13, 14 , and that alcohol consumption 68 , standing or walking, sitting, sports, and total leisure-time physical activity 15 do not seem to be associated with low back pain. Psychosocial factors that traditionally have been reported to be associated with low back pain are anxiety, depression, emotional instability, and alcohol or drug abuse 16 . A recent systematic review of observational studies of psychosocial factors for the occurrence of back...

Psychological Assessments

The Fear-Avoidance Beliefs Questionnaire (FABQ Waddell et al. 1993) is a 16-item instrument that assesses the beliefs and fears a patient associates with back pain. Each item is ranked along a 7-point Likert scale that ranges from strongly agree to strongly disagree. The patient's beliefs and fears can have an impact on his or her range and extent of activity. The FABQ assesses fears the patient has about eliciting pain through behaviors required at work and in


As previously highlighted by Gatchel,1 it is extremely important to be aware of the important distinctions among the constructs of pain, impairment, and disability. This is due to the fact that there is often a discordance or low degree of correlation among levels of chronic pain, impairment, and disability. For example, in an early influential report by Waddell,9 the problem of discordance in the evaluation of chronic low back pain was noted (see Figure 9.1). Although correlations were found among these three constructs, there was not perfect overlap among these phenomena. Although they are all logically and clinically related to one another, there is usually not a 1 1 1 relation among them. Waddell9 found correlations among them to be in the range of only about 0.6. Also, what makes these imperfect correlations even more complex is the wide range of individual differences in such concordance from one individual to the next.10 Healthcare professionals, therefore, need to be aware of...

David B Morris

What distinguishes intractable pain is less its intensity or even its resistance to treatment than its persistence over time 1 . Time matters in chronic pain, however, far beyond the persistence or duration implied in the concept of chronicity. Time seemed to stop for 13 chronic pain patients, according to a phenomenologic study, and the future was unfathomable 2 . This distinctive relation to time not only separates intractable pain from many other chronic illnesses, such as diabetes 3 . It raises important questions about the treatment of chronic pain, because different perceptions of time by doctors and by patients may reduce quality in healthcare 4 . In general, patients and physicians differ in their perceptions of what constitutes timely access to care 5 . In particular, low back pain patients in primary care (according to a study conducted in the western United States) develop their own beliefs about their back pain, about what it means for them, and such beliefs remained very...

Bone scan

The foremost application of bone scan in pain medicine lies in the detection of stress fractures, in patients with leg pain and foot pain precipitated by prolonged activity, and in athletes with back pain. Bone scanning is particularly useful for detecting a stressed pars inter-articularis before it actually fractures. Doing so allows rest from the offending activity to be implemented with a good chance of averting fracture. The utility of bone scan once a fracture has occurred is more contentious. Classical teaching maintains that a positive bone scan would indicate a recent fracture, which would implicate the fracture as the source of pain. However, the relationships between bone scan, pars defect, and symptoms are imperfect. Although a positive scan is likely to be associated with pain, scans are negative in the majority of patients with pain.37 In patients with a radiologically evident pars fracture, bone scans are just as likely to be

Diagnostic blocks

Among the possible sources of low back pain are the lumbar zygapophysial joints and the sacroiliac joints. Among the sources of neck pain and headache are the cervical zygapophysial joints, the lateral atlantoaxial joints, and the atlantooccipital joints. For these joints, a variety of diagnostic blocks has been devised and implemented in some circles. Yet their use has met with acrimonious dissidence. Even though the validity of these blocks has been established in double-blind, controlled studies, they have been decried as amounting to no more than placebos.81 The irony is that the same critics extol the virtues of sympathetic blocks, which lack doubleblind, controlled studies.81 In the pursuit of back pain, the sacroiliac joints can be


Many randomized controlled trials have been conducted and published on conservative and complementary treatments for nonspecific low back pain. A substantial number of systematic reviews have also been published, in which the evidence from these trials has been summarized 1, 2 . Recently, the evidence from trials and reviews has formed the basis for clinical practice guidelines on the management of low back pain that have been developed in various countries around the world 3 . This chapter on evidence-based medicine for chronic low back pain provides an overview of the evidence on diagnosis and treatment of chronic nonspecific low back pain and summarizes how this evidence has been translated into guideline recommendations.


A large epidemiological study in The Netherlands included data from a random sample of 161 general practitioners in 103 practices with a total population of 335,000 patients 9 . The registration period was from April 1987 to April 1988 using the ICPC classification. The incidence of low back pain was 28.0 episodes per 1000 persons per year. The reported incidence of low back pain with sciatica was 11.6 per 1000 per year. The incidence of low back pain was higher for men (32.0) than for women (23.2) and was highest for people between 25 and 64 years of age. Another epidemiological study from The Netherlands reported data collected by 59 general practitioners in 21 practices with a population of 41,000 patients 10 . The ICPC was used for classification. The incidence of low back pain (ICPC code L03) was 30 episodes per 1000 persons per year. The incidence of low back pain with sciatica (ICPC code L86, including herniated disk and diskopathy) was six episodes per 1000 persons per year....


Reported lifetime prevalence ranges widely, from 49 to 70 , as does point prevalence from 12 to 30 , and period prevalence from 25 to 42 . A large epidemiological study on low back pain among the general population in The Netherlands was conducted from 1993 to 1995 12 . The study population consisted of a sample of 13,927 men and women aged 20-59 years. Almost half of the respondents (49.2 , of whom 45.5 men and 52.4 women) reported low back pain in the previous year. More than 40 of the respondents reported that the episode lasted for more than 12 weeks (7.1 ) or that the low back pain was continuously present (34.7 ). Chronic low back pain was more common among women (22.6 ) than men (18.3 ) and increased with age from 12 at 20-29 years of age to 27.1 at 50-59 years of age. In general, the conclusion from these prevalence estimates is quite clear low back pain is a common disorder in Western countries. The estimates of prevalence may vary because of national variations, age or...

Diagnostic imaging

One systematic review was found that included 31 studies on the association between X-ray findings of the lumbar spine and nonspecific low back pain 6 . The results showed that degeneration, defined by the presence of disk space narrowing, osteophytes and sclerosis, is consistently and positively associated with nonspecific low back pain with OR ranging from 1.2 (95 CI 0.7-2.2) to 3.3 (95 CI 1.8-6.0). Spondylolysis listhesis, spina bifida, transitional vertebrae, spondy-losis and Scheuermann's disease did not appear to be associated with low back pain. There is no evidence on the association between degenerative signs at the acute stage and the transition to chronic symptoms. A review of the diagnostic imaging literature (MRI, radionuclide scanning, computed tomography, radiography) concluded that for adults younger than 50 years of age with no signs or symptoms of systemic disease, diagnostic imaging does not improve treatment of low back pain. For patients 50 years of age and older...


Various healthcare providers may be involved in the treatment of low back pain in primary care. Although there may be some variations between countries, general practitioners, physiotherapists, manual therapists, chiropractors, exercise therapists, McKenzie therapists, orthopedic surgeons, neurologists neu-rosurgeons, rheumatologists and others may all be involved. The primary care physician has a central role in the management of nonspecific low back pain. The therapeutic management of specific spinal disorders is generally the domain of medical specialists. It is important that information and treatment are consistent across professions, and that healthcare providers collaborate closely with each other. Within the framework of the Cochrane Back Review Group, systematic reviews of RCTs on therapeutic interventions for back pain are promoted, conducted, and disseminated 33, 34 . In 1997, the Cochrane Back Review Group developed and published method guidelines for systematic reviews in...

Musculoskeletal Pain

Analgesics are commonly prescribed for musculoskeletal pain in the general population.7 Many of the prescription and nonprescription agents commonly used are likely to contain NSAIDs. There is some good evidence for the beneficial role of NSAIDs in chronic low back pain compared to placebo, but it becomes limited when compared to paracetamol. When considering chronic low back pain there was insufficient evidence to perform subgroup analysis, suggesting that further research is required.78 I A more recent review of drugs used to treat low back pain again suggests further research is required.77 I A series of N-of-1 trials that examined the efficacy of NSAIDs for chronic musculoskeletal pain demonstrated the difficulties encountered with research in this area. There was no benefit for NSAIDs but there was a high incidence of side effects and high drop-out rates resulting in small numbers completing the trial.86

Muscle Relaxants

Muscle relaxants are a good addition to a pain regimen for low back pain, where muscle spasms occur regularly. They are also useful for conditions such as fibromyalgia, where cyclobenzaprine is considered a first-line option (APS, 2005 D'Arcy & McCarberg, 2005). The group of medications generically called skeletal muscle relaxants (see Table 5.5) consists of several different groups of medications benzodiazepines, sedatives, antihistamines, and other centrally acting medications (APS, 2008).

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