STUDY - Technical - New Dacian's Medicine
Cervical
and Back Pain (5)
Translation Draft
Although my impatience to approach the new medicine, from the point of view of this blog, was "pushing" me to at least move on to the next sign of illness, fever, I see myself obliged, for reasons that you will understand later (at least in terms of respect for traditional, current medicine), to perform a post and about the treatment of cervical and back pain. So...
I'll start with acute low back pain. A practical approach to the treatment of low back pain is to consider acute and chronic pain separately. Acute low back pain is defined as pain lasting less than 3 months.
Complete recovery can be expected in 85% of patients with acute low back pain, unaccompanied by pain on the lower limb. Most of these patients have "mechanical" symptoms (aggravated movement pain and improved rest). Studies in this regard have certain limitations: 1. comparing treatment groups often does not have a placebo control group, 2. It is assumed that patients who consult doctors of different specialties (generalists, orthopaedics, neurologists) have similar etiologies of their dorsolumbar pain, 3. there is no information on the details of treatment within a healthcare group or between groups and 4. catalogue of serious causes of low back pain has not been attempted.
This leads to a simple conclusion that the appropriate methods of diagnosis and specific treatment for low back pain cannot be established as a result of these studies. Furthermore, competition in the product market has encouraged the rapid development of clinical practice guidelines (and not only) for the treatment of back pain.
However, the following characteristics were taken into account in the composition of the guidelines: the quality and quantity of evidence of efficacy, the weight of an effect for the therapeutic or diagnosed method, the consistency of findings between studies, when more studies were available, the clinical applicability of the evidence in adult patients and data on costs and complications.
But let's "draw some conclusions" from the best known such guide (AHCPR). The first phase of this guide begins with adults (patients over 18 years of age) who have less than 3 months of activity intolerance due to lower back pain and/ or lower limb symptoms. The term "dorsolumbar problems" has been defined as pain of sufficient amplitude to limit a return to functional activities.
Identifications have been made of traits that suggest the possibility of a serious underlying disease requiring rapid evaluation and treatment, the elements of the neurological examination having great weight in the initial assessment. If no such traits are reported, symptomatic (allopathic, of course) treatment of patients will be carried out. Diagnostic tests are not considered necessary and frequent serious etiologies considered as "red flags" are vertebral metastases, spinal fracture and medullary infections.
However, the applicability of these assessments to current outpatient clinical situations is limited for many reasons: 1. many studies used to calculate the specific value of sensitivity and specificity were retrospective and included patients who eventually surgically intervened and excluded patients who were not operated on with abnormal elements at examination, 2. patients were selected on the basis of their presentation to orthopaedic surgeons and thus did not reflect the general population , 3. different input criteria and evaluation protocols were analysed in different studies, 4. many studies have been done without the intake of neuroimaging, 5. surgical results were evaluated on anatomical criteria (compression of nerve roots) and not functional status after and 6. none of the studies tracked the natural evolution of disc lesions associated with a focal neurological deficit. These limits underline that the use of current guidelines for the treatment of low back pain should not replace serious clinical judgment in specific circumstances.
In addition, the algorithms proposed for attitude to acute back pain vary considerably between published guides. The initial assessment should exclude serious causes of spinal disease requiring urgent intervention, including infections, cancer and trauma.
Risk factors for a serious cause of back pain include: age over 50 years, pre-existence of a diagnosis of cancer or other serious illness, bed rest without pain relief, duration of pain greater than one month, urinary incontinence or recent nocturia, local weakness or hypoesthesia in the lower limb, irradiation of back pain to the lower limbs, chronic use of intravenous drugs , chronic infections (pulmonary or urinary), pain accentuated by orthostatism and improved by sitting position, history of spinal trauma or use of glucocorticoids.
Clinical signs associated with a possible serious etiology include unexplained fever. well-documented and unexplained weight loss, direct, inverted or positive cross-reference, sensitivity to percussion on the spine or costovertebral angle, presence of an abdominal (pulsatial or non-pulsatill) or rectal formation, loss of focal sensitivity (anaesthesia in the saddle or focal loss of sensitivity in a limb), weakness, spasticity and asymmetrical reflexes in the lower limb.
Laboratory elements are not necessary at this time unless a serious cause is suspected on the basis of symptoms and signs. Column X-rays are rarely indicated in the first month of symptoms, except for suspected a fracture of the spine.
The role of bed rest, early exercise and treatment of acute low back pain in patients who do not have clinical signs suggestive of a serious disease have been the subject of recent studies. Clinical studies could not demonstrate any benefit of prolonged bed rest (more than 2 months).
The theoretical advantages of early activity after the onset of acute low back pain include maintaining cardiovascular training, improving disc and cartilage nutrition, improving bone strength and muscle strength, and increasing endorphin levels. A recent study showed that there is no benefit of the early program of vigorous exercise, but the advantage of less sustained exercises or other workouts remain unknown.
The effects of bed rest for patients with sciatica or acute low back pain with focal neurological signs are also unknown. Early resumption of normal physical activity (without heavy manual labor) is beneficial. Well-designed clinical studies of traction, including simulated traction groups, have failed to show the benefit of this treatment in acute low back pain.
Despite this knowledge, a recent study of therapeutic efficacy as perceived by a doctor (classic, believer of the allopathic system) showed that strict bed rest for more than 3 days, injections at target points and physical therapy are beneficial in more than 50% of patients with acute low back pain.
A great variability in the perception of therapeutic efficacy was present among doctors of the same specialty (in many cases, the therapeutic conduct of the attending physician not reflecting the current medical literature).
Evidence is missing in support of the treatment of low back pain and cervical pain through acupuncture, transcutaneous electrical nerve stimulation, massage, ultrasound, diatermia or electrical stimulation. Cervical collars may limit spontaneous cervical movements or reflexes that exacerbate pain. evidence of the effectiveness of ice and heat self-application or the use of beading is lacking.
These methods remain as therapeutic options due to the lack of negative reactions, low cost and risk, without rigorously studying biofeedback. Moreover, injections into the joints of the facets, painful points or ligaments are not recommended for the treatment of acute low back pain.
The beneficial role of specific exercises or postural changes has not been validated by rigorous clinical trials. From a practical point of view it may be useful to temporarily suspend activities known to increase mechanical stress on the spine, such as lifting weights, prolonged sitting, bending or twisting or difficult defecation.
Patient education is an important part of treatment. Clinical studies show that patient satisfaction and the possibility of follow-up increase when patients are trained on prognosis, treatment methods, activity changes and strategies to prevent further exacerbations.
In one study, patients who felt they had received adequate explanations for their symptoms wanted more diagnostic tests. Evidence of the effectiveness of structured educational programs for back pain is not relevant, in a controlled study, patients who attended educational programs had a shorter duration of illness during the first episode, but not in subsequent episodes.
Medications used in the treatment of acute low back pain include NSAID, acetaminophen, myorelaxants and opioids. A slight benefit of massage is encountered only in the first 2 weeks after initiation of treatment, but can relieve pain and improve daily activity in this situation. The optimal frequency and duration of spinal manipulation were not adequately established.
Chronic low back pain, chronic low back pain (DLC) is defined as pain lasting more than 12 weeks, with these patients comprising 5% of all patients with back pain, but consuming 50% of the total costs. The initial approach of these patients is similar to that of patients with acute low back pain, with the treatment of this heterogeneous group of patients based on the identification of the underlying cause.
Many diseases that cause chronic low back pain can be diagnosed by combining neuroimaging studies with electrophysiological studies (MRI, TC). Reproduction of the patient's typical pain by injection proves that the pain originates in the disc, but there is controversy regarding the usefulness of this information to decide whether to intervene surgically or not.
Thermography does not have a proven role in the evaluation of radiculopathy. Nervous driving studies in the sensory and motor nerves and needle EMG are used to assess the functional integrity of the peripheral nervous system in the case of back pain. EMG and nerve conduction studies will be normal when only pain in the limb or a lesion or irritation of the sensitive nerve root are present.
Chronic low back pain can be treated by several conservative measures. Acute and subacute exacerbations are treated with NSAID and measures on patient comfort. Bed rest should not exceed 2 days, the main objective being exercise tolerance, while pain relief is second.
Exercise programs can improve atrophies and improve body extension force. Supervised intensive exercise or "hard work regimes" (under the guidance of a physiotherapist) are effective for returning patients to work, improving walking distances and lessening pain.
The benefit is sustained in patients who are training and at home. Compliance with exercise regimes greatly influences evolution. Reducing sick days, long-term medical care and retirement expenses can offset the initial costs of multidisciplinary treatment programmes.
Hydrotherapy causes decreased duration and intensity of low back pain, decreased use of painkillers, increased spinal mobility and functional score.
Although my impatience to approach the new medicine, from the point of view of this blog, was "pushing" me to at least move on to the next sign of illness, fever, I see myself obliged, for reasons that you will understand later (at least in terms of respect for traditional, current medicine), to perform a post and about the treatment of cervical and back pain. So...
I'll start with acute low back pain. A practical approach to the treatment of low back pain is to consider acute and chronic pain separately. Acute low back pain is defined as pain lasting less than 3 months.
Complete recovery can be expected in 85% of patients with acute low back pain, unaccompanied by pain on the lower limb. Most of these patients have "mechanical" symptoms (aggravated movement pain and improved rest). Studies in this regard have certain limitations: 1. comparing treatment groups often does not have a placebo control group, 2. It is assumed that patients who consult doctors of different specialties (generalists, orthopaedics, neurologists) have similar etiologies of their dorsolumbar pain, 3. there is no information on the details of treatment within a healthcare group or between groups and 4. catalogue of serious causes of low back pain has not been attempted.
This leads to a simple conclusion that the appropriate methods of diagnosis and specific treatment for low back pain cannot be established as a result of these studies. Furthermore, competition in the product market has encouraged the rapid development of clinical practice guidelines (and not only) for the treatment of back pain.
However, the following characteristics were taken into account in the composition of the guidelines: the quality and quantity of evidence of efficacy, the weight of an effect for the therapeutic or diagnosed method, the consistency of findings between studies, when more studies were available, the clinical applicability of the evidence in adult patients and data on costs and complications.
But let's "draw some conclusions" from the best known such guide (AHCPR). The first phase of this guide begins with adults (patients over 18 years of age) who have less than 3 months of activity intolerance due to lower back pain and/ or lower limb symptoms. The term "dorsolumbar problems" has been defined as pain of sufficient amplitude to limit a return to functional activities.
Identifications have been made of traits that suggest the possibility of a serious underlying disease requiring rapid evaluation and treatment, the elements of the neurological examination having great weight in the initial assessment. If no such traits are reported, symptomatic (allopathic, of course) treatment of patients will be carried out. Diagnostic tests are not considered necessary and frequent serious etiologies considered as "red flags" are vertebral metastases, spinal fracture and medullary infections.
However, the applicability of these assessments to current outpatient clinical situations is limited for many reasons: 1. many studies used to calculate the specific value of sensitivity and specificity were retrospective and included patients who eventually surgically intervened and excluded patients who were not operated on with abnormal elements at examination, 2. patients were selected on the basis of their presentation to orthopaedic surgeons and thus did not reflect the general population , 3. different input criteria and evaluation protocols were analysed in different studies, 4. many studies have been done without the intake of neuroimaging, 5. surgical results were evaluated on anatomical criteria (compression of nerve roots) and not functional status after and 6. none of the studies tracked the natural evolution of disc lesions associated with a focal neurological deficit. These limits underline that the use of current guidelines for the treatment of low back pain should not replace serious clinical judgment in specific circumstances.
In addition, the algorithms proposed for attitude to acute back pain vary considerably between published guides. The initial assessment should exclude serious causes of spinal disease requiring urgent intervention, including infections, cancer and trauma.
Risk factors for a serious cause of back pain include: age over 50 years, pre-existence of a diagnosis of cancer or other serious illness, bed rest without pain relief, duration of pain greater than one month, urinary incontinence or recent nocturia, local weakness or hypoesthesia in the lower limb, irradiation of back pain to the lower limbs, chronic use of intravenous drugs , chronic infections (pulmonary or urinary), pain accentuated by orthostatism and improved by sitting position, history of spinal trauma or use of glucocorticoids.
Clinical signs associated with a possible serious etiology include unexplained fever. well-documented and unexplained weight loss, direct, inverted or positive cross-reference, sensitivity to percussion on the spine or costovertebral angle, presence of an abdominal (pulsatial or non-pulsatill) or rectal formation, loss of focal sensitivity (anaesthesia in the saddle or focal loss of sensitivity in a limb), weakness, spasticity and asymmetrical reflexes in the lower limb.
Laboratory elements are not necessary at this time unless a serious cause is suspected on the basis of symptoms and signs. Column X-rays are rarely indicated in the first month of symptoms, except for suspected a fracture of the spine.
The role of bed rest, early exercise and treatment of acute low back pain in patients who do not have clinical signs suggestive of a serious disease have been the subject of recent studies. Clinical studies could not demonstrate any benefit of prolonged bed rest (more than 2 months).
The theoretical advantages of early activity after the onset of acute low back pain include maintaining cardiovascular training, improving disc and cartilage nutrition, improving bone strength and muscle strength, and increasing endorphin levels. A recent study showed that there is no benefit of the early program of vigorous exercise, but the advantage of less sustained exercises or other workouts remain unknown.
The effects of bed rest for patients with sciatica or acute low back pain with focal neurological signs are also unknown. Early resumption of normal physical activity (without heavy manual labor) is beneficial. Well-designed clinical studies of traction, including simulated traction groups, have failed to show the benefit of this treatment in acute low back pain.
Despite this knowledge, a recent study of therapeutic efficacy as perceived by a doctor (classic, believer of the allopathic system) showed that strict bed rest for more than 3 days, injections at target points and physical therapy are beneficial in more than 50% of patients with acute low back pain.
A great variability in the perception of therapeutic efficacy was present among doctors of the same specialty (in many cases, the therapeutic conduct of the attending physician not reflecting the current medical literature).
Evidence is missing in support of the treatment of low back pain and cervical pain through acupuncture, transcutaneous electrical nerve stimulation, massage, ultrasound, diatermia or electrical stimulation. Cervical collars may limit spontaneous cervical movements or reflexes that exacerbate pain. evidence of the effectiveness of ice and heat self-application or the use of beading is lacking.
These methods remain as therapeutic options due to the lack of negative reactions, low cost and risk, without rigorously studying biofeedback. Moreover, injections into the joints of the facets, painful points or ligaments are not recommended for the treatment of acute low back pain.
The beneficial role of specific exercises or postural changes has not been validated by rigorous clinical trials. From a practical point of view it may be useful to temporarily suspend activities known to increase mechanical stress on the spine, such as lifting weights, prolonged sitting, bending or twisting or difficult defecation.
Patient education is an important part of treatment. Clinical studies show that patient satisfaction and the possibility of follow-up increase when patients are trained on prognosis, treatment methods, activity changes and strategies to prevent further exacerbations.
In one study, patients who felt they had received adequate explanations for their symptoms wanted more diagnostic tests. Evidence of the effectiveness of structured educational programs for back pain is not relevant, in a controlled study, patients who attended educational programs had a shorter duration of illness during the first episode, but not in subsequent episodes.
Medications used in the treatment of acute low back pain include NSAID, acetaminophen, myorelaxants and opioids. A slight benefit of massage is encountered only in the first 2 weeks after initiation of treatment, but can relieve pain and improve daily activity in this situation. The optimal frequency and duration of spinal manipulation were not adequately established.
Chronic low back pain, chronic low back pain (DLC) is defined as pain lasting more than 12 weeks, with these patients comprising 5% of all patients with back pain, but consuming 50% of the total costs. The initial approach of these patients is similar to that of patients with acute low back pain, with the treatment of this heterogeneous group of patients based on the identification of the underlying cause.
Many diseases that cause chronic low back pain can be diagnosed by combining neuroimaging studies with electrophysiological studies (MRI, TC). Reproduction of the patient's typical pain by injection proves that the pain originates in the disc, but there is controversy regarding the usefulness of this information to decide whether to intervene surgically or not.
Thermography does not have a proven role in the evaluation of radiculopathy. Nervous driving studies in the sensory and motor nerves and needle EMG are used to assess the functional integrity of the peripheral nervous system in the case of back pain. EMG and nerve conduction studies will be normal when only pain in the limb or a lesion or irritation of the sensitive nerve root are present.
Chronic low back pain can be treated by several conservative measures. Acute and subacute exacerbations are treated with NSAID and measures on patient comfort. Bed rest should not exceed 2 days, the main objective being exercise tolerance, while pain relief is second.
Exercise programs can improve atrophies and improve body extension force. Supervised intensive exercise or "hard work regimes" (under the guidance of a physiotherapist) are effective for returning patients to work, improving walking distances and lessening pain.
The benefit is sustained in patients who are training and at home. Compliance with exercise regimes greatly influences evolution. Reducing sick days, long-term medical care and retirement expenses can offset the initial costs of multidisciplinary treatment programmes.
Hydrotherapy causes decreased duration and intensity of low back pain, decreased use of painkillers, increased spinal mobility and functional score.
Happy
birthday to all the martyrs, men or other "correlations" that
you can achieve related to this
day!
day!
Dorin, Merticaru