This guideline from the ACP provides clinical recommendations about noninvasive pharmacologic and nonpharmacologic treatment of low back pain.

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians

Non-specific low back pain

STUDY DESIGN: A systematic review of randomized controlled trials. OBJECTIVES: To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic nonspecific low back pain. SUMMARY OF BACKGROUND DATA: Many treatment options for acute and chronic low back pain are available, but little is known about the optimal treatment strategy. METHODS: A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results. RESULTS: The number of randomized controlled trials identified varied widely with regard to the interventions involved. The scores ranged from 20 to 79 points for acute low back pain and from 19 to 79 points for chronic low back pain on a 100-point scale, indicating the overall poor quality of the trials. Overall, only 28 (35%) randomized controlled trials on acute low back pain and 20 (25%) on chronic low back pain had a methodologic score of 50 or more points, and were considered to be of high quality. Various methodologic flaws were identified. Strong evidence was found for the effectiveness of muscle relaxants and nonsteroidal anti-inflammatory drugs and the ineffectiveness of exercise therapy for acute low back pain; strong evidence also was found for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short-term effects. CONCLUSIONS: The quality of the design, execution, and reporting of randomized controlled trials should be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain.

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Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions.

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Congenital dysplasia and dislocation of the hip in children and adults

1. The avascular zone in the tendon of the supraspinatus near its insertion was not seen in the other tendons comprising the rotator cuff, except for the superior portion of the insertion of the infraspinatus which, on occasions, showed a small avascular area. The biceps tendon, however, also showed an avascular zone as it coursed over the head of the humerus. It is suggested that the anatomical disposition of these tendons makes them subject to constant pressure from the head of the humerus, which tends to wring out the blood supply to these tendons when the arm is held in the resting position of adduction and neutral rotation. 2. Although this study did not produce any evidence that the relative avascularity of the tendons over a prolonged period could be indicted as the sole cause of the degenerative changes that so commonly occur, it was noted that the degenerative changes occurred first and that they were always most extensive in the areas of avascularity. It was also observed that the zones of relative avascularity preceded, and were not the result of, the degenerative changes. 3. With the onset of tendon degeneration, secondary vascular phenomena were observed. Firstly, there was a reaction that appeared to be a foreign body inflammatory response with the development of vascular tufts of granulation tissue. It was thought that these vascular changes were secondary to the breakdown in the tendons and were not the cause of the breakdown as previously suggested by Anderson and Moore. it was noted, moreover, that with the progression of degenerative changes in the supraspinatus tendon, the tendon became much attenuated and, as it did so, the zone of relative avascularity appeared to extend. This secondary shut-down of the vascular bed might well be caused by an increased tension in the tendon. In those tendons in which spontaneous rupture had occurred, it was noted that the major part of the tendon proximal to the rupture was avascular and showed evidence of much degenerative change. This study therefore suggests that in the operative repair of such lesions it is necessary to excise the degenerate avascular tendon in order to effect a sound repair. It is also suggested that detachment of the supraspinatus muscle from the supraspinous fossa in order to advance the whole muscle belly is the only technique possible to enable the surgeon to replace healthy tendon directly into bone, as suggested by Debeyre and his colleagues.

The microvascular pattern of the rotator cuff

Study of the morphological pattern of the arteries in the rotator cuff does not produce any evidence that the "critical zone" for ruptures and calcified deposits is much less vascularised than any other part of the tendinous cuff. This work, however, does show conclusively that the "critical zone" of the rotator cuff corresponds to the zone of the anastomoses between the osseous and tendinous vessels. Age does not seem to have a decisive influence on the morphology of the vascular pattern.

The arterial pattern of the rotator cuff of the shoulder

(1969). Synovial pH in Rheumatoid Knee-Joints I. The Effect of Synovectomy. Acta Orthopaedica Scandinavica: Vol. 40, No. 5, pp. 634-641.

Synovial pH in rheumatoid knee-joints. I. The effect of synovectomy.

A clinical evaluation of 46 patients treated for fractures of the neck of the talus has been made after a mean follow-up period of 6 years. The cause of injury was most frequently motor vehicle accidents (26) and falls from heights (11). In non-displaced fractures plaster with immobilization was used and displaced fractures were treated by closed or open reduction. At follow-up most of the patients complained of symptoms hampering daily activities. Objectively, excellent to good results were obtained in 75 per cent of the non-displaced fractures and in 42 per cent of the displaced. Delayed union occurred in 15 per cent. Avascular necrosis was found in 15 per cent and degenerative changes in 97 per cent. A decreased density of bone under the articular cartilage, called subchondral atrophy, was seen in 50 per cent.

https://www.tandfonline.com/doi/pdf/10.3109/17453677708994820

Fracture of the Neck of the Talus: A Clinical Study

(1970). Evaluation of Radiation Treatment of Painful Conditions of the Locomotor System: A Double Blind Study. Acta Radiologica: Therapy, Physics, Biology: Vol. 9, No. 4, pp. 311-322.

https://www.tandfonline.com/doi/pdf/10.3109/02841867009129108

Evaluation of Radiation Treatment of Painful Conditions of the Locomotor System: A Double Blind Study

(1974). The Arterial Supply of the Talusa. Acta Orthopaedica Scandinavica: Vol. 45, No. 1-4, pp. 260-270.

Ian Goldie

Papers

The arterial pattern of the rotator cuff of the shoulder

Synovial pH in rheumatoid knee-joints. I. The effect of synovectomy.

Fracture of the Neck of the Talus: A Clinical Study

Evaluation of Radiation Treatment of Painful Conditions of the Locomotor System: A Double Blind Study

The Arterial Supply of the Talusa