Recommendation 1: Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence). Recommendation 2: Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). Recommendation 3: Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence). Recommendation 4: Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). Recommendation 5: Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence). Recommendation 6: For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs. Recommendation 7: For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

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Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society

This review provides the reader with the up-to-date evidence-based basis for prescribing exercise as medicine in the treatment of 26 different diseases: psychiatric diseases (depression, anxiety, stress, schizophrenia); neurological diseases (dementia, Parkinson's disease, multiple sclerosis); metabolic diseases (obesity, hyperlipidemia, metabolic syndrome, polycystic ovarian syndrome, type 2 diabetes, type 1 diabetes); cardiovascular diseases (hypertension, coronary heart disease, heart failure, cerebral apoplexy, and claudication intermittent); pulmonary diseases (chronic obstructive pulmonary disease, asthma, cystic fibrosis); musculo-skeletal disorders (osteoarthritis, osteoporosis, back pain, rheumatoid arthritis); and cancer. The effect of exercise therapy on disease pathogenesis and symptoms are given and the possible mechanisms of action are discussed. We have interpreted the scientific literature and for each disease, we provide the reader with our best advice regarding the optimal type and dose for prescription of exercise.

/pdf/exercise-as-medicine-evidence-for-prescribing-exercise-as-4ap89k53ch.pdf

Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases

Non-specific low back pain

Biomedical applications of polymer-composite materials: a review

LOW back pain is usually a self-limiting symptom, but it costs at least $16 billion each year1 , 2 and disables 5.4 million Americans.3 The fact that a benign physical condition has such an importa...

Back pain and sciatica.

Seventy-three patients with lumbar radicular pain syndromes were treated in a prospective, randomized, double-blind fashion with either seven milliliters of methylprednisolone acetate and procaine or seven milliliters of physiological saline solution and procaine. All patients had radiographic confirmation of lumbar nerve-root compression, consistent with the clinical diagnosis of either an acute herniated nucleus pulposus or spinal stenosis. No statistically significant difference was observed between the control and experimental patients with either acute disc herniation or spinal stenosis. Long-term follow-up, averaging twenty months, failed to demonstrate the efficacy of a second injection of epidural steroids administered to the patients whose pain did not respond within twenty-four hours to an injection of either eighty milligrams of methylprednisolone acetate combined with five milliliters of 1 per cent procaine or two milliliters of sterile saline combined with five milliliters of 1 per cent procaine. Therefore, a decision to use epidural steroids must be made with the realization that we failed to demonstrate its clinical efficacy in this study and that reports of serious complications of this procedure have been published.

The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study.

Cementing with poly(methyl methacrylate) (PMMA) is a common means of fixing total hip prostheses. Bone cement fails mechanically, and subsequent loosening frequently requires correction via revision surgery. An initial step in optimizing bone cement properties is to establish which properties are critical to the material's in vivo performance. The objectives were to discern the critical in vivo failure mechanisms of bone cement. Fracture surfaces of bone cement specimens that failed in vivo were compared with fatigue and rapid fracture surfaces created in vitro. In vivo fracture processes of bone cement were positively identified and explained by the elucidation of PMMA fracture micromechanisms. The ex vivo fracture surfaces are remarkably similar to in vitro fatigue fracture surfaces. The fractographic data document that the primary in vivo failure mechanism of bone cement is fatigue, and the fatigue cracks grow by developing a microcraze shower damage zone. Agglomerates of BaSO4 particles can be implicated in some bone cement failures, large flaws or voids in vivo can lead to a rapid, unstable fracture, pores in the PMMA mass have a clear influence on a propagating crack, and wear of the fracture surfaces occurs, and may produce PMMA debris, exacerbating bone destruction.

A fractographic analysis of in vivo poly(methyl methacrylate) bone cement failure mechanisms.

Calcium phosphate ceramic coatings as carriers of vancomycin

In vivo inflammatory response to polymethylmethacrylate particulate debris: effect of size, morphology, and surface area.

The roles of bedrest, antiinflammatory medication, and analgesic medication in the treatment of acute back strain were objectively analyzed to determine whether they have a measurable effect on the return of patients to full daily activities as well as on the relief of pain. Two hundred patients were studied prospectively. Each patient had the diagnosis of acute back strain, which was defined as nonradiating low-back pain. The results of the patient's neurologic examination, straight leg raising test, and lumbosacral spine roentgenograms had to be within normal limits for the patient to be included in the study. The results showed that bedrest, as compared with ambulation, will decrease the amount of time lost from work by 50%. Bedrest will also decrease the amount of discomfort by 60%. Analgesic medication, when combined with bedrest, will further decrease the amount of pain incurred, particularly when used in the first three days of the healing process. However, analgesic medication will not allow a more prompt return to work. Antiinflammatory medication, when added to bedrest in the treatment of lumbago, does not provide an advantage over bedrest alone.

John M. Cuckler

Papers

The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study.

A fractographic analysis of in vivo poly(methyl methacrylate) bone cement failure mechanisms.

Calcium phosphate ceramic coatings as carriers of vancomycin

In vivo inflammatory response to polymethylmethacrylate particulate debris: effect of size, morphology, and surface area.

Acute low-back pain. An objective analysis of conservative therapy.