Holistic Solution to get rid of Back Pain

My Back Pain Coach

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My Back Pain Coach Summary


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Neuropathic Lowback Pain

Low-back pain (LBP) is one of the most common disorders, effecting about two-thirds of the adult population at some time in their lives. It may or may not be associated with radiation to the sciatic and or femoral nerves (121). The etiology of the pain may be secondary to a large number of possible problems, making the differential diagnosis large however, it may be broken down to mechanical, compression,

The Norwegian Back Pain Network Active Back Campaign Norway 20022005

In 2002, to coincide with the launch of the multidisciplinary Norwegian guidelines for acute low back pain, the Norwegian Back Pain Network initiated a broad implementation project in two counties (Vestfold and Aust-Agder). Like the Australian campaign, the Norway project combined a media campaign with additional targeted strategies. The project consisted of four separate activities a media campaign directed towards the general public, an information campaign directed towards physicians, physiotherapists and chiropractors in primary health care, an information campaign directed towards social security officers and a practical intervention in six co- operating workplaces. Back pain is rarely caused by any dangerous illness. X-rays rarely show the reason for back pain. Only a few persons with back pain need surgery. In addition to the media campaign, the project also specifically targeted health professionals and social security officers, providing these groups with the same messages....

Considering the Design and Evaluation of Back Pain Media Campaigns

There are several general theories of health behavior change that have been advocated. However, a detailed discussion of these theories is beyond the scope of this paper. Several authors have incorporated these theories as an integrated model 50, 51 . From this we identified five considerations relevant to the planning and evaluation of mass media interventions for low back pain (Figure 21.1). We have used these as a framework for discussing the Australian, Scottish, Norwegian and Canadian back campaigns and to guide future planning. 1. What are current back pain attitudes and behaviors, or management practices that need to be changed and why The rationale on which existing back campaigns have been based to date is that public attitudes and behaviors related to low back pain and disability are out of keeping with the currently available best evidence. To a varying degree they have also recognized the need to change primary care providers - attitudes and behavior in view of the lack of...

Mass Media Campaigns for Back Pain

A summary of the key campaign elements and evaluation strategies of four back pain mass media campaigns are shown in Table 21.1 and are described below. Back pain, don't take it lying down Working backs Scotland Back It Active back Back pain, don't take it lying down Working backs Scotland Back It Active back The Hospital of Rehabilitation, Stavern and The Norwegian Back Pain Network, The Communication Unit Back pain, don't take it lying down Rising cost of back pain claims recognition that educational interventions directed at general practice likely to be ineffective without concomitant education of the public and employers and recognition of importance of attitudes and beliefs in development of disability from back pain Consulted widely with international and local experts, multidisciplinary committee composed of representatives from national or state professional organizations with an interest in back pain, medical defence organization, employer and employee groups Rising cost of...

What is the best way to deliver back pain messages to the target audience

Australian and Norway campaigns used state-based and local county television for delivering the campaign messages to the target audience whereas both Alberta and Scotland primarily used radio. The level and saturation of the campaigns also varied. It is also important to know what other messages are being delivered in competition or in support of the campaign at the time. Prior to the onset of the campaign in Australia, 50 of the public were already aware of advertising about back pain, indicating that there were lots of other messages being delivered by others at the time. 5. How do we best study the effects of back pain mass media campaigns Evaluating the effects of communication campaigns is complex and multifaceted. For example, decisions need to be made about the study design and measurement of intermediate or final outcomes. Also, the interpretation of the study results should include separating campaign effects from those of other sources of influence, and expectations for...

Low Back Pain

Low back pain may be associated with leg pain. This may simply be pain radiating from the spine or if it extends to the foot may be neuropathic and due to irritation of nerves in the spine. A thorough history, examination and, if indicated, special tests including MRI scanning, may be necessary to exclude treatable causes such as a prolapsed disc or narrowing of the spinal canal through which the spinal cord or nerves pass. Many patients, however, have mechanical low back pain and do not have any nerve involvement. Most often MRI scanning does not show any specific cause 7 . The relationship between MRI scans and symptoms is not straightforward and often MRIs do not distinguish between individuals with pain and those without. Similarly, X-rays are often of little help. As a result, there is no specific explanation for the patient's pain and no specific treatment to offer. Patients, not unreasonably,

Studies in MS and Other Conditions

Musculoskeletal conditions that are seen in MS may respond favorably to chiropractic therapy. Most notably, multiple studies have evaluated the chiropractic treatment of low back pain, which may occur in people with MS. Of note, besides chiropractors, physical therapists and osteopaths also perform spinal manipulation. In addition, low back pain may resolve with no therapy at all and may respond to nonmanipulative forms of therapy given by primary care doctors, orthopedic physicians, neurologists, and physical therapists. The relative effectiveness and expense of these different approaches is debatable. In 1994, the Agency for Health care Policy and Research endorsed chiropractic therapy for low back pain that is recent and not longstanding. The effects of chiropractic therapy on neck pain are less clear. Some studies have reported positive results, but this is less definitive than are the studies of low back pain. Also, a rare chance exists of producing a stroke through manipulation...

Public Health Its for Our Own Good

Example, a study of 1155 school-attending children (aged 6-13 years) found that 19 reported recurrent stomach pain, 23 reported weekly recurrent headache, and 18 reported back pain. The focus on positive health-related behavior is also at an early stage of development. With an increased awareness of chronic pain in children and adolescents comes a flurry of theories of cause, most of which have some element of dismay at the habits of current youth. The most common concern seems to be associated with sedentary behavior. For example, walking to school (4) and carrying school bags (5,6) are frequent examples. It seems that, except in the minority of pupils who persistently carry more than 20 of their body weight, carrying backpacks alone cannot explain future disability (7). Similarly, sedentary behavior alone is not associated with pain and disability. For example, in a study of adolescents, no association between objectively measured activity and back pain was found (8). For a second...

Failed Back Surgery Syndrome

Failed back surgery syndrome (FBSS) is the general term used to describe cases in which back surgery performed for back pain has left the patient with pain and those in which decompressing a nerve has failed to resolve nerve pain in the leg. The patient will typically have had symptoms for many months and several imaging studies and surgical opinions. There is usually activity-dependent pain, which may limit activities of daily living and work, a constriction of social life and pleasurable activity and often a considerable burden of side-effects from drugs given to ease the symptoms. FBSS patients are often reluctant to exercise, believing that this may worsen their predicament, and this often becomes a self-fulfilling prophecy as lack of exercise leads to physical deconditioning and yet more disability.

Evidencebased Medicine Reviews

Finally, another Cochrane Database systematic review looked at the efficacy of TENS in the treatment of chronic low back pain. Five trials were included (N 170 patients receiving sham-TENS and N 251 patients receiving active TENS). It was concluded that the results of the meta-analysis found no evidence to support the use of TENS in the treatment of chronic low back pain. It also notes that the meta-analysis lacked data on how TENS effectiveness is affected by four important factors type of application, site of application, treatment duration of TENS, optimal frequencies and intensities (39).

Pregnancy and Lactation

Third trimester or shortly after delivery. Densitometry has demonstrated markedly low bone density in both the spine and proximal femur (81). Five cases of postpregnancy osteoporosis have been reported by Yamamoto et al. (82). These women ranged in age from 24 to 37 years. Of the five women, four were diagnosed after their first pregnancy. The fifth was diagnosed after her second pregnancy. All of the women presented with back pain and vertebral compression fractures, most within 1 month of delivery. BMD measurements were made at the 33 radial site with SPA (Norland-Cameron) and at the spine by either QCT or DXA (Hologic QDR-1000). Measurements were made at various times in the evaluation and management of these patients. BMD at the 33 radial site was not decreased in these women when compared to a reference population. BMD at the spine by either QCT or DXA revealed values lower than expected for the population.

Tricyclic Antidepressants

Effective in diabetic neuropathy, postherpetic neuralgia, tension headache, migraine, atypical facial pain, fibromyalgia and low back pain. In neuropathic pain, TCAs relieve brief lancinating pain, constant dysesthetic pain, allodynia and spontaneous pain. The pain relief from TCAs is generally moderate in degree. Side effects such as sedation, postural hypotension, dry mouth and constipation are common. The sedative property of this class of drugs is often exploited when pain is accompanied by sleep difficulty by administering them in the evening. TCAs with a balanced inhibition of serotonin (5-hydroxytryptamine or 5-HT) and norepinephrine (NA) reuptake, such as amitriptyline, imipramine and clomipramine, as well as agents with greater NA reuptake inhibition such as desipramine and nortriptyline, appear to be effective analgesics. The mechanism of action is unknown. It is probably multi - factorial as these agents are capable of multiple actions of relevance to pain transmission 8 .

Clinical Symptoms and Evaluation

Patients with small or even occult primary testicu-lar tumors may present with symptoms of large metastases (10 ). These most commonly occur in the retro-peritoneum and may cause low-back pain, small bowel or ureteral obstruction, and even compression of the inferior vena cava. Anterior mediastinal tumors may be extra-gonadal primaries and may present with superior vena cava syndrome and associated testicular

Manipulation and Mobilization

Manipulation is movement of short amplitude and high velocity that moves a joint beyond where a patient's muscles could move it by themselves but that does not cause ligament rupture. Mobilization is movement administered by the clinician within normal joint range in order to increase the overall range of motion. Manipulation is considered to have a higher complication rate compared to mobilization due to the velocity and movement of the joint. There is very limited information about the effectiveness of manipulation and mobilization in conditions associated with chronic pain. Neither mobilization nor manipulation was superior when compared to each other. There is little evidence in mechanical neck disorders that manipulation or mobilization used in isolation or with other passive physical medicine modalities is beneficial (although some benefits when used in association with exercise were seen 20 ). In chronic low back pain, manipulation was beneficial, but only reduced pain by less...

Cervical and Lumbar Epidural Injections

In a literature review, completed in 1995, of randomized trials of epidural steroid injections in the treatment of low back pain and or sciatica 3 twelve trials were identified, all with flaws in their study design. Six studies showed benefit and six showed either no benefit or worse outcomes after epidural steroid injection. The best quality studies showed inconsistent results and any benefits appeared to be only short term. Therefore the efficacy of epidural steroids was not established. A significant number of side effects and complications, including headache, backache, water retention, fever, bacterial meningitis and epidural abscess, were noted.

Trigger Point Injections

There are no data to suggest that TPIs with either steroid or local anesthetics alone provide long- lasting benefit for patients with chronic low back pain 16 . Furthermore, there is conflicting evidence about the effectiveness of TPIs for the short-term relief of low back pain. A recent systematic review of invasive procedures for low back pain concluded that TPIs have not clearly been shown to be effective and cannot be recommended 18 .

Multidisciplinary Treatment but Without Workplace Intervention

A systematic review 7 of 65 studies of multidisciplinary treatment for chronic back pain found proportionally greater improvement for multidisciplinary programs on outcomes of work, medication use, healthcare use, activity, and pain behavior. Patients treated in a multidisciplinary clinic were almost twice as likely to return to work compared to the untreated or single modality treated patients (68 versus 36 ). The overall benefit was seen both in the short-term (less than six months) and long-term (more than six months). Another review 8 of multiple randomized comparisons of multidisciplinary versus control treatment for chronic low back pain found moderate evidence that intensive multidisciplinary rehabilitation reduced pain when compared with outpatient usual care or non-multidisciplinary rehabilitation. There was contradictory evidence regarding vocational outcomes. More intensive programs had a significant beneficial outcome for pain and functional status that was not evident in...

Deriving Frequent Directory Topics via Data Mining

A topic can be viewed as a condensed synopsis of a subcollection of documents. For example, lung cancer and chemotherapy'' is a topic that covers all the documents on the treatment of lung cancer'' with chemotherapy. To capture the meaning of a subset of documents, we typically need multiple concepts, such as lung cancer'' and chemotherapy. Therefore, a specific topic should consist of multiple concepts. Further, the concepts that belong to one topic should frequently co-occur in the documents. For example, it is meaningless to combine back pain'' and heart surgery'' within a topic, because very few medical documents mention both concepts.

Historical Context

Cancer is a leading cause of death in Americans, second only to heart disease. While breast cancer kills the most women, many gynecological cancers are part of the overall cancer statistic. Ovarian cancer, the so-called whispering disease because of its insidious nature, is detected in one in 70 predominantly perimenopausal and postmenopausal American women and often metastasizes undetected. Risk factors include family history of ovarian and breast cancer, high dietary fat, delayed menopause, and no or late childbearing. The use of oral contraceptives appears to decrease risk. Ovarian cancer often presents itself with a cluster of three persistent and severe symptoms a swollen abdomen, a bloated feeling, and urgent urination. Other symptoms associated with the disease include gas pains, anorexia, backache, and indigestion. Unfortunately most women seek medical advice when their ovarian cancer is in the advanced stage because the symptoms might be associated with other gynecological...

Psychological Factors

Several systematic literature reviews summarizing multiple studies of pain outcome in workers have found positive relationships between psychological functioning and RTW outcomes. Hoogendoorn et al. 27 reviewed 1363 studies from 1966 to 1997 that investigated the impact of back pain on work. The authors conclude that, among these studies, there was strong evidence for low social support and low job satisfaction as risks for back pain. However, insufficient evidence was found for high work pace or high qualitative demands, job content, job control, and decision latitude. Linton summarized 975 studies, 21 of which met inclusion criterion for review in his study 28 . Of the 11 types of psychological risk factors, strong evidence was found for six factors (job satisfaction, monotonous work, work relations, work demands, stress, and perceived ability to work), moderate evidence for four variables (control, work pace, emotional effort at work, and belief that work is dangerous) and one...

Workers Broader Contexts

Research has extended its emphasis on individual variables to include much broader factors such as the work environment and the greater social milieu. For instance, Battie and Bigos 31 examined over 56 variables in 3000 Boeing workers for their relation to future industrial back pain reporting. Physical factors (including past medical history, specific outcomes from a physical examination, and functional movements) that were long suspected to be risk indicators of poor outcomes were included in the study. Surprisingly it was the characteristics of the workplace setting, such as job satisfaction and emotional distress on the job that were most highly correlated with initial reports of pain. In fact, the various physical factors were not significantly associated with the report of back pain. Moreover, the pervading economic climate has been demonstrated to be intricately associated with pain-related behaviors and disability. A classic study by Clemmer and Mohr examined the relationship...

Psychologically Based Interventions

Recent studies have evaluated cognitive behavioral therapy, social marketing interventions, and psychologically-based physical therapy treatment. Each of these approaches aim to alter disability behaviors through altering beliefs and attitudes. Authors of two recent systematic reviews of chronic back pain report that rehabilitation programs are effective at reducing duration of work-related disability only when they contain a component of cognitive behavior therapy 48, 49 . Importantly, the articles also highlight that cognitive behavior therapy embedded in a multi-disciplinary treatment program yields significantly better results when compared with unimodal treatments 50 . However, newer approaches in primary care have shown promising results when such cognitive behavioral principles are incorporated into routine physical therapy practice 51, 52 . In this approach, clinicians are trained to identify psychological barriers to recovery early in the treatment process, then provide goal-...

Clinical Features

The most common symptom initially is pain at the site of the skeletal lesion. Severe back pain or cord compression may be the presenting feature. Pathologic fractures or a soft tissue extension of a solitary plasma-cytoma, such as in a rib, may result in a palpable mass.

Why Public Health Campaigns

Several recent studies performed in different countries have shown a mismatch between public beliefs about back pain and current evidence about the condition's prognosis and management 8, 26, 27 . Authors of recent evidence-based clinical practice guidelines advocate that back pain is a benign, self-limiting condition and recommend that early management include minimal medical intervention, reassurance and advice to stay active 28, 29 . In contrast, results of an on-the-street survey undertaken in the United Kingdom indicate widely held beliefs that back pain most often results from major pathology such as a slipped disc or trapped nerve 27 . This is consistent with public beliefs in Norway 30 . In Canada, the general public also holds overly pessimistic views about back pain, believing that back pain will eventually stop one from working, becomes progressively worse with age, and makes everything in life worse 8 . As beliefs and attitudes about back pain are associated with the...

The Working Backs Scotland Campaign Scotland 20002003

In Scotland, the Health Education Board for Scotland (HEBS) (www.healthscot-land.com) and the Health and Safety Executive (HSE) (www.hse.gov.uk) launched a major public education campaign about back pain in October 2000. The primary messages were (i) Stay active (ii) try simple pain relief (iii) if you need it, get advice. Specific recommendations regarding work were not presented as preliminary focus showed that advice about work was viewed with suspicion and perceived to be provided on behalf of government or employers. Twenty organizations representing health professionals, employers and unions were involved. The Scottish campaign used radio as opposed to television to reduce costs. The radio campaign broadcast 1777 15-second advertisements on all 15 commercial radio stations. Skilled packaging and support from a well-known Scottish sports personality were also used and garnered attention from the free press. Leaflets and posters were provided to employers and treating health...

The Alberta BackIt Campaign Canada 20052008 ongoing

The apparent success of the Australian and Scottish campaigns and the fact that back pain continues to be one of the most prevalent and costly medical conditions stimulated a related intervention in Alberta, Canada. The Alberta campaign builds on the Australian and Scottish experiences, maintaining the general themes of the Australian campaign while focusing on radio to reduce costs. The campaign initially aired between May 2005 and April 2006 but was extended two more years due to positive feedback and overwhelming support from the organizers and health professional groups. The campaign is sponsored by the Alberta Government (Alberta Human Resources and Employment, Workplace Health and Safety), the Workers' Compensation Board-Alberta (WCB-Alberta) and local safety associations (Alberta Hotel Safety Association, Manufacturers' Health and Safety Association, Alberta Construction Safety Association). It has also received widespread endorsement from local health associations (physicians,...

Skeletal Complications

The skeletal complications of MM are the most distressing of all the end-organ complications encountered in this disease. Osteopenia and lytic bone lesions are a cause of disabling pain and pathologic fractures. Spinal cord compression may result as well. Thirty percent of patients will present with nonvertebral fractures and more than 50 will present with back pain or vertebral fractures.44,45 Approximately 80 of patients will have radiographic evidence of osteoporosis, lytic lesions, or fractures at the time of diagnosis.2 Osteoporosis, focal lysis, and hypercalcemia all result from increased osteoclastic activity. The molecular mechanism causing this enhanced activity is incompletely understood, but continues to be an area of intense investigation. The current paradigm proposes that an imbalance in osteoprotegerin (OPG) and osteoprotegerin ligand (OPGL) are central to bone resorption.46 OPGL is known to activate osteoclastic cells via the receptor activator of NF-kB (RANK).46 Ex...

Credible and Reliable Research Evidence

A total of 13 systematic reviews on chronic nonspecific low back pain met our inclusion criteria. An additional five systematic reviews were included on interventions that were not specifically targeted to nonspecific low back pain. From these 18 reviews, the clinical and HTA research ambassadors developed the Evidence in Brief summaries.

What Is in the Future

The success of the initial Ambassador Program has led to additional funding for two years. The program is being expanded to include headache pain, which is also subject to widely varying treatment patterns in community practice. The project team is also working with a multidisciplinary group of local opinion leaders from across the province to develop clinical pathways for low back pain and headache that will be adapted to the treatment options available in local communities. These pathways will be converted into paper-based and electronic point-of-care tools. Dissemination strategies for these tools will be developed by local opinion leaders, with support from administrative leaders and project staff.

Chiropractic Treatment in Epilepsy

Alcantara described a 21-year-old woman who presented with low back pain after a fall and a history of grand and petit mal seizures (34). Before treatment, the patient reportedly experienced a seizure every 3 hours, with a duration of 10 seconds to 30 minutes per episode. Treatment consisted of spinal manipulative therapy directed to the cervical, thoracic, and lumbar regions. During one seizure, the chiropractor administered a cervical adjustment. On administration of the adjustment, the seizure stopped abruptly. This is the only published report of such a phenomenon. At the 18-month follow-up, the patient reported that her low back complaint had resolved, and her seizures had reduced in frequency to as little as one every 2 months (34).

The Victoria Work Cover Authority Back Campaign Australia 19971999

In 1997 the Victoria WorkCover Authority (VWA), the manager of the workers ' compensation system in the Australian state of Victoria, began a state-wide public health campaign aimed at shifting the general population' s attitudes and beliefs about back pain (henceforth called the VWA Back Campaign). The VWA Back Campaign was developed according to messages in The Back Book, an educational booklet for patients based on the biopsychosocial model 42 . Various unambiguous messages were included, focusing on staying active, exercising, not resting for prolonged periods, and staying at work. The campaign ran with varying intensity over three years. Television commercials were aired in prime -time slots and included dialogue by recognized national and international medical experts, sports and television personalities, and were endorsed by relevant professional bodies. The television campaign was supported by other mass media including extensive outdoor billboards and radio but minimal...

Healthcare Seeking Behavior

Despite the high frequency of pain complaints in workers, management strategies vary considerably. It appears that many sufferers cope independently and do not seek care for their pain. In the Swedish working population, only 5 of individuals experiencing a new episode of back pain sought care for the condition 10 . Within the Alberta survey mentioned above, 12 of people reported doing little to treat or otherwise manage their last episode of back pain 4 . They simply continued their regular daily activities as recommended in most international guidelines for the management of back pain. Approximately 40 reported seeking assistance from a healthcare professional such as a physician, physical therapist or chiropractor. This is similar to study results from Australia, Belgium, USA and the UK where a minority of individuals report seeking care 11-14 .

The Perspective of People with Pain

Brenda is 52 years old and worked for a number of years as a medical receptionist prior to being involved in a car accident where she was badly injured and was unable to return to work. She experiences back pain and has had multiple interventions including Facet joint injections, physiotherapy and TENS. Her current medication is dihydrocodeine, co-proxomol, buprenorphine (Temgesic) for flare-ups, and diazepam for muscle spasms. Brenda lives with her dog who she credits with keeping her motivated and active.

Role of Compensation Insurance Systems

Within North America, most compensation systems operate under an injury model 33 . This gives rise to some difficulties in the case of regional pain disorders such as back pain in that often no specific injury event precipitates the condition 34, 35 . Multiple studies of individuals with back pain as well as other painful conditions have shown that receipt of compensation benefits is associated with worse outcomes 36-39 . The explanation for this is unclear. Those receiving workers' compensation may have higher occupational physical demands that are confounding the observed relationship, or the fact these patients are being paid for being off work may have an influence. Clearly, broader societal influences and systems have an influence on workers with pain. Often these influences are supportive, but frequently they are detrimental.

Acupuncture and Traditional Chinese Medicine

The recognition of acupuncture by Western medicine is not entirely new. In the late 1800s, Sir William Osler, one of the most honored and respected physicians and medical educators, wrote a textbook of medicine in which he recommended acupuncture for low back pain and sciatica. In 1901, Gray's Anatomy, a classic medical text, also referred to acupuncture as a treatment for sciatica.

CAM Approaches for Pediatric Pain 21 Acupuncture

In adults, acupuncture is among the most frequently used CAM treatments for chronic medical conditions (15-17), and its effectiveness has been supported for several specific pain problems, such as headaches (18) and chronic back pain (19). Reports of serious adverse effects are rare (20,21). Although the exact mechanisms by which acupuncture exerts analgesic effects have not been specified, numerous investigations have demonstrated that the nervous system, neurotransmitters, endogenous substances, and Jingluo (meridians) may respond to needling stimulation and electroacupuncture (EA) (22), in which an acupuncture needle is attached to a low-voltage electricity source.

Patient Education and Back Schools

A meta-analysis 23 was conducted of controlled studies dealing with back schools (a short term educational and exercise program focusing on optimal back care) published from 1977 to 1993, and the control groups were placebo, waiting lists, or minimal treatment. Within six months of treatment, the back school had the strongest effect on improving back posture and movement and on acquiring content information, and medium effects on spinal mobility, recurrent back pain and health care utilization. For pain intensity, functional status and analgesic intake, positive effect sizes were not identified. Evidence was not found for efficacy beyond six months.

Additional Readings Books

Hurwitz IL, Morganstern H, Harber P, et al. A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain 6-month follow-up outcomes from the UCLA back pain study. Spine 2002 27 2193-2204. Kaptchuk TJ, Eisenberg DM. Chiropractic origins, controversies, and contributions. Arch Intern Med 1998 158 2215-2224. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurol 2003 60 1424-1428.

Based ori the History and i

2 Tulder, M.W., Ostelo, R.W.J.G., Vlaeyen, J.W.S., Linton, S.J., Morley, S.J. and Assendelft, W.J.J. (2000) Behavioral treatment for chronic low back pain. The Cochrane Database of Systematic Reviews, 2000, Issue 2, Art. No. CD00214, accessed June 30, 2008 (http www. cochranelibary.com ). 3 Ostelo, R.W.J.G., Tulder, M.W., Vlaeyen, J.W.S., Linton, S.J., Morley, S.J. and Assendelft , W.W.J. ( 2007 ) Behavioral treatment for chronic low back pain. The Cochrane Database of Systematic Reviews, 2, 2008, accession number 0075320-100000000-D2103, accessed June 30, 2008 (http www.cochranelibary.com). 4 Tulder, M.W., Koes, B.W. and Bouter, L.M. (1997) Conservative treatment of acute and chronic nonspecific low back pain a systematic review of randomized 5 Panel, P. (2001) Philadelphia panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain. Physical Therapy, 81,1641-74. F. (1994) Group education interventions for people with low back pain. An...

Perioperative Pain

More than 2 million African Americans and Hispanic Americans are affected by sickle cell disease. Other peoples affected include those of Arab, Indian, and Asiatic descent or of descent from wherever there was malarial spread from equatorial Africa. Generally, patients present with abdominal pain, back pain, or extremity pain, especially of the legs. Any one or a combination of these regions may be affected during a VOC (88). Shapiro and coworkers in the 1990s described the event as a painful episode to deemphasize the emotional component in an effort to improve coping (89). Despite an attempt to control the behavioral facet by deemphasizing the anxiety, it has been shown that many patients objectively test positive for anxiety and a sense of helplessness.

Chronic Pain

Detailed discussion of the evaluation of each of the common chronic pain problems (abdominal pain, back pain, headache, limb pain, widespread muscu-loskeletal pain) is significantly beyond the scope of this chapter, and there are excellent review articles available. In addition to the typical aspects of the history and physical that are considered for each of these pain problems, a few aspects of the routine evaluation that are not often discussed but may yield additional information deserve emphasis.

Massage Therapy

Strokes, kneading of individual muscles, friction, hacking or tapping, and vibration. Massage therapy has been studied in systematic reviews for tendonitis 23 , chronic low back pain 24 , and mechanical neck disorders 25 . Massage, particularly acupressure massage, may be beneficial in the treatment of chronic low back pain, especially when combined with exercise and education, although it is not necessarily better than other types of treatment. The evidence for massage therapy in neck pain and tendonitis is lacking. Long-term effects of massage therapy are unclear. Massage therapy in conjunction with other therapies (such as relaxation therapy, acupuncture and self-care education) may be of benefit.

Relaxation Therapy

There are many different types of relaxation techniques which include meditation, mind body interaction, music- or sound-induced relaxation, mental imagery, and biofeedback. Rhythmic, deep, visualized or diaphragmatic breathing may also be used. Most studies of relaxation therapies are of poor quality and provide conflicting results. There is some evidence of short-term benefit in chronic low back pain for combined cognitive therapy and progressive relaxation therapy 28 . Mindfulness based stress reduction, a learned meditation technique that has been applied to many chronic psychological and physical health conditions, appears to be associated with significant and sustained improvements in pain intensity 29 , but has yet to be subjected to adequately sized randomized trials.


A pivotal, multicenter phase III trial was then performed to evaluate the activity of denileukin diftitox in patients with CD25+ CTCL.119 Patients were randomized to receive denileukin diftitox given at a dose of either 9 g kg day for 5 days every 3 weeks or 18 g kg day for 5 days every 3 weeks, with no steroid premedication. Thirteen of 36 patients receiving the higher dose had an objective response, as compared to eight of 35 patients in the lower dose cohort. Overall, 20 of patients had PRs while 10 had CRs, with the mean duration of response being 6.9 months. There were CRs in both groups, with the 3 CRs in the lower dose group having early stage (IB) disease, while the 3 CRs in the higher dose group had stage IIB or higher disease, suggesting a role for the higher dose in patients with advanced-stage disease (Table 60.4). An increase in the titer of antidenileukin diftitox antibodies was seen in most patients, which did not have a significant effect on antitumor efficacy....

Behavior Therapy

There is some evidence that behavioral treatment is better than no treatment for chronic low back pain intensity, and there is some evidence that behavioral treatment results in greater functional improvement. At least shortlerm benefit in chronic back pain relief was noted with cognitive-respondent therapies and relaxation therapy. (Cognitive therapies are based on identification of negative thoughts and catastrophizing and teaching the patient to replace them with coping thoughts. Respondent therapies are usually based on desensitizing a patient to fear of harm during activity by setting quotas to gradually increase exercise and activity, in an environment in which the therapist gives support, advice and reassurance. Relaxation therapies, including hypnosis and progressive relaxation or applied relaxation are techniques for reducing tension that is contributing to pain and anxiety). Behavioral treatments, combined respondent and cognitive therapy, and progressive relaxation therapy,...

Treatment Method

Massage may be effective through several possible mechanisms. First, massage appears to relax muscles (although only limited studies have formally evaluated this effect). This effect may be helpful for conditions that are worsened by muscle stiffness, such as headaches, neck pain, and low back pain. Also, massage may release chemicals known as endorphins, which reduce pain. Through a theoretical process known as gate control, which presumes that only a certain number of impulses may reach the brain from a specific body part, stimulation by massage in a painful area may decrease the number of pain impulses received by the brain from that area. Finally, the simple act of touching that occurs with massage may convey positive feelings that are difficult to evaluate rigorously, such as caring, comfort, and acceptance. Touching is a simple and possibly beneficial act


While workers experience pain in multiple body parts, back pain is the leading cause of work loss. The high prevalence and social and economic impact of back pain has led to its inclusion as one of four musculoskeletal conditions specifically targeted by the Bone and Joint Decade (2000-2010) initiative endorsed by the World Health Organization 1 . A recent systematic review presenting data on the prevalence of back pain yielded point prevalence estimates from 12 to 33 , one-year prevalence estimates from 22 to 65 and lifetime prevalence estimates from 11 to 84 2 . Another recent review of the literature on back pain prevalence estimated the point prevalence specifically in North America at 5.6 3 A recent survey undertaken in Alberta found a lifetime back pain prevalence of 84 and 1- week prevalence of 34 4 . The wide ranges in the reported estimates are likely due to variations in the questions asked of respondents, however, it is clear that back pain is extremely common and affects...

Bone Pain

Bone pain is the most frequent presenting symptom. It may precede the diagnosis for months. It most commonly begins in the back and lower chest, less often in the ribs or extremities. Back pain is usually insidious, and is aggravated by weight bearing and movement. Acute exacerbation of back pain often occurs with compression fractures of the vertebrae. The chest pain from rib lesions is generally mild, aggravated by movement and position, but may be pleuritic and associated with dyspnea, particularly when rib fracture or pleural effusion develops. Bone pain may become severe when pathologic fracture occurs spontaneously or with trivial trauma. Physical examination may illicit bone tenderness of the affected regions. Radicular pain

Primary Prevention

To date most primary prevention interventions for back pain that have been studied have attempted to reduce the incidence of occupational low back pain in the workplace 23, 24 . However, such primary prevention strategies for back pain have generally been unsuccessful. In one recent review the only intervention supported by adequate evidence was exercise therapy 25 . Recognizing that back pain is nearly ubiquitous and difficult to prevent, one of the main aims of public health campaigns for back pain is to prevent disability due to the condition. This may be considered secondary prevention of disability with the aim of reducing the risk of chronicity.


We used the Cochrane Effective Practice and Organization of Care Review Group (EPOC) data collection checklist 40 to summarize the key campaign elements and evaluation strategies of three back pain mass media campaigns that had formal scientific evaluations of effectiveness as part of their processes (Australia, Norway and Canada). The data extraction checklist provides a guide about relevant campaign and study characteristics including the setting (e.g. country and reimbursement system), the population and healthcare provision for the general population and for injured workers, details about the campaign itself including the rationale for the campaign and any underlying basis for the campaign, the period of time over which it ran, who performed the campaign, who provided input into the content endorsements if any the major media of the campaign, the overall costs, the intensity and frequency of the campaign, the intended audience, the main messages, the messengers, any additional...


Pathology After a typical 14-day incubation, smallpox causes high fever, malaise, prostration, headache, backache, myalgias, cramping abdominal pain, delirium, and a characteristic centrifugal rash with the synchronous appearance and resolution of initial red macules, then vesicles, pustules, ulcers, crusts, and pitted scars, most prominent on the face and extremities. CFR 30 .


Within healthcare systems in general, a chronic pain patient who wishes to access a specialist or be admitted to a pain clinic must be referred by a GP. Several management issues arise with the referral process, whether for diagnostic testing or treatment. One relates to the primary healthcare provider knowing when and where to refer a patient. A second relates to timely patient access to the next level of care, which can be problematic. For some types of chronic pain (e.g. back pain, complex regional pain syndrome), waiting too long for appropriate diagnosis and treatment contributes to the development of long-term disability. Ideally, a referring GP will explicitly commit to continuing to treat the patient once he she is discharged from specialty care.

Recent Studies

Demyttenaere and colleagues 22 asked questions about chronic neck and back pain as part of a face to face administration of the Composite International Diagnostic Interview (CIDI) used to examine mental health. The survey was carried out in 17 countries in the Americas, Europe, the Middle East and Africa, Asia, and the South Pacific. The total sample size was 85088 and the weighted average response rate was 70.8 . A subsample of 42 697 completed additional questions including questions about the 12 month presence of, or treatment for, chronic back or neck problems. The mean age of participants by country ranged from 35.2 and 51.4. The overall prevalence was 23.0 and the weighted prevalences ranged widely across country (range Colombia 9.7 to Ukraine 42.2 ).

Back Pain Revealed

Back Pain Revealed

Tired Having Back Pains All The Time, But You Choose To Ignore It? Every year millions of people see their lives and favorite activities limited by back pain. They forego activities they once loved because of it and in some cases may not even be able to perform their job as well as they once could due to back pain.

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