Low Back Pain

Goals and Objectives Review evaluation and differential diagnosis of low back pain Discuss when to obtain imaging Discuss selected etiologies/radiography of back pain Discuss treatment modalities Have trivial Pennsylvania fun

Image Challenge Q: What is the diagnosis? 1. Atlanto-occipital dislocation 2. Atlanto-axial subluxation 3. Pillar fracture 4. Spinous process avulsion 5. Wedge fracture

Image Challenge Q: What is the diagnosis? Answer: 1. Atlanto-occipital dislocation This computed tomogram of the cervical spine shows major atlanto-occipital dislocation in the lateral view that proved to be fatal.

Low Back Pain Treatment for low back pain dated to Hippocrates (460-370 BCE), who reported joint manipulation and use of traction Second most common office visit 2/3 of all adults will suffer from 85% idiopathic “strain/sprain” Most common pain syndrome Risk factors: heavy lifting, twisting, bodily vibration, obesity, and poor conditioning Deyo R and Weinstein J. N Engl J Med 2001;344:363-370 Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008

Differential Diagnosis of Low Back Pain Mechanical Low Back Pain 97%: HNP: 4% Spinal Stenosis 3% Cancer: 0.7% Infection: 0.1% Inflammatory Arthritis: 0.3% Strain and sprain have never been anatomically or histologically characterized, should be referred to as “idiopathic low back pain” Table 1. Differential Diagnosis of Low Back Pain. Deyo R and Weinstein J. N Engl J Med 2001;344:363-370

Common Pathoanatomical Conditions of the Lumbar Spine Figure 1. Common Pathoanatomical Conditions of the Lumbar Spine. A superior view of a lumbar vertebra with normal anatomy and canal configuration is shown in the upper right. In the superior view of a lumbar vertebra and intervertebral disk (center right), herniation of the nucleus pulposus into the spinal canal is evident. The nucleus pulposus has a soft consistency, at least from childhood to middle age, and may protrude through confluent fissures in the anulus fibrosus. This usually occurs in the lateral part of the spinal canal, as shown. The usual abnormalities that result in spinal stenosis (lower right) include hypertrophic degenerative changes of the facets and thickening of the ligamentum flavum. These processes may result in a severely narrowed canal, either centrally or in the lateral recesses of the canal. A lateral view of the lumbosacral spine, illustrating spondylolysis of the L5 vertebra with associated spondylolisthesis at L5-S1, is shown on the left. Spondylolysis refers to a defect in the pars interarticularis of the vertebra, which may be congenital or a result of stress fracture. Spondylolisthesis refers to the anterior displacement of a vertebra on the one beneath it. This may occur as a result of spondylolysis as shown (called isthmic spondylolisthesis) or as a result of degenerative disk disease, usually in the elderly. This process may contribute to narrowing of the spinal canal in spinal stenosis. Deyo R and Weinstein J. N Engl J Med 2001;344:363-370

Examination of the Low Back and SI Joints Observed walk Heel and toe walking Skin exam…focused -zoster -café au lait spots -hair tuft “faun’s beard” -scoliosis http://images-3.redbubble.net/img/art/size:large/view:main/2841048-2-the-faun-2.jpg Fauns goat feet, satyrs human feet

Physical Exam Palpate all of the spinous processes of the thoracolumbar spine Neurologic, muscle strength and reflex testing Straight leg testing Bowstring sign Distracted straight leg test, positive with Tripod sign or Flip sign Femoral Stretch Test Anal Wink

Straight Leg Testing Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier 2006.

Bowstring Sign With onset of pain posterior tibial nerve is stretched like a bowstring across the popliteal fossa Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier 2006.

Femoral Stretch Test Pain in the anterior thigh or L2/3 region indicates a positive test (tests for HNP compressing nerve roots L2/3/4) Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier 2006.

Anal Wink

SI Joint Testing Gaenslen test Patrick test SI distraction SI compression Spondylitis measuring

Gaenslen Test http://www.hughston.com/hha/b.gaenslen.jpg ***Pain on the side of the hyperextended hip

Patrick Test (FABERE) Flexes, ABducts, Externally Rotates, and Extends http://www.mhhe.com/hper/physed/athletictraining/illustrations/ch25/25-30a.jpg

SI Distraction Testing http://www.aptei.com/report/samples/spring_2001/image011.jpg

SI Compression http://www.netterimages.com/images/vpv/000/000/010/10997-0550x0475.jpg

Spondylitis Measuring Normal Finger to Floor: 0-5 cm Normal Modified Schobers 15 increases to 20 cm Distances: Normal Modified Schobers 15 increases to 20 cm Normal Occiput to Wall: 0-2 cm Normal Finger to Fibula: 0-5 cm Normal Finger to Floor: 0-5 cm Normal Finger to Fibula: 0-5 cm Normal Occiput to Wall: 0-2 cm Fam. Musculoskeletal Examination and Joint Injection techniques. Mosby Eslevier 2006.

Is This Back Pain Serious? Is there a serious underlying illness? Does the back pain have a neurogenic claudication or sciatic-type syndrome? Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008

When to Image? Limited to patients with systemic disease or trauma Guidelines recommend plain radiography for patients: -with fever -unexplained weight loss -history of cancer -neurologic deficits -alcohol or injection-drug abuse -age of more than 50 years -trauma Bigos S, Bowyer O, Braen G, et al. Rockville, Md.: Agency for Health Care Policy and Research, December 1994. (AHCPR publication no. 95-0642.)

When to Imag ACR Guidelines? Recent significant trauma Milder trauma age >50 Unexplained weight loss Unexplained fever Immunosuppression History of cancer Intravenous (IV) drug use Osteoporosis Prolonged use of corticosteroids Age >70 Focal neurologic deficit progressive or disabling symptoms Duration greater than 6 weeks Low back pain. American College of Radiology. ACR Appropriateness Criteria. Copyright ©2005 American College of Radiology

Plain Films There is no evidence that plain xrays in patients with nonspecific low back pain are associated with improvement in patient outcomes over selective imaging RCT 421 patients with lumbago x 6 weeks Exclusion criteria: -if they had xrays of spine within 1 year -unexplained weight loss or fever, were taking oral steroids, had a history of malignancy, tuberculosis, injecting drug use, or a positive result on a HIV test -symptoms or signs of a cauda equina lesion -were pregnant or planning a pregnancy Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. BMJ. 2001;322:400-5.

Plain films: Results Kendrick D, Fielding K, Bentley E, Kerslake R, Miller P, Pringle M. BMJ. 2001;322:400-5

MRI’s for Back Pain Researchers evaluated patients with baseline MRI Repeated MRI when developed low back pain Less than 5% developed new pathologic lesion

Representative Results of Magnetic Resonance Imaging Studies in Asymptomatic Adults Table 2. Representative Results of Magnetic Resonance Imaging Studies in Asymptomatic Adults. Deyo R and Weinstein J. N Engl J Med 2001;344:363-370

Etiologies of Back Pain/Abnormal Radiography Degenerative Disc Disease Paget’s DISH Ochronosis Renal Osteodystrophy Sickle Cell Scheuermann Kyphosis Infectious, briefly Idiopathic hemispherica sclerosis?

Degenerative Disc Disease Signs of degeneration include loss of disk height, sclerosis of the endplates, or osteophytic ridging Rajeev K Patel, MD. Lumbar Degenerative Disk Disease: Differential Diagnoses & Workup. emedicine.com, updated 03 Aug 2009

DDD Vaccuum Effect and Schmorl's Nodes http://images.google.com/imgres?imgurl=http://www.eorthopod.com/images/ContentImages/spine/spine_thoracic/scheuermanns/thoracic_scheuermanns_anatomy02.jpg&imgrefurl=http://www.eorthopod.com/public/patient_education/6544/scheuermanns_disease.html&usg=__gbUJ3-BOd0C9rVfqMX7tLWloKAI=&h=400&w=400&sz=134&hl=en&start=1&um=1&tbnid=Sc9fEGPaMQdFAM:&tbnh=124&tbnw=124&prev=/images%3Fq%3Dschmorl%2527s%2Bnodes%26hl%3Den%26rlz%3D1T4GGLL_enUS318US319%26sa%3DN%26um%3D1 http://images.google.com/imgres?imgurl=http://uwmsk.org/moodle/file.php/48/DDDgas.jpg&imgrefurl=http://courses.rad.washington.edu/mod/resource/view.php%3Fid%3D424&usg=__ZOW5gRqbQaaqE8haNiq0xVUSyjs=&h=668&w=512&sz=46&hl=en&start=4&um=1&tbnid=n-ly2XZUTozU6M:&tbnh=138&tbnw=106&prev=/images%3Fq%3Ddegenerative%2Bdisc%2Bdisease%2Bvacuum%26hl%3Den%26rlz%3D1T4GGLL_enUS318US319%26sa%3DN%26um%3D1 Intervertebral Osteochondrosis (dehydration and dessication of the nucleus pulposis) leads to the vaccuum phenomenom, nitrogen gas formation, bone sclerosis and disc space loss. This cavity then becomes surrounded by a rim of sclerosis (Schmorl’s node)

MR images of lumbar spine with degenerative changes at L1 Schellinger, D. et al. Am. J. Roentgenol. 2004;183:1761-1765 Copyright © 2006 by the American Roentgen Ray Society

Paget’s Disease Results from disturbance in bone modelling and remodelling due to increase in osteoblastic and osteoclastic activity Spine is the second most common site of bone involvement (Pelvis #1) Lumbar spine (L4 and L5 levels) are the most frequently involved sites (58%) Thoracic (45%) Cervical vertebrae (14%) Why does Paget’s hurt? -Periosteal stretching -Vascular engorgement -Microfractures -Facet arthritis -Intervertebral disc disease -Overt fractures -Spondylolysis/-listhesis -Sarcoma—very rare Langston A, Ralston SH .Rheumatology (Oxford). 2004 Aug;43(8):955-9. Epub 2004 Jun 8. C. Dell’Atti, V. N. et al Skeletal Radiol. 2007 July; 36(7): 609–626.

CT Findings of Paget’s Axial CT sections in different patients showing the various mechanisms and their effect on marrow size (long white arrow) and cortical thickness (short white arrow). a Periosteal apposition, normal endosteum. b Periosteal apposition, endosteal resorption. c Periosteal and endosteal apposition. d Pumice stone type (dashed arrow) of focal periosteal apposition. Similar focal periosteal apposition of the spinous process is seen C. Dell’Atti, V. N. et al Skeletal Radiol. 2007 July; 36(7): 609–626.

Plain Film Findings of Paget’s a Lateral and b antero-posterior radiographs demonstrate expansion of the vertebra with characteristic sclerotic lines parallel to the end-plates due to trabecular hypertrophy, an “early” sign of PD. c Lateral radiograph in a different patient demonstrates the “picture frame” vertebra due to thickening of the cortex and trabecular hypertrophy at the end-plates C. Dell’Atti, V. N. et al Skeletal Radiol. 2007 July; 36(7): 609–626.

Other Findings with Pagets Differential diagnoses of “ivory vertebra” include, Paget’s, metastasis, osteosarcoma, carcinoid and Hodgkin’s lymphoma . This is a case of metastatic prostate CA Graham T S Radiology 2005;235:614-615 Langston A, Ralston SH .Rheumatology (Oxford). 2004 Aug;43(8):955-9. Epub 2004 Jun 8. C. Dell’Atti, V. N. et al Skeletal Radiol. 2007 July; 36(7): 609–626.

DISH: Diffuse idiopathic skeletal hyperostosis Most patients present with stiff back or non-specific back pain Dysphagia, stridor, chronic pneumonia, and vascular compression are all complications from advanced disease Khozaim Nakhoda Diffuse Idiopathic Skeletal Hyperostosis. emedicine .com

DISH Clinical Criteria: - Flowing calcifications/ossifications along anterolateral aspect of 4 contiguous vertebral bodies, with or without osteophytes -Preservation of disk height in involved areas and abscence of excessive disk disease -Absence of bony ankylosis of facet joints and absence of sacroiliac erosion, sclerosis, or bony fusion (narrowing and sclerosis of facet joints ok) Khozaim Nakhoda Diffuse Idiopathic Skeletal Hyperostosis. emedicine .com

DISH Paraspinal ligaments undergo attrition, degenerate then ossify Three clinical variants of spinal enthesopathy Forestier’s disease involves the anterior longitudinal ligament DISH involves extra-axial sites Ossification of the posterior longitudinal ligament Khozaim Nakhoda Diffuse Idiopathic Skeletal Hyperostosis. emedicine .com

DISH Etiology is unknown however there are some associations: -Hyperglcyemia and Diabetes - Dyslipidemia -Hyperuricemia -Vitamin A derivatives used to treat acne -Chronic fluoride intoxication Vezyroglou G, Mitropoulos A, Antoniadis C. A . J Rheumatol. Apr 1996;23(4):672-6. DiGiovanna JJ SO J Am Acad Dermatol 2001 Nov;45(5):S176-82. Utsinger PD; Resnick D; Shapiro R . Arch Intern Med 1976 Jul;136(7):763-8.  

DISH, Unique Radiographic Findings Ankylosing Spondylitis DISH Syndesmophytes arise from anterosuperior and anteroinferior margins of the vertebral body Syndesmophytes may be best seen in the frontal projection The presence of sacroiliac joint erosions and extensive intra- articular bony ankylosis of the sacroiliac and apophyseal joints in ankylosing spondylitis The ossification in DISH attaches to the vertebral body several millimeters from these margins Changes are most prominent on the lateral radiographic projection None Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008

DISH Radiography Diffuse idiopathic skeletal hyperostosis. There is bone formation along the anterior aspects of more than four vertebral bodies. The disk spaces are maintained, and the sacroiliac joints were normal. Most common in thoracic but also noted in cervical and lumbar spine Calcification and ossification of the anterior longitudinal ligament of the spine http://api.ning.com/files/ZP9RLYMPy0ODENKDSJ75VtqZ*Jb8fDHA42qLeMxb528iXMu*iE*MMLHrtjsHgt9UO-kvQJ4vovGHM8830KGGx*u5kWS-hwYv/300pxAnkylosing_spondylitis_lumbar_spine.jpg Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008

Ochronosis Absence of homogentisic acid oxidase Consequent accumulation of homogentisic acid Autosomal recessive inheritance discovered by Garod in 1902 http://images.google.com/imgres?imgurl=http://www.clinmedres.org/content/vol2/issue4/images/large/209.fig3.jpeg&imgrefurl=http://www.gfmer.ch/genetic_diseases_v2/gendis_detail_list.php%3Fcat3%3D18&usg=__ZX4Nmwofz15dn2XQak8fac7IZck=&h=950&w=1280&sz=153&hl=en&start=12&um=1&tbnid=RRhUteHFtSdETM:&tbnh=111&tbnw=150&prev=/images%3Fq%3Dochronotic%2Burine%26hl%3Den%26rlz%3D1T4GGLL_enUS318US319%26um%3D1 Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008 Garrod, AE. The incidence of alkaptonuria: a study in chemical individuality. Lancet 1902; 2:1616.

Ochronosis Dystrophic (hydroxyapatite crystal) calcification involving disks but calcification also seen in cartilage, tendons, and ligaments. The most specific is in spine, which appears osteoporotic with dense disk calcification. Other joints involved show changes of mild degenerative joint disease, but this is a much less specific . http://www.learningradiology.com/caseofweek/caseoftheweekpix/ochronosis.jpg Firestein: Kelley's Textbook of Rheumatology,8th ed. WB Saunders 2008

Renal Osteodystrophy http://images.google.com/imgres?imgurl=http://rhodesiawassuper.com/images/SOME%2520SMALL%2520BOYS.jpg&imgrefurl=http://rhodesiawassuper.com/index.php%3FcPath%3D32&usg=__kDoWzDUEp64TiXvCsJWhtZpPhuk=&h=976&w=2076&sz=328&hl=en&start=88&um=1&tbnid=AwCLxgqh1CtXTM:&tbnh=71&tbnw=150&prev=/images%3Fq%3Drugby%2Bstriped%2Bjersey%26ndsp%3D18%26hl%3Den%26rlz%3D1T4GGLL_enUS318US319%26sa%3DN%26start%3D72%26um%3D1 http://images.google.com/imgres?imgurl=http://www.rad.washington.edu/staticpix/mskbook/RuggerJersey.jpg&imgrefurl=http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/osteopenia&usg=___IYrjlmaDejpkdX4ioy297EKDRY=&h=447&w=288&sz=19&hl=en&start=8&um=1&tbnid=yNQlhCQQ4qkq6M:&tbnh=127&tbnw=82&prev=/images%3Fq%3Drenal%2Bosteodystrophy%26hl%3Den%26rlz%3D1T4GGLL_enUS318US319%26um%3D1 Sclerosis is noted adjacent to the endplates (rugger-jersey spine) in a patient with renal osteodystrophy -- of osteoid in these areas. DDX osteomalacia and hyperparathyroidism. University of Washington Department of Radiology website. Musculoskeletal Radiology

Sickle Cell Disease http://www.gentili.net/signs/images/400/spinefishlsop.JPG http://www.lugaluda.com/wp-content/uploads/2009/05/snakehead_fish.jpeg BONUS: What type of fish is pictured to the right of the screen?

Scheuermann Kyphosis Scheuermann kyphosis is defined as anterior wedging of ≥5º in at least three adjacent vertebral bodies, as measured on lateral spine radiographs Most common cause of structural kyphosis in adolescence. The mode of inheritance is likely autosomal dominant Etiology remains largely unknown Indications for treatment remain controversial because the true natural history of the disease has not been clearly defined Brace treatment appears to be very effective if the diagnosis is made early Surgical treatment is rarely indicated for severe kyphosis (>75 degrees ) with curve progression, refractory pain, or neurologic deficit  Lowe TG Orthop Clin North Am 1999 Jul;30(3):475-87, ix

Scheuermann Kyphosis This lateral radiograph of the thoracic spine demonstrates moderate endplate irregularity, preserved vertebral disc spaces, and mild anterior wedging of the vertebral bodies, all of which are consistent with Scheuermann kyphosis. Courtesy of Jeanne Chow, MD, and Children's Hospital Boston.

Infectious Etiologies Discitis Epidural Abscess Osteomyelitis

Discitis http://www.ispub.com/ispub/ijrh/volume_2_number_1_57/infective_discitis_mimicking_infective_endocarditis_and_osteoarthritic_back_pain/discitis-fig1.jpg http://www.mghradrounds.org/clientuploads/nov_dec_2006/plain_film_fig1.jpg To differentiate from vaccuum phenomenom look for gas, extension, osteophytes that occur in the upper outer annular attachmentgrowing horizontal then vertical (traction vs claw)

Idiopathic Hemispherica Sclerosis Occurs in young women Vertebral level L4 Appears as gas in an intervertebral body Pneumocyst vs AVN

Treatment of Low Back Pain NSAID’s Tylenol Narcotics Tricyclic Antidepressants Muscle Relaxants Physical Therapy Non-Surgical Intervention therapy Surgery

Medication Therapy In a study of primary care patients 80% of patients prescribed at least 1 medication Greater than 1/3 were prescribed 2 or more drugs Cherkin DC, Wheeler KJ, Barlow W, Deyo RA. Spine. 1998;23:607-14.

Cochrane Review 5 acetaminophen trials 57 NSAID trials 10 trials of duloxetine and venlafaxine 8 trials of benzodiazepines 2 trials gabapentin 2 trials topiramate 36 trials of muscle relaxants 9 opiod trials 3 trials of tramadol 4 trials of systemic corticosteroids ...so what is the bottom line Dave?

Medications for Low Back Pain Good evidence of short-term effectiveness for acute low back pain are: - NSAIDs -acetaminophen -skeletal muscle relaxant *tricyclic antidepressants for chronic low back pain Evidence that opioids, tramadol, benzodiazepines, and gabapentin are effective for pain relief of radiculopathy. Good evidence that systemic corticosteroids are ineffective. Chou, Roger MD; Huffman, Laurie Hoyt MS Annals of Internal Medicine Issue: Volume 147(7), 2 October 2007, pp 505-514

Treatment Regimen Tylenol first line NSAID’s for more severe pain Opioids in select patients with more severe pain My treatment regimen -NSAID and muscle relaxant for mild to moderate pain followed by manipulation -Narcotic plus benzodiazepine followed by manipulation for severe pain Chou, Roger MD; Huffman, Laurie Hoyt MS Annals of Internal Medicine Issue: Volume 147(7), 2 October 2007, pp 505-514

Osteopathic Manipulation Recommendation 7: For patients who do not improve with self-care 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 -Progressive relaxation ***(weak recommendation, moderate-quality evidence). Chou, roger et al. Diagnosis. Ann Intern Med October 2, 2007 vol. 147 no. 7 478-491

Pilates and Low Back Pain One RCT 39 patients Results: -The individuals in the specific-exercise-training group reported a significant decrease in LBP and disability -Maintained over a 12-month follow-up period -Treatment with a modified Pilates-based approach was more efficacious than usual care in a population with chronic, unresolved LBP Rydeard R Leger A, Smith D J Orthop Sports Phys Ther. 2006 Jul;36(7):472-84

Non-Surgical Intervention Therapy??? For low back pain with radiculopathy, 10 of 17 trials found no difference in pain or function between epidural glucocorticoid and placebo injection Similar findings for facet and nerve branch blocks Discography or injection of the disc at the level of pain remains unproven Other therapies out there: -Chemonucleolysis -Electrothermal -Radiotherapy -Botulinum toxin Chou R; Atlas SJ; Stanos SP; Rosenquist RW Spine (Phila Pa 1976). 2009 May 1;34(10):1078-93 UptoDate.com

Indications for Surgical Referral among Patients with Low Back Pain Table 3. Indications for Surgical Referral among Patients with Low Back Pain. Deyo R and Weinstein J. N Engl J Med 2001;344:363-370

ACP and APS Joint Guidelines 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 -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).   Chou, Roger MD et al. Annals of Internal Medicine Issue: Volume 147(7), 2 October 2007, pp 478-491

ACP and APS Joint Guidelines 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 self-care 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).   Chou, Roger MD et al. Annals of Internal Medicine Issue: Volume 147(7), 2 October 2007, pp 478-491

Additional Tidbits Gibbus www.googleimages.com Sir Percival Pott's description of paralysis in association with tuberculosis of the spine in the 18th century led to the eponym of Pott's paraplegia.

Key Review Articles Chou, R et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society . Ann Intern Med October 2, 2007 vol. 147 no. 7 478-491 Deyo R and Weinstein. Low Back Pain. J. N Engl J Med 2001;344:363-370