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Francis D. Ferdinand MD, FRCSEd, FACS, FACC

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• Division of Thoracic and Cardiovascular Surgery, Lankenau Hospital, Wynnewood,
• Pennsylvania

Adding to the likelihood of this interpretation acne in your 30s cheap cleocin online master card, the home was known as the locus for illness and related rituals acne leather jacket purchase cheapest cleocin. In fact acne face chart cheap 150mg cleocin free shipping, the eighth century saw the rise of an increasingly interconnected world that might be respon sible for the spread of illness and a change in the public health landscape 3 (Gallagher 1999 skin care untuk kulit berjerawat purchase cleocin without a prescription, 247) acne mechanica discount 150mg cleocin with mastercard. As to the question of who the figurines represent acne body wash cheap cleocin master card, one possibility is that the figurines represent a mid-range deity. Despite biblical depictions of the ancient world, pantheons were relatively fluid, with multiple levels of divinities. The eighth century saw an increasing diversification of bureaucratic positions and mid-level bureaucratic mediator deities. The biblical text reflects something of this development in the passages dealing with seraphim, cherubim, spirits, and the messenger of Yahweh. In some texts these forces were used to inflict illness and 4 destruction, and in others they save people from the same. Rather they seem to arise in distinct settlements perhaps reflecting a grass-roots move ment rather than one tied solely to a central authority. At the same time, the state mechanism that provides the infrastructure for urbanization and the development of production industries seems to have enabled the propagation of the images and their distribution. Gallagher notes the evidence for plagues in Assyria during 802, 765, 759, and 707. Both Gallagher and Martinez argue that plague may have been even more widespread than these dates suggest, based on the common six-year inter val between plague outbreaks. Whatever our interpretation, the facts suggest a complex interaction between the rise of national identity and the state infrastructure that facilitated its develop ment. The stylistic coherence in Judah in the eighth through sixth centuries might be contrasted with more heterogeneous pillar figurine styles attested in surround ing polities. Does this suggest that various Judean sites, artisans, or ritual experts were, in some ways, more integrated when compared to surrounding polities This means that we do not have enough data to decide whether figurines arose at the end of the ninth century, at the beginning of the eighth cen tury, or in the middle of eighth century. Nor do we have enough data to know whether they emerged at different times in different regions within Judah. Mesopotamian Witchcraft: Toward a History and Understanding of Babylonian Witchcraft Beliefs and Literature. Illness and Health Care in the Ancient Near East: the Role of the Temple in Greece, Mesopotamia, and Israel. Zukunftsbewaltigung: Eine Untersuchung altorientalischen Den kens anhand der babylonisch-assyrischen Loserituale (Namburbi). Tell en-Nasbeh Excavated under the Direction of the Late William Frederic Bade, vol. At the same time, children represented the future of Israelite culture and religion; more than just receptacles for the wisdom of the ages, they were the living, breathing incarnation of Israelite culture and the insurance for its continuity. Aries asserted that, until the modern era, children were understood as miniature versions of adults. As such, children went through rites of passage, each moving the child further toward becoming a full-grown adult. Parker along with Laurel Koepf-Taylor (2013) and Naomi Steinberg examine Israelite children and childhoods via a literary and linguistic methodology. Others, 415 416 Kristine Garroway have incorporated archaeological sources from the larger world in which the He brew Bible arose and placed them in conversation with the biblical texts (Garroway 2014). Taking a cue from feminist scholarship, which considers gender, social clas ses, and ethnicity, my childist interpretation also takes a multi-disciplinary approach to the text. My childist approach also considers how the archaeological record can aid our understanding of the child in biblical Israel. While the data from a single discipline alone offers much, combining data from various disciplines can provide even more insights into the child in biblical Israel. A childist approach is complicated because it is difficult to find children in the ancient historical record, whether in texts or in material cultural remains. For example, the Bible, which is a production of male adults, focuses on male adults. The collection of stories about the patriarchs, judges, military leaders, and kings, as well as tales of long journeys, spiritual quests, wars, et cetera, has little to say about children. As feminist biblical scholarship proved, scratching below the surface re veals more layers that concern the voiceless other whose stories offer fresh insight 2 into another dimension of biblical Israel. The difficulties faced by scholars seek ing to uncover women in biblical Israel are multiplied exponentially for the scholar focusing on children, for we have fewer extant texts and artifacts related to children. Nevertheless, by engaging all the tools at our disposal we can flesh out various aspects of biblical Israelite children and their childhoods. Other extended family might live close by in adjacent houses sharing a common courtyard. The household encompasses the most basic 6 unit of society, representing a microcosm of the society in which it exists. Each member of the household, no matter their age, was responsible for contributing to the economic wellbeing of the household. Older adults were given less strenuous tasks, ones that could be done without great physical effort. Even though they were young, children were not exempt from contributing to the household. Unlike modern Western society in which children might have more emotional value than eco nomic value, cultures based on subsistence agriculture, like Israelite culture, 3. For those wishing to know more about families in Ancient Israel, the bibliography in this background section provides references to many of the staple works in the field. The field of household archaeology is dedicated to researching various aspects of the household, including gender, production, archaeology of the family, social organiza tion, and the household cult. Young chil dren could gather firewood while older ones could tend animals, draw water, watch younger siblings, and help the women with time-consuming domestic 7 chores. The older a child, the more she can contribute and the more vested she becomes in the household. To some extent, one can compare member ship in a household to membership at a country club. The older and more vested children become, the more integral they are to the household, and thus the more they are understood as members. The degree to which children were con sidered members of the household is also contingent upon where they are in the process of being enculturated and engendered (Levi-Strauss 1963; Garroway 2014). It is reflected in the legal instructions as one of the many commandments given to the Israelites. This act of passing on information to the next generation is called encultura 9 tion, and it is how a society hands down their culture. The process of enculturation is multifaceted, so that there are many ways to help children learn the values, skills, language, and behaviors that their society understands to be nor mative. Articulating key societal values through written texts, like those of Deuter onomy and Proverbs, is one means of enculturating a child into society. Cultural behaviors include reproduction of material culture, religious beliefs, and engenderment, among oth 10 ers. Parents, peers, siblings, and other members of society model correct cul tural behavior for the child. Children and other members of a society learn how to become male or female by watching others within their society act out these roles (Butler 1990). The repeated actions demon strating femaleness and maleness are passed on to future generations. Many essays within the volume the Archaeology of Childhood (2015) provide ex amples of the enculturation of children through the use of material culture both by the adult, and by the child. The women in this group passed down their ethnic and cultural identity by teaching their children how to make traditional Lakota dresses. Through this process, children not only learned key elements of their ethnic and cultural heritage, but also participated in producing tangible objects of their culture. Ideologies within a society can and do change over time and through interaction with other cultures. When a culture takes on elements of another culture, the process is called acculturation (Berry 2005). A less subtle means of engendering children comes today via the toys or stories children are encouraged to associate with. Just as children today are products of the society they live in, so too were children 3000 years ago. This is because the basic struc ture of the Israelite household did not change much. When the family structure breaks down, when children are no longer viewed as members of the Israelite household, children cannot be enculturated and Israelite 12 culture cannot be properly reproduced. Archaeological remains, while not with out their own challenges, are often easier to date and can be combined with textual data for a more complete picture.

The multi-modal package consisted of more effective at two months than rest and analgesia and no relaxation training based on diaphragmatic breathing skin care lab discount 150 mg cleocin overnight delivery, postural less effective than outpatient treatments tailored to individual re-education acne 8 yr old girl purchase cleocin american express, psychological support acne guidelines buy cleocin on line amex, proprioceptive exercise patient needs (comprising thermal modalities acne homemade mask discount cleocin online, short wave and cervical passive mobilisation skin care 1 month before wedding generic cleocin 150 mg otc. The comparison treatment diathermy acne 17 year old male 150 mg cleocin visa, hydrotherapy, active and passive movements, trac was application of transcutaneous electrical nerve stimulation tion, advice on posture and home exercises). At one and six months after treat with hom e exercises were pain-free com pared with those ment, pain scores were significantly less in the multi-modal treated either by rest (54%) or tailored outpatient treatments group. This proportion was significantly greater than the an active program of gentle, active, small-range and small control group, where the corresponding figures were two and amplitude rotation movements (consistent with M cKenzie one, respectively, in a group of 30 people. W hat is not evident from the study is whether the therapy (mobilisation and stabilisation techniques), 59 with attributable effect depends on providing all of the components physical therapy (exercise therapies, manual traction, massage of this combination of therapy. A further limitation is that the and heat) and 64 who received usual care consisting of results cannot be extended to all patients with acute neck pain. The remainder had acute ening and proprioceptive exercises versus treatment using a neck pain. The study found that a greater proportion of those who Both publications (H oving et al. The methodological limita in pain at seven weeks compared with 39% for those treated tions of the study were noted in another systematic review with physical therapy and 30% for those under usual care. At four weeks and eight Reductions in disability amounted to 30% and were not signif weeks after treatment, the mobilisation and exercise group icantly different between groups. Improvements in quality of exhibited a significantly greater reduction of pain, from a mean life measures were significantly better for the manual therapy score at baseline of 5. For the group and amounted to 22% for manual therapy, 12% for control group the corresponding figures were 6. Even so, there was consider For relief of pain, the effect size for manual therapy was able variance in the outcomes of the index treatment group. For improvement in quality of life, diathermy, hydrotherapy, active and passive movements, trac the effect size for manual therapy was not much higher than tion, advice on posture and home exercises) tailored to indi that of physical therapy (0. Overall, these results indicated that and the effects of instruction to perform mobilisation exercises manual therapy was moderately more effective than usual care at home and postural education. Tailored multi-modal therapy and marginally more effective than physical therapy (Hoving et was not more effective than home exercises, but both interven al. They reported this study is the only one that has provided long-term that 68% of their patients treated with manual therapy had follow-up (M cKinney 1989). At two years, 77% of the home recovered at seven weeks compared with 51% of patients exercise group were pain-free compared with 56% in the treated by physical therapy and 36% of patients under usual outpatient group and 54% in the rest and analgesia group. In these terms, there was substantially greater than that of the tailored package of fore, manual therapy is substantially more favourable than outpatient treatments (1. This could be an important factor in light of the fact Pulsed electrom agnetic therapy reduces pain intensity com pared to that those treated with manual therapy averaged six visits, placebo in the short term but is no different to placebo at 12 weeks for whereas those under usual care averaged only two visits. The thesis (Hoving 2001), however, the literature on acupuncture for neck pain is limited to reveals that any difference in outcome diminishes with time. At studies involving chronic pain, mixed acute and chronic pain 13 weeks, a significantly higher proportion (72%) of people or specific conditions causing pain. It provides insufficient who had manual therapy felt they had recovered compared evidence concerning the management of acute neck pain. Neither of these proportions was Exploring the literature on mixed populations does not different from that of the physical therapy group (59%). Clinical Evidence (2002) cited two systematic reviews (W hite and Ernst 1999; Smith et al. Both reviews concluded that M ulti-m odal (com inbed) treatm ents inclusive of cervical passive m obili there is insufficient evidence that acupuncture is effective sation in com bination with specific exercise alone or specific exercise compared with placebo or other interventions in the treatment with other m odalities are m ore effective for acute neck pain in the short of neck pain. Loy (1983) reported that acupuncture was collar embedded with a device that delivers a pulsed electro more effective than shortwave diathermy and traction for magnetic stimulus for eight hours a day. Each compared active therapy with wearing a collar A review by H arms-Ringdahl and Nachemson (2000) embedded with a placebo device. Those > There are no random ised controlled studies on the effect of treated with the active device exhibited significantly greater acupuncture or infrared acupuncture in the treatm ent of acute neck reduction in pain scores at two and four weeks during treat pain. At four weeks, a significantly > There is conflicting evidence that acupuncture is m ore effective greater proportion (p < 0. The second study (1992) involved patients with Analgesics (Opioid) acute whiplash-associated neck pain whereas the first study No studies have described or investigated the efficacy of (1990) involved people with mixed durations of neck pain. For the treatment of acute spinal pain, the guidelines on acute musculoskeletal pain Gross et al. Although differences in favour of cervical Harms have been associated with the use of opioids. The most commonly reported adverse effects (analgesic, postural advice, home exercises and other treat were nausea, dizziness, vomiting, constipation and drowsiness. Both the active treatment and the advice groups fared Cervical passive mobilisation is the application of forces to the better than the rest and analgesia group at one and two months neck in a slow, rhythmic fashion in order to increase the avail (p = 0. System atic reviews have 1 199 1 differed in their interpretations and treatment of the studies available on mobilisation therapy. Sim ple analgesics m ay be used to treat m ild to m oderate pain however Clinical Evidence (2002) located four systematic reviews there is insufficient evidence that paracetam ol is m ore effective than placebo, natural history or other m easures for relieving acute neck pain. These reviews identified three studies involving patients Cervical M anipulation with acute neck pain (Nordemar and Thorner 1981; M ealy et Cervical manipulation is movement performed to move a joint al. These studies are efficacy of cervical manipulation in acute neck pain were located. After one week, the group sive evidence on the effectiveness of cervical manipulation. At six weeks and three months, there were no differ the immediate effects of cervical manipulation versus muscle ences between the groups. H owever, the effect disappeared when the data with other treatments in mixed populations. Four studies identified in the reviews involved patients There is insufficient evidence that taking regular breaks from com puter work is m ore effective com pared to irregular breaks for preventing with a mixture of acute and chronic pain (Cassidy et al. The results were conflicting and none of the studies compared cervical passive mobilisation to natural history or placebo. M ulti-Disciplinary Treatment Any benefit of cervical passive m obilisation appears M ulti-disciplinary treatment comprises a combination of treat restricted to its use in combination with other interventions. Although the authors did not formally compare exercises versus a lecture recommending exercise. At three differences between groups, their data show no significant months, there was significantly less pain (p = 0. H endriks and H organ (1996) home exercise and proprioceptive exercise groups compared to compared ultra-reiz current with no treatment and found that the advice only group, but no difference after 12 months. Gymnastics reduced neck pain no more than natural history and seasonal variations (Takala > There is insufficient evidence that m ulti-disciplinary treatm ent is effective com pared to other interventions for reducing neck pain in et al. The subjects compared to diazepam and placebo but neither provided follow were pain-free at inception and undertook a three-hour task, up data. An additional study (Basmajian 1983) compared the during which they took breaks at their own discretion or at effect of diazepam, phenobarbital and placebo for the treatment scheduled 20-minute or 40-minute intervals. Dependency has been 20-minute intervals were found to reduce subjective discom reported after one week of use (Bigos et al. The study compared neck school (exercise, self-care and compared spray and stretch therapy versus placebo versus relaxation) to no treatment, with and without individual control (heat, exercise and education). The authors concluded advice, and found no significant reduction in pain in the inter that vapocoolant spray was no more effective than placebo and vention groups compared to no treatment. Another systematic review > N eck school appears no m ore effective than no treatm ent for neck (Harms-Ringdahl and Nachemson 2000) noted the negative pain in m ixed populations. Consequently, it is not possible to determine the effect of > There are no random ised controlled trials investigating the effec education from this study. M usculoskeletal disorders (Level I) of the neck and upper limb among sewing machine operators: a clinical investigation. Clinical indications for cervical spine radiographs in the traumatised Evidence of No Benefit patient. The pathophysiology versus no treatment (both groups received rest and analgesics) of whiplash. The prevalence Nachemson (2000) concluded that no evidence exists that of chronic cervical zygapophyseal joint pain after whiplash. Reflex cervical m uscle spasm: treatm ent In many of these studies, collars were used as the control by diazepam, phenobarbital or placebo. M agentic resonance imaging for the evaluation Soft collars are not effective for acute neck pain com pared to advice to of patients with occult cervical spine injury. Cyclobenzaprine in the treatment of skeletal >References muscle spasm in osteoarthritis of the cervical and lumbar spine. A prospective study of resonance imaging: application in musculoskeletal infection. Acute low back problems an adjunct treatment in patients with non-specific neck or low in adults. Etofenamate and transcuta neous electrical nerve stimulation treatment of painful spinal Bogduk N (2000). The cervical zygapophysial joints as Constantin A, M arin F, Bon E, Fedele M, Lagarrigue B, Bouteiller G a source of neck pain. Biomechanics of the cervical spine pain and its related disability in the Saskatchewan population. Superior facet fractures of the axis Prospective randomized controlled study of activity vs collar and vertebra. A randomised trial of treatment during the first 14 days 35 cases and review of literature. Review of 43 cases and cervical hyperextension-flexion injuries after car accidents. A comparative study of asymptomatic and pain patterns I: a study in normal volunteers. Controlled two year follow up of rehabilitation for disorders Fukui S, Ohseto K, Shiotani M, Ohno K, Karasawa H, Nagaauma Y, in the neck and shoulders. Aortic dissection presenting as a neuro Eliastam M, Rose E, Jone H, Kaplan E, Kaplan R, Seiver A (1980). Scandinavian Journal Fagerlund M, Bjornebrink J, Pettersson K, Hildingsson C (1995). W aking cervical pain and ligamentous disruption of the cervical spine an easily overlooked stiffness, headache, scapular or arm pain: gender and age effects. Roentgenographic findings Experim ents on referred pain from deep som atic tissues. Atlanto-axial rotatory fixation (fixed Incidence of common postural abnormalities in the cervical, rotatory subluxation of the atlanto-axial joint). M anual therapy in the treat for persistent pain: a double blind, placebo-controlled study of ment of neck pain. M anual therapy for mechanical differences between intervention programmes on neck, shoulder neck disorders: a systematic review.

One of these studies involved patients with acute low back pain however there is no indication whether the pain is non Topical Treatments specific (H ackett et al skin care kit purchase 150mg cleocin. There was no control group in this study and no signif versus placebo electroacupuncture and paracetamol (n = 37) acne neonatorum order cleocin 150 mg mastercard. There is insufficient evidence for the effectiveness of spiroflar hom eo pathic gel or crem ol capsici for treatm ent of acute low back pain acne leather jacket generic cleocin 150 mg without prescription. This study included mainly male patients with acute low back pain; there was no description of whether the pain was non-specific acne 5 pocket jeans order cleocin 150 mg line. At four weeks follow up skin care jakarta selatan purchase cheap cleocin on-line, the control group had effects of traction acne laser treatment cost cheap cleocin line, citing studies by van der H eijden et al. Treatment of acute low back pain and acute low back pain, a small sample size and the results with piroxicam: results of a double-blind placebo-controlled trial. A comparison of osteopathic spinal manipulation with standard care for patients by Herman et al. Growing body of evidence on massage as a treat ment for low back pain: recent studies and systematic reviews. Treatment of acute lumbosacral back pain with sions; usual activities avoiding bed rest; and bed rest. The diclofenac resinate: results of a double blind comparative trial versus costing analysis suggested that undertaking usual activities and piroxicam. A double-blind study of cyclobenzaprine and although the Cochrane reviewer suggested the results should be placebo in the treatment of acute musculoskeletal conditions of the interpreted with caution as there were only 50 to 60 people per low back. At four weeks the manipulation group had low back pain and sciatica in the United States: treatm ent less pain and at 12 months there was very little difference outcomes. Acute low back pain therapy, it was unlikely to be cost effective to refer for manipu in industry: a controlled prospective study with special reference lation or M cKenzie therapy. Tizanidine and ibuprofen in acute low back pain: results of a double-blind multicentre study in (comprised of four therapist-led one hour exercise classes over general practice. Published data is very lim ited; however there is som e evidence that Blomberg S, Hallin G, Grann K, Berg E, Sennerby U (1994). Epidemiology, etiology, diagnostic evalu antirheumatic: a randomised controlled study. The efficacy naproxen versus naproxen alone in the treatment of acute low back and tolerability of an 8-day administration of intravenous and oral pain and muscle spasm. Current M edical Research m usculoskeletal conditions: thoracolum bar strain or sprain. Chiropractic technique procedures for specific low back minophen in the treatment of patients with osteoarthritis of the conditions: characterising the literature. Clinical course and prognostic risk factors in acute low back treatment in patients with non-specific neck or low back pain. Comparison of diflunisal and acetaminophen with codeine in the M ulti-centre trial of physiotherapy in the management of sciatic treatment of initial or recurrent acute low back pain. Outcome of low back pain in general practice: a prospective Information and advice to patients with back pain can have study. Cancer as a cause of back pain: frequency, provision of an educational booklet for the treatment of patients clinical presentation and diagnostic strategies. Forsch Komplementarmed Klass Naturheilkd, 7: 2860293 of centralisation of lum bar and referred pain. Selective criteria m ay increase lum bosacral spine Dreyfuss P, Dreyer S, Griffin J, Hoffman J, W alsh N (1994). The role of fear-avoidance Dreyfuss P, M ichaelsen M, Pauza K, M cLarty J, Bogduk N (1996). Sudden unexpected deaths from Fukui S, Ohseto K, Shiotani M, Ohno K, Karasawa H, Naganuma Y ruptured abdominal aortic aneurysms. Acupuncture for back pain: a meta-analysis Controlled comparison of shortwave diathermy with osteopathic of randomized controlled trials. M edical Journal of Australia, 1: compared with paracetamol for acute low back pain. Stress reactions of the lumbar pars interarticularis: the of Bone and Joint Surgery, 83: 789. Cauda equina syndrom e differences between intervention programs on neck, shoulder and in patients undergoing manipulation of the lumbar spine. Platt K, efficacy of a risk factor-based cognitive behavioral intervention and Hoehler F, Reinsch S, Rubel A (2002). Effectiveness of four conser electromyographic biofeedback in patients with acute sciatic pain: vative treatments for subacute low back pain: a randomised clinical an attempt to prevent chronicity. Functional of the effects of a placebo chiropractic treatment with sham outcomes of low back pain: comparison of four treatment groups adjustm ents. Long-term effectiveness of bone-setting, light exercise questionnaire for predicting 1-year follow-up in patients with low therapy, and physiotherapy for prolonged back pain: a randomized back pain Quality of life and cost of care of back pain technique in acute low back pain: a preliminary investigation. Second prize: the effectiveness individual non-steroidal anti-inflam m atory drugs: results of of physical m odalities am ong patients with low back pain a collaborative m eta-analysis. A randomised controlled trial of transcutaneous electrical nerve Indahl A, Velund L, Reikeraas O (1995). Prognostic factors for return Hernandez-Reif M, Field T, Krasnegor J, Theakston H (2001). M agnetic resonance imaging of the is not automatic after resolution of acute first episode low back lumbar spine in people without back pain. Evaluation and management of occupational low active as a single treatment for low back pain and sciatica. On the distribution of pain arising from deep a screening tool for return to work in patients with acute low back somatic structures with charts of segmental pain areas. A double-blind placebo Kendrick D, Fielding K, Bentley E, Kerslake R, M iller P, Pringle M controlled study of piroxicam in the management of acute muscu (2001). European Journal of Rheumatology and with low back pain: randomised controlled trial. Can custom-made biome Kerry S, H ilton S, D undas D, Rink E, O akeshott P (2002). A randomised controlled intervention trial of 146 mili observational study in primary care. Kilpikoski S, Airaksinene O, Kankaapaa M, Leminem P, Videman T, Larsson U, Choler U, Lidstrom A et al. Double blind parallel group investigation in general of m agnetic resonance im aging: the Australian experience. Incidence of foot rotation, pelvic crest unleveling, back pain: a clinical trial to assess efficacy and prevent relapse. A randomised of non-steroidal anti-inflammatory drugs for low back pain: prospective clinical study with a behavioural therapy approach. The effect of graded activity on patients steroid injections for low back pain and sciatica: an updated system with subacute low back pain: a randomised prospective clinical atic review of randomised clinical trials. A prospective study of the effects of sexual or physical European Journal of Physical M edicine and Rehabilitation, 4: abuse on back pain. Controlled A randomized trial of a cognitive-behavioiur intervention and two trial of balneotherapy in treatment of low back pain. Effectiveness and the effects of an early intervention on acute musculoskeletal pain cost-effectiveness of neuroreflexotherapy for subacute and chronic problems. Preventive interventions for back M cIntosh G, Frank J, H ogg-Johnson S, H all H, Bom bardier C and neck pain problems: what is the evidence Low back pain prognosis: structured review of the litera Little P, Roberts L, Blowers H, Garwood J, Cantrell T, Langridge J, ture. A randomized controlled facto resonance imaging in low back pain instead of plain radiographs: rial trial of a self-management booklet and doctor advice to take experience with first 1000 cases. Loisel P, Gosselin L, Durand P, Lemaire J, Poitras S, Abenhaim L Descriptions of Chronic Pain Syndromes and Definitions of Pain (2001). Discriminative and predictive validity assessment of the M ilgrom C, Finestone A, Lev B, W iener M, Florman T (1993). Journal of Occupational of osteopathic manipulation in non-specific low back pain. Randomised controlled trial of exercise in clinical manual lumbar spine examination. Physical Therapy, 74: for low back pain: clinical outcomes, costs and preferences. Prescription of activity for M ohseni-Bandpei M A, Stephenson R, Richardson B (1998). International Journal of Rehabilitation Research, 24: M ooney V, Robertson J (1976). Treatment of mild to Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V, Hernberg moderate pain of acute soft tissue injury: diflunisal vs acetamino S (1995). Back pain and sciatica: controlled trials of manipu lation, traction, sclerosant and epidural injections. Variance in the measurement of sagittal lumbar spine range of motion among examiners, subjects, and instruments. Commonwealth of Australia: M cGuirk B, King W, Govind J, Lowry J, Bogduk N (2001). Psychosocial differences gluteus medius: a prospective study in non-specific low back pain in high risk versus low risk acute low back pain patients. Scientific Review of Alternative W illiams and M cKenzie protocols in back pain management. M anipulation in treatment of low back pain: Onorato A, Rosin C, Schierano S, Zampa A (2001). A critical review of the evidence for a pain-spasm pain cycle in spinal disorders. Acute and chronic effects Legrand E, Valat J, Blotman F, M eadeb J, Rolland D, Hary S, of pneumatic lumbar support on muscular strength, flexibility and Duplan B, Feldman J, Bourgeois P (2002). Randomized controlled trial of back Chiropractic adjustments: results of a controlled clinical trial in school with and without peer support.

The consequences are staggering: of the workers presenting an acute episode of low back pain connected with occupational accidents 72% were absent from work acne dark spot remover purchase cheap cleocin, and of this total figure 8 skin care products online order generic cleocin,2% were absent for three months or more acne conglobata cheap cleocin 150 mg without prescription. A total of 62 skin care products for rosacea 150mg cleocin overnight delivery,4% and 95% of workers are temporarily or permanently disabled respectively acne gel 03 purchase genuine cleocin line. The sectors most affected are the timber industry skin care jakarta barat buy cleocin 150 mg with amex, the construction industry and the metalworking industry. The construction and health/social sectors have the highest figures for permanent disability. Furthermore, the data reveal the geographic disparities, as the number of permanent partial disabilities is higher in Wallonia than in Flanders. Overexertion is the most frequently declared cause of accidents, while falling is the most frequent cause of injuries leading to permanent disability. The primary role of these medical practitioners must be to inform workers: backache is a frequent disorder; certain posts and certain positions involve more risks; acute back pain often resolves itself spontaneously (90% within six weeks); it is important to keep active in spite of the pain. Although the physical constraints involved in work play a role at an etiological level, psychosocial factors (such as stress, anxiety or dissatisfaction with work) affect the seriousness of the ongoing disorder and the likelihood of chronicity. The second role of these physicians is to promote prevention strategies aimed at preventing chronicity. The literature gives evidence in favour of back schools (in the workplace, including an exercise component) and multidimensional or multidisciplinary interventions (see above). A multidisciplinary approach based on a combination of a program of exercises and psychological and/or social care is particularly beneficial. Occupational physicians and advisory physicians therefore bear some responsibility for the care of workers disabled by low back pain, along with family doctors. The physician should ideally reduce the period of disability by advising the patient to pursue his normal activities. In the event of recurrent or constant lumbar pain, an analysis of the "yellow flags" will identify workers at risk of chronicity (psychological problems or depression). In this regard, a return to work program backed up by cooperation between the curative sector and the occupational medicine sector is beneficial as it encourages the worker to return to work and reduces the number of days lost. The first basic step in this care program is to maintain normal activities as much as possible. Furthermore, exercise programs play a positive role in re-education and multidisciplinary care is beneficial. Many noninvasive treatments that are currently applied are based on scanty evidence or do not work at all. Based on the existing studies, we cannot yet define precisely the efficacy or the potential side effects of many invasive techniques (injections). Due to a lack of data in Belgium, it is not possible to evaluate the extent of chronic low back pain with any accuracy. The available databases provided by occupational medical services and by the mutuality sector do not provide a means of systematically identifying these workers/patients or monitoring them in the care circuit. In addition, these databases do not yield any hypotheses on the geographic disparities that are observed. The evaluation of medical costs that we propose in this study is largely underestimated. A proper evaluation would require a data collection program geared specifically to the epidemiology and to the costs connected specifically with that particular pathology. Given that the indirect consequences of the pathology account for the bulk of the cost, occupational physicians and advisory physicians have a crucial role to play when it comes to helping workers get back to work as quickly as possible (in cooperation with the family doctor), bearing in mind that the data demonstrate that prolonged absence can lead to chronicity. In cases of chronic low back pain, it is crucial for the patient to get back to work as quickly as possible. Prescribing useless tests and applying inappropriate treatments maintains the chronicity of the backache and does the patient more harm than good. The respective tasks and responsibilities of the occupational physician and of the advisory physician must be redefined: their role in preventing chronicity must be strengthened, as the rapid reintegration of workers suffering from chronic low back pain is a priority for the authorities. From a policy standpoint, they do not provide a means of properly monitoring the consequences of a societal problem such as low back pain. A first part analyses the evidence-based literature on the diagnosis and treatment. The second part analyses the available databases in Belgium in order to assess the size of this public health problem and its related costs. The literature review in part I summarizes the evidence based literature sources currently available. It aims to serve as a clinical practice guideline to help primary care and specialized practitioners involved with chronic low back pain. This part mainly searched for the available evidence in guidelines, meta-analyses and systematic reviews. Hence, it should not be considered as an exhaustive list of all available evidence on all diagnostic and therapeutic procedures. No specific search has been conducted on the safety aspects of the procedures and only the most common ones that have been described in the selected references are summarized in this report. Those literature reviews allow appraising to what extent Belgian medical care for chronic low back pain is based on an evidence-based approach. These decisions can relate to multiple facets as for example the availability of databases, their content, the quality and organisation of care. Nielens Important preliminary remarks this report focuses on evaluation and treatment of patients with non-specific chronic low back pain (lasting for more than three months) with or without nerve root/radicular pain. Less common origins of chronic low back pain such as spinal stenosis, spondylolisthesis, spinal tumor or infection are not specifically addressed in this report. Chronic low back pain is a symptom: the different possible etiologies are voluntary not cited. Numerous other references have been consulted and added in this systematic literature search, in particular if they were more recent or addressed specific techniques. Recommendations based on the available evidence are also be included in this report. The detailed searching methodology and references selection after critical appraisal are described in the appendices. Likewise, it is generally admitted that a thorough physical examination including a well-conducted history-taking should also be repeated in the chronic stage. For instance, pain localization must be taken into account, as it often constitutes the first clinical information that may lead to suspect radicular pain (see next section on red flags). Evidence Some tools have been developed to assess pain characteristics (Visual Analogic Scale, Dallas). Koes added the following red flags suggesting radicular pain due to nerve root 6 compression: x Unilateral leg pain > low back pain, x Pain radiating to foot or toes, x Numbness and parenthesis of same distribution, x Passive Straight Leg Raise test (see below) inducing more leg pain than back pain, x Localized neurological deficit (limited to one nerve root). More over, red flags are not always associated with any specific pathology, but merely indicate a higher probability of an underlying condition that may require further investigation. Psychological evaluation may be performed using specific tools (Hamilton scale, Beck Depression Inventory). Likewise, some signs and behaviours (the so-called Waddell non-organic signs such as tenderness, simulation, distraction, regional weakness or sensory abnormality, over reaction) may suggest the presence of psychological distress, which may be associated with an elevated risk of pain perpetuation. Psychological evaluation may identify psychological distress that may be related to pain perpetuation. The so-called Waddell non-organic signs do not correlate with any psychological distress, nor do they discriminate organic from non-organic problems. Such tools may be helpful in daily practice but their utility and validity have not been demonstrated. They may be explicable by an underlying organic condition and are associated with poorer treatment outcome, with greater pain levels and are not associated with secondary gain. The rationale is that chronic pain often leads to physical inactivity, physical capacity reduction (so-called physical deconditioning), work loss and ultimately may greatly alter quality of life of the patients. Our additional search identified two systematic reviews on functional status assessment 13 14;. Several versions of the 2 most commonly used questionnaires, the Roland-Morris Questionnaire (6 versions) and the Oswestry Disability Index (4 versions), have been identified. Ten questionnaires were considered as well-validated and recommended without further validation studies: the original 12 version of the Roland-Morris Disability Questionnaire, the Oswestry Disability Index 15 16 1. Noteworthy, the version of the 24 Dallas Pain Questionnaire by Lawlis had been evaluated as insufficiently validated by 13 Grotle et al. However, the validity and utility of tools specifically designed to assess pain characteristics have not been established, x Red flags are traditionally used to rule out any specific underlying medical condition in patients with acute low back pain. Some radicular pain-specific red flags have been also proposed to identify nerve root pain during history-taking. Some specific tools are traditionally used in that context although their utility has not been established yet. Numerous specific tools have been developed therefore but only a limited number of them may be considered as sufficiently valid. This section addresses the relevant findings obtainable through physical examination. It may help to reassure the patient and act in this way as a therapeutic intervention by addressing for instance misbelieves that may be identified and corrected. Preferably, the information should be given consecutively during the clinical examination and when evaluating imaging. Likewise, concepts such as vertebral instability, disc displacement, isthmic fracture (spondylolisthesis), hyper mobility, that refer to mechanical disorders not yet clearly defined nor verified by experimental or clinical studies, should thus be avoided. In this model, the message is focused on patients beliefs and attitudes and stresses the advantage of remaining active and avoiding best rest, combining with reassurance that there is likely nothing seriously wrong. Traditional information on anatomy, ergonomics, and back specific exercises is markedly reduced. Nevertheless, information delivery alone is not 25 sufficient to prevent absenteeism and reduce health care costs. Traditionally, physical examination aims at assessing the level of pain, the mobility of the lumbar spine, at identifying the presence of nerve root/radicular pain, at ruling out any neurological deficit or clinical red flag and at identifying the pain generator as precisely as possible. Physical examination aims at gathering the useful information needed by the clinician to elaborate an adapted treatment strategy. It identified two trials with unknown methodological quality that aim at establishing a physical examination total score. This neurological examination should be performed on a regular basis during follow-up. Traditionally, it encompasses the osteo-tendinous reflexes testing, motor and sensory testing and the Lasegue test. An important methodological weakness is that disc herniation was selected as the outcome variable. The use of the Lasegue test as a valid and reliable test to identify radicular pain due to nerve root compression at the lumbar level (L4-L5 and L5-S1) is not supported by the quality of evidence available in the selected references. Such tests consist in the assessment of symmetry of bony landmarks (posterior superior iliac spines for instance), evaluation of regional segmental motions, Para spinal soft tissue abnormalities, tenderness during active trunk movements and palpation. The validity and reliability of such pre 2 manipulative tests remain vastly debated. Our additional 34 search identified one more systematic review by van Trijffel et al. However, this review was excluded from this analysis: most included studies did not fulfill the criteria for external and internal validity. Regional range of motion is more reliable than segmental range of motion (level A). Intra-examiner reliability is better than inter-rater reliability for all palpatory tests (level A). As palpatory diagnostic tests have not been established as reliable and valid, the presence of the manipulable lesion remains hypothetical (level B). For instance, the presence of red flag such as loss of weight, general unwellness, should lead to test biology. Evidence 2 Cost B13 related one systematic review of 36 studies that evaluated the accuracy of history-taking, physical examination and erythrocytes sedimentation in diagnosing low 35 back pain in general practice. The review found that few of the studied signs and symptoms seemed to provide valuable diagnosis. The combined history and the erythrocytes sedimentation rate had relatively high diagnostic accuracy in vertebral 2 cancer. Some imaging techniques (fluoroscopic guidance) may also be used as an aid in the context of invasive therapeutic procedures: those techniques will be addressed in the following sections. The Recommandations du Consilium Radiologicum Belge (currently being revised) are based on a European experts consensus (Radioprotection 118: recommandations en matiere de prescription de limagerie medicale de la Commission Europeenne). Moreover, conventional radiography is not a good screening procedure for the suspicion of compression fractures, cancer and metastases, as its sensitivity is too low. Degeneration, defined by the presence of disc space narrowing, osteophytes, and sclerosis, turned out to be associated with non specific low back pain, but odds ratio were low, ranging from 1. Advanced imaging should be reserved for patients who are being considered for surgery or those in whom systemic disease is strongly suspected. Belgian Consilium Radiologicum recommendations recall that degenerative changes that can be seen on plain lumbosacral films are frequent and not specific. Those recommendations also state that conventional radiography should only be systematically obtained in patients below the age of 20 and older than 55 years old. Discography has been proposed as a diagnostic tool, as it allows imaging degenerative discs and as it may also elicit pain during intra-discal injection, which is generally interpreted as the disc acting as a pain generator (so-called discogenic pain). There is moderate-quality evidence that discography is not a reliable procedure for the diagnosis of common chronic low back pain. One systematic review on invasive techniques concluded that there are inherent limitations in the accuracy of all diagnostic tests, 7 including discography. The review of Carragee and Hannibal reported that 73% and 69% of discs with a high intensity zone were positive on discography in symptomatic and asymptomatic individuals respectively.

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