BIOSOFT HELP FILES

1)      Lumbar Muscle Sprain – backache, worsen with spinal movements, worsen with maintained postures like prolonged sitting or squatting, may be preceded by an initiating trauma like lifting a heavy weight, unusual physical activities, Tx – Investigations determined by the presence of red flags, plain radiography only for fever, weight loss, past cancer, neurological deficits, drug abuse, elderly and trauma in the absence of improvement within 4-6 weeks, CT and MRI for detection of early infections and cancer, analgesics for pain, usually continuously rather than PRN basis, day to day activities within the limits of spinal pain, rapid return to normal activities, avoid exercises and physical therapy in acute phase, exercise program for chronic backache starts with stretching exercises, then strengthening exercises, finally stabilization exercises.  Stretching exercises are done for hip flexors, hamstring, hip internal and external rotators, lumbar extensors, leg lifts, trunk lifts, sit-ups, and lateral pull-downs.  Strengthening exercises are done for abdominal and gluteal muscles, and pelvic tilts.  Stabilization exercises are carried out by bridging exercises.  Abdominal muscles are strengthened by vertical leg crunch, long arm crunch, and reverse crunch.

2)      Lumbosacral Facet Syndrome – backache spreading to the buttocks and the posterior thigh, worsened by twisting, stretching, lateral bending, rest, and hyperextension, relieved by repeated motions, painful spinal movements,  lumbar extension, and rotation painful.

3)      Herniated Disc – Tx -  Exercises therapy includes neural mobilization exercises, cat and camel exercises and nerve flossing exercises, progressive leg weakness is an indication of spinal surgery (for instance toe weakness of 1 day becoming a foot drops in a few days’ time surgery is indicated)

4)      Myofascial pain syndrome - buttock pain posterior as in gluteus maximus MFPS, buttock pain posterior spreading to upper posterior thigh in gluteus medius MFPS, buttock pain spreading up the lumbar region in iliocostalis lumborum and longissimus thoracis MFPS, flank pain spreading to the posterior chest wall, down to iliac crest in iliocostalis thoracis MFPS, backache lumbar paraspinal area and anterior thigh pain upper 1/3rd in iliopsoas MFPS, sacral area pain, midline in multifidi and rotators MFPS, backache upper lumbar and low lumbar regions in multifidi MFPS, buttock pain spreading down to the posterior thigh in  piriformis buttock and lateral hip pain in quadratus lumborum MFPS, buttock pain, sacral pain spreading to posterior thigh in quadratus lumborum, glut maximus, levator ani and piriformis MFPS, area just below iliac crest in rectus abdominis lower end MFPS, upper buttock pain in soleus MFPS, sacral area pain spreading to the posterior thigh in sphnicter ani, levator ani, coccygeus, obturator internus ( SALACO complex) MFPS.  See notes under myofascial pain syndrome for diagnosis and treatment of myofascial pain syndrome.

5)      Spinal Stenosis – unilateral or bilateral leg pain with/without backache, Tx - Exercise therapy includes neural mobilization exercises, cat and camel exercises, and nerve flossing exercises.

6)      Osteoporotic compression fractures

7)      Spondylolisthesis

8)      Traumatic fractures

9)      Diskogenic low back pain

10)  Postural back pain – back pain with following postural defects at the spine – frontal view shoulders slanted, space between arms and sides unequal, hips slanted,  knee caps face sideways, side view head thrust forward, chin tilted up/down, shoulder not aligned with ears, low back hyperlordosis, Tx – Correct the factors maintaining the poor posture – obesity, weak muscles, high heeled shoes, tight muscles, decreased flexibility of the spine, poor work environment, poor sitting habits, poor standing habits, proper posture requires the strong set of posture muscles namely abdominal muscles, hip flexors, hip extensors, lateral trunk muscles, hip abductors, therefore exercise these muscles  regularly,

11)  Fibromyalgia

12)  Ischial bursitis - Buttock pain radiating down the posterior thigh, mimicking sciatica, prolonged sitting on hard surfaces, point tenderness over the ischial tuberosity

13)  Piriformis syndrome – unilateral pain in the hip region and low buttock spreading widely and down the sciatic distribution as well, and also to the external genitals, pain worsens with walking and squatting, bowel movement, sex, prolonged sitting, tenderness over the gluteal region, pain reproduction with flexion, adduction and internal rotation of the hip of the affected side, Lasegue sign positive (greater sciatic notch pain with extension of the knee when the hip I flexed to 90*), resisted abduction and external rotation of the thigh painful, passive internal rotation of the thigh when the leg is extended and the patient is supine – Mx – NSAIDs and piriformis exercises (See notes). 

1)      Younger than 20 yrs at the onset (discitis, congenital vertebral anomalies)

2)      Older than 55 yrs at the onset (Mechanical backache unlikely, tumors and cancer likely, compression fracture from osteomyelitis)

3)      Backache followed major trauma (fall from a height or RTA) to the spine

4)      Pain is constant and/or progressive and/or severe and/or lack of trauma (spinal pathology like infection, tumor inflammation or referred pain)

5)      Pain at the back of the chest

6)      P/H or current cancer (malignant backache)

7)      Using steroids now

8)      Alcohol or Using illegal drugs – IV drug use (increased incidence of osteomyelitis, trauma, fracture)

9)      HIV now

10)  Systemically unwell with fever, chronic infection like UTI, skin infections

11)  Loss of weight more than 5 kg or 10% of body weight in 3-6 months

12)  Difficulty in bending forwards

13)  Leg weakness, tingling or numbness

14)  Obvious spinal deformity

15)  Unexplained backache in a female with abdominal and/or VE mass (exclude ovarian Ca if not due to fibroids, GIT, or GUS masses)

16)  Unexplained backache in a male do a DRE and OSA to exclude prostate Ca

17)  Persistent back pain in a child or young person (FBC, BF)

18)  Unexplained backaches in a child with Down syndrome, neurofibromatosis (FBC, BF)

19)  Backache with evidence of hypotension  like collapse, sweatiness, pallor (? Leaking abdominal aortic aneurysm, hypertensive patient with abdominal aortic aneurysm)

20)  Very severe backache with no evidence of lumbar spine painful movements or limitation of movements – very severe backache with painless spinal movements  (? Leaking abdominal aortic aneurysm)

21)  Thoracic pain

22)  Pain radiating down both legs OR any disturbance of motor power (upgoing plantars, gait disturbances), bladder or bowel  function (loss of sphincter tone, altered S4 sensation) (immediate referral to hospital to exclude cauda equina syndrome)

23)  Recent onset urine incontinence, fecal incontinence, perineal paresthesiae, leg weakness, sensory level (cauda equina syndrome)

24)  Gradual onset before 40 yrs, marked morning stiffness, persistent limitation of spinal movement in all directions, peripheral joint involvement (arthritis type of backache with spondylitis)

25)  Pain at rest (rules out mechanical cause for backache)

26)  Bilateral sciatica OR bladder or bowel dysfunction (cauda equina)

27)  Any 1 of the following diseases – alcoholism, anorexia nervosa, breast cancer, celiac disease, diabetes, immobility and bed rest, IBD, lactose intolerance, osteoarthritis, rheumatoid arthritis, SLE – these are risk factors for osteoporosis

28)  Any bladder OR gait dysfunction with backache excludes cauda equine syndrome which is a neurosurgical emergency

29)  Past OR Current – cancer, TB, HIV, IV drug abuse, Osteoporosis,

30)  Night pain (Infections and tumors more likely and mechanical causes lessen nocte)

31)  Bilateral paresthesiae in hands and/or feet

32)  Blood in sputum.

33)  Bilateral or unilateral radiculopathy

34)  Numbness and paresthesiae in the perineal region

35)  Writhing pain

36)  Nonhealing sores and wounds

37)  Upper or lower limb weakness

38)  Progressive neurological deficits

39)  Gait disturbance, hyperreflexia, planters upgoing, hyperactive abdominal reflexes (myelopathy)

40)  Pulsatile abdominal mass (Abdominal aneurysm)

41)  Unexplained neurological deficits ()

42)  Recent bowel or bladder changes (cauda equine, compression or other myelopathy)

43)  Unexplained neurological deficits (Gullian Barre, stroke, head injury)

44)  Age > 50 And long-term corticosteroid use (spinal compression fracture)

45)  Failure of conservative reatment And unexplained weight loss And Cancer  history And Age geater than 50 (virtually 100% sensitive to spinal maligancy)

46)  Sudden onset change of bowel or bladder control (retention on incontinence) (Cauda equina syndrome – requires emergent evaluation and surgery)

47)  Sudden onset loss of bowel or bladder control (retention on incontinence) (Cauda equine syndroma – requires emergent evaluation and surgery)

48)  Unexplained change of bowel or bladder control (retention on incontinence) (Cauda equina syndrome – requires emergent evaluation and surgery)

49)  Unexplained loss of bowel or bladder control (retention on incontinence) (Cauda equina syndrome – requires emergent evaluation and surgery)

50)  Sudden onset or otherwise unexplained bilateral leg weakness (Cauda equine syndrome)

51)  Saddle area numbness (Cauda equina syndrome)

52)  Extremely severe backache in an elederly person without any spinal signs (exclude abdominal aortic aneurysm)

(NCC-PC Referral Guidelines for Suspected Cancer  in Adults and Children)

(FitzSimmons and Wardrope 2005)

(NCC-PC Referral Guidelines for Suspected Cancer  in Adults and Children)

(Deyo and Weinstein 2001)

(Chang and Talbot-Stern 2006)

(Sizer, Brismee and Cook 2007)

(Shah and Wang 2006)

List :

Disruptive behavior problems like aggression, fears, lying and stealing, poor self-image, shyness, sibling rivalry, temper tantrums, School phobia, anxiety, depression, inattention, hyperactivity, negativism, aggression, destruction, deceitfulness, rule violations, autistic spectrum symptoms

Bullies others, threatens others, intimidates others, initiates physical fights, uses weapons, is cruel to animals, cruel to people, steals while confronting, forces sex,

Fears of objects, thunderstorms, lightning, dark, persons, peers, school, performance, danger for self, danger for loved ones, sleeping alone, being alone, separate from parents, 

Lying to get favours, lying to get goods, lying to avoid obligations, cheating, manipulations, breaking into houses

Withdrawal, crying, lack of enjoyment, avoidance of enjoyment, sadness, unable to enjoy happy things, psychomotor agitation, retardation

Fire setting, property destruction

A set of diseases characterized by poor social relationships due to aggression, lying, defiance, irritability, blaming others, cruelty, stealing, destructiveness, and rage.  Common causes include oppositional defiant disorder and more severe conduct disorder.