The management of acute low back pain in adults : a guide for the primary care physician, Part II

When a patient presents with acute low back pain (LBP), any red flag warnings of serious disease should first be excluded. Yellow and blue flag warnings of psychological factors should be noted. A psychological opinion of patients with substantial psychological distress could be sought. Advice may be offered on the benign nature of non-specific LBP. The person should be encouraged to be physically active and to continue with normal activities as far as possible. A structured exercise programme, that includes aerobic activity, movement instruction, muscle strengthening, postural control and stretching, should be devised. A combined exercise and psychological treatment programme that includes a cognitive behavioural approach can be considered in patients with significant disability or substantial psychological distress. A course of acupuncture may also be added. Manual therapy, including spinal manipulation, could be considered. Paracetamol should be the first medication option. If this is inadequate, a non-steroidal anti-inflammatory drug or weak opioid, or both, can be added. Individual risks for side-effects and the patient's preference should be taken into account. Strong opioids should be considered in patients in severe pain, but for short-term use only. Antidepressants and gabapentine or pregabolin can be considered when there is a neurogenic component of the pain. Consider obtaining a surgical opinion on patients who have completed an optimal package of care and who still have persistent severe non-specific LBP. Progressive neurological fallout requires a surgical opinion.http://www.safpj.co.zaam201

The management of acute low back pain in adults : a guide for the primary care physician

To diagnose patients with acute low back pain (LBP), a focused physical examination needs to be conducted and a detailed history obtained. The patient should then be placed into one of three broad categories, namely nonspecific LBP, pain associated with radiculopathy or spinal stenosis, or back pain potentially associated with serious organic disease. The history should include an assessment of psychosocial risk factors that predict delayed healing and progression to chronic pain. Routine imaging is not required within the first three weeks of nonspecific LBP. Imaging should be performed for patients with severe or progressive neurological deficits, or when serious underlying pathology is suspected, based on the history and the physical examination. Patients should be advised of the benign course of nonspecific LBP and that over 90% of patients recover within a few weeks. Occasionally, the pain may last for a few months. Patients should be advised to remain active and should be provided with information on effective self-care options. Usually, first-line medication options are paracetamol or nonsteroidal anti-inflammatory drugs. To treat severe pain, a stronger drug approach that includes opioids may be considered, but only for a short time. Other therapies to be taken into account are spinal manipulation, intensive interdisciplinary rehabilitation, exercise therapy, massage therapy, or progressive relaxation. Spinal surgery is an option in the event of progressive neurological fallout, severe persistent pain of more than three months and patient unresponsiveness to recommended treatment, or if there is acute cauda equina syndrome.http://www.safpj.co.z

Chikungunya virus infection - A retrospective study of 107 cases

A retrospective study of 107 cases of serologically proven chikungunya (CHIK) virus infection was undertaken. All respondents had contracted the disease at least 3 years previously; 87,9% had fully recovered, 3,7% experienced only occasional stiffness or mild discomfort, 2,8% had persistent residual joint stiffness but no pain, while 5,6% had persistent joint pain and stiffness and frequent effusions. Synovial fluid from 3 patients was analysed. All the patients with persistent joint pain and, stiffness had very high antibody titres against CHIK virus

Visual function and long-term chloroquine treatment

Ophthalmic examinations and selected tests of visual function were perfonned on 64 patients with rheumatoid arthritis who had received daily doses of 200 mg chloroquine sulphate for periods ranging from 3 to 11 months. Visual fields were determined by Humphrey automated perimetry and Amsler grids and a further battery of four tests of macular function (visual evoked potentials, critical flicker fusion threshold, Cambridge contrast sensitivity and the macular dazzle test) were administered. No case of retinal pigmentary abnormalities plus visual loss was found, but 2 patients were advised to cease chloroquine therapy on the basis of funduscopic findings. A small group of patients with relatively poor scores on one or more tests had normal visual fields and ophthalmic findings. There were no significant partial correlations between test results and the cumulative dose of chloroquine. These results support the opinion that currently recommended doses of chloroquine pose a minimal risk of retinal toxicity