Baillière's clinical rheumatology
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A wide variety of mechanical and non-mechanical disorders are associated with the clinical symptom of low back pain. Mechanical disorders are the cause of the vast majority of low back pain. Despite this frequency, the specific cause of mechanical low back pain can not be elucidated in spite of extensive diagnostic evaluation in a majority of individuals. ⋯ The diagnostic process is more successful in identifying systemic disorders as the specific cause of low back pain. Non-surgical management is effective therapy with most patients with mechanical disorders of any form. Systemic illnesses require interventions directed specifically at healing the affected organ system.
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The main challenge of surgery in the treatment of low back pain lies with the poor knowledge of the aetio-pathogenesis of this symptom. Surgical treatment requires the precise diagnosis of a surgically curable lesion. In low back disorders this research of a precise source of nociception remains elusive even in the presence of radiological abnormalities. ⋯ However, there is a wide choice of attitudes, techniques and procedures for each of those indications and numerous conflicting result reports have been published. This chapter will try to present the best available consensus regarding the indications and results of different surgical procedures in spinal disorders. Most of all, physicians should bear in mind that, in spine surgery perhaps more than in other fields, unreasonable patient (and surgeon) expectations will most likely lead to poor outcomes.
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Baillieres Clin Rheumatol · Nov 1995
ReviewPsycho-educational interventions in the treatment of arthritis.
Patient education has a long history as an integral part of clinical practice; however, controlled clinical trials of psycho-educational interventions for the rheumatic disorders emerged in significant numbers over the last 15 to 20 years. In this chapter, the efficacy of these interventions was reviewed in 34 reports (54 separate treatment arms) published in the last 10 years. Psycho-educational interventions included both traditional educational or teaching activities and psychological interventions. ⋯ Utilization of health care services may be reduced following educational interventions. Although the overall improvement is small, it is probably of the order of that seen with therapy with NSAIDs and is independent of medical treatment. Psycho-educational interventions are a useful additional modality in the management of rheumatic diseases and may improve treatment effects and patient quality of life.
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Classification of back pain is a difficult task. Traditional schemes have focused on the small percentage of cases which have specific causes. Structural anomalies observed on X-ray examination explain only a small proportion of back pain cases, and the emphasis placed on these in the traditional schemes is, as Anderson put it, the tail wagging the dog (Anderson, 1977). ⋯ More pragmatic approaches start with the separation of the serious from the less serious, and the distinction between spinal pain and pain arising from outside the spine. The classification of the large majority of back pain cases which are 'non-specific' is best approached by grading the severity of the clinical and psychological features of back pain and their disabling consequences. Such grading schemes also provide the most appropriate outcome measures for clinical and epidemiological back pain research.
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Systemic lupus erythematosus (SLE) is the most common of the connective tissue disorders and can involve virtually any organ in the body. It is associated with pleuropulmonary manifestations in well over 50% of cases. Pleuritis with or without pleural effusion is the most common manifestation and can be particularly troublesome to manage but is rarely life-threatening. ⋯ Several drugs can produce a clinical syndrome that has many of the clinical and immunological features of SLE. Pleuritis may be seen in up to half of these cases of drug induced SLE. The development of SLE and conditions such as sarcoidosis or asbestosis in the same patient may represent a simple coincidence but there is some evidence for a closer association between these disorders.