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II.  INITIAL CARE - Assurance & Comfort to cope with Back Problem Episode and Activity to prevent Persistent Symptom Disability. 
 
Initial care is to help the patient cope with symptoms and accompanying fear that can lead to the debilitation of inactivity and job jeopardy.  Serious problems demand urgent referral and once adequately addressed, the patient can re-enter the activity paradigm.  The point of re-entry depends upon initial and delay related subsequent debilitation for work-up or treatment in a different paradigm. If reduced activity is prolonged, conditioning is usually needed to overcome the debilitating impact. The patient usually can enter the activity paradigm at initial care point if less than a few weeks have lapsed.     
 
 
1. Assurance about Expectations -"No hint of anything serious." 
   "Modern medicine is pretty good at finding serious conditions and we have no hint of anything bad causing your symptoms. Symptoms usually resolve in the next few weeks.  If you are in the slowest 10% to recover and not improving we will address special studies. We only do so to address serious problems as they can be specifically diagnosed and treated.  We expect to see age related “degenerative” changes on any imaging tests that alone are not the culprit.  Reality No Nobel Prize explains the cause of back problems that temporarily limit about 1/3 of us by age 30, 3/4 of us by age 40 and virtually all of us by age 50. We have addressed and found no hints of any serious conditions.  That is good news.  When we can't explain the exact cause the outcome is better and we usually can avoid spring training needed to rebuild comfortable activity tolerance through conditioning helping you keep your activity as normal as possible.  We now intend to help you feel more comfortable without slowing your progress." The great importance of convincing the patient of these points have been elucidated well by Burton et al., '99Pincus et al.`'06 to overcome "fear and avoidance."  (See Patient Discusson Handout I
 
The activity paradigm is therapeutic or it can further elucidates non-physical issues sometimes evinced by the patient's response to the assurance of "nothing serious" and suggestions "to maintain as normal as possible" activity to avoid disability.  After  "Red Flags" are eliminated, address both of these major issues in the activity paradigm.  First, appropriately display your relief that "nothing serious" was detected to combat the patient's fear of a serious physical problem.  If successful, you will be rewarded with a patient's willingness to return to reasonably normal activity.  After offering help with comfort, address the importance of keeping daily activity as normal as possible to avoid the need for "spring training" to regain comfortable daily activity tolerance.  Should the patient refuse reasonable activity, e.g., demand more than one week of limited duty and recommended alternative activity to maintain some endurance — quickly get some help!    
 
Get another opinion, as soon as possible, from a colleague or coerce a quick consult from a specialist within the first week.  Make your consultant's job easy.  Explain that you need ONLY know if there is a SERIOUS PROBLEM so that if not you can further assure the patient and continue your intended care.  Make it clear that there is no need for the consultant to takeover the care or be bothered with limitations or treatment.  Ask only for a quick opinion about anything serious to either alleviate patient fears or detect evidence of something other than routine back pain or sciatica.   
 
2. Comfort help 
a. Clinical Comfort Help – The emphasis is on maintaining normal activity. 
       "We have many options to help with comfort but nothing totally wipes out the pain and lets you go about your business as usual.  Thus, we will recommend the best combination that allow you to most comfortably stay as active as possible and avoid debilitation (Remember: It usually takes twice as long to regain conditioning than it does to lose it). This minimizes how much work you would have to do later to have a similar activity tolerance. Most medication and techniques only takes the edge off the pain.  We have all heard of darfa-cet, perga-cet, lory-cet, rocksa-cet and crapa-cet.  As you surely have noticed if a company has a medication that doesn’t work that well they add the —acet, then have a product people will buy. The -cet is Acetaminophen - Tylenol.  It blocks the pain highway at a different place than other medications, thus, works well in combination.  We try Safe-acet.  The worst part of an episode lasts up to 5 days, but that length of time is rare.  That is the longest you might need intense help with comfort.  Most often your medication will allow you to continue with most of your normal activities.  Try to avoid medication like opioids or muscle relaxants that might cloud your mind or disrupt your sleep anymore than necessary."  Passive modalities should be avoided whenever possible.  
 
Without a hint of kidney and/or liver dysfunction, or the mitigating factor of advanced age, a combination of  Acetaminophen and NSAIDs is adequate and usually are as effective as more dangerous, less well tolerated medications claiming to be more effective.  If patients feel manipulation has helped before, remind them that it only helps symptoms about as much as two Advil or Motrin and does not correct the problem without conditioning.  Newer Cox-2 inhibitors may add more to the choices that avoid mind-altering medications that interfere with activities, sleep and needed conditioning.  At present the new NSAIDs are under scrutiny for other safety issues.  
 
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Table Comfort Help 
 
 
Previously, we might have recommended staying away from work to help control symptoms but somewhat alarming data has forced us to realize the ineffectiveness and potential risks.  Now we help patients cope with symptoms so they can keep activity as normal as possible - to avoid prolonging symptoms, financial hardship and reducing the risk of increased mortality. 
 
CAUTION: AVOID RISKS - KEEP ACTIVITY NORMAL IF AT ALL POSSIBLE ! ! ! 
Activity Paradigm Confirmed. Assurance about recovery, help with comfort and real treatment is either preventative or overcoming reduced activity tolerance. Activity needs to be addressed for all patients - sooner is better by imploring patients to keep activity as normal as possible. Periods of inactivity then require longer uncomfortable physical conditioning to regain comfortable activity tolerance. Severe symptoms expectedly abate within a few days. Age, individual variation and specific pathology may vary how long lesser symptoms linger. Continuing normal activity does not to carry physical risks. Comparative studies find that continuing normal activity, especially work activity, does not prolong symptoms and avoids debilitation, avoids threats to livelihood due to reduced productivity, reduces your risks of an ineffective surgery and most important, avoids becoming chronically disabled with a 50% increase in mortality before age 65 years (Disabilities Mortality dangers). 
 
For a long time we had been too conservative according to the NEJM article by Malmivaara, et al.`95 (summarized in Table below). Studies indicate our greatest positive impact on patients is to assure them ASAP that there is no hint of anything serious (providing psychological relief and assurance) and to encourage patients to continue with normal activity “As Soon As Possible” to avoid the inactivity lulls that creates a need for spring training to again be comfortable providing (psychological and physical help). Where are the trials finding improved health, shorter duration of symptoms or improved physical ability with activity and work avoidance ?  
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Table Malmivaara: Note impact of Encouraging Return to activity to speed recovery & avoid debilitation  
 
The findings suggest, even with heavier work demands, the symptoms abated faster with assurance of nothing serious and recommending "continue normal activity as soon as possible" compared to two days of rest or attempting passive stretching (MacKenzie-like) correction techniques (also see Indahl, et al, '98, Burton, et al, 1999, Hagen, et al, 2000, Atcheson et al, 2001, Buchbinder et al, 2001, McGuirk et al, 2001, Pincus et al.`'06 and impact of activity in chronic patients). If limitations linger, offer further assurances (validated the lack of serious findings and reflect further questions toward "normal activity as soon as possible" to avoid a need for "spring training" or "boot camp" to again comfortably tolerate daily activity) with reassurance that further diagnostic studies will be considered in a few weeks if progress is slow. More importantly the above comparisons find early return to normal activity and work decreased long term disability, decreased number of elective surgeries with a reduced loss of productivity and livelihood. See Why Conditioning and be aware of mortality dangers of unemployment
 
Chemical irritation might best explain rapid recovery and lingering spine symptoms  
Even with sciatica pain resolution occurs in most cases much more rapidly than can be explained by any reduction in mechanical stimulation when due to herniated disk or spinal stenosis. Patients can have periods of time ranging from no to severe symptoms without any noticeable change in MRIs. Nerve roots seem to have a hyper-sensitivity that resolves allows the nerve root to be less sensitive to the same mechanical irritation.  Beyond the unexplainable rapid recovery beyond mechanical explanations, chemical issues may explain why regular activity whether walking, working jogging or even jumping rope seems not only to be safe but advantageous.  Though limited, we have evidence of a nerve hypersensitivity having a chemical relationship in studies of substance P vaso-active-intestinal peptide (Peng et al.`05) and Nerve growth factor noted to cause immuno-reactive activity of neuro-filaments (Onda et al.`05).  Potentially irritating polypeptides may help us further explain back pain and sciatica's often rapid natural recovery. In the spine a receding inflammation of the neural tissue would better explain most patients rapid recovery from even severe sciatica long before there can be any physical change in the mechanics of a large disk herniation or stenosis. Perhaps activity, regularly loading/unloading of the spine, expels potentially toxic substances from the disk keeping them deluted to levels below toxic concentrations. Conversely, inactivity might allow potentially neurotoxic substances in the aging disk to accumulate to levels that can inflame neural tissue resulting in less tolerance of physical pressure. This might explain sudden and severe exacerbations and recurrences after a period of relative inactivity. It may also explain the acute onset of back symptoms related to a mechanical incident that may squirt concentrated irritating substances through the cracked annulus of the aging disk making nerves more sensitive to pressure. 
 
The relationship between chemical inflammation and mechanical irritation may be analogous to pink eye. Here with severe blephoritis the eye inflammation hardly allows the eye lids to be touched but once the inflammation recedes, the most superficial extension of our central nervous system, the eye can be vigorously rubbed without discomfort. Perhaps a neuro-toxic substance buildup with inactivity can explain the recurrent back problems when resuming activity after an extended rest. How about explaining the protection provided by regular exercise needed to improve activity tolerance and the reduced recurrence of the severe episodes? Maybe activity regularly dilutes inflammatory substances before they can accumulate in concentrations sufficient to inflame the nerve tissue that is then susceptible to mechanical irritation. Chemical issues may also explain why the frequency, severity and duration of back problem episodes are no different despite an acute onset due to minor, or not so, minor trauma
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