In episode 96, Mike and James continue on with the discussion around evidence for low back pain treatment. They discuss things like traction, heat, exercise and bedrest and then finally get into drugs – not personally of course, at least not much, but into the discussion  of which ones work and by how much. We conclude with an expert discussion of experts and suggest that experts are not necessarily experts when it comes to evidence.

Show notes

1) Traction

Cochrane 2007;2:CD003010

2) Heat and ice

Cochrane 2006;1:CD004750

3) Lumbar support

Cochrane 2008;2:CD001823

4) Transcutaneous electrical nerve stimulation

Cochrane 2008;4:CD003008

5) Exercise

Cochrane 2005;3:CD000335

6) Bedrest

Cochrane 2004;4:CD001254

7) Yoga and transcutaneous electrical stimulation

Ann Intern Med 2007;147:492-504

8) Acetaminophen

Eur Spine J 2008;17:1423-30

9) NSAIDs

Cochrane 2008;1:CD000396

10) Opioids

Cochrane 2007; 3:CD004959

Ann Intern Med 2007;146:116-27

11) Muscle relaxants

Ann Intern Med 2007;147:505-14

12) Benzodiazepines

Ann Intern Med 2007;147:505-14

13) Gabapentin

N Engl J Med 2009;361:1963-71

14) GPs with special interest in back pain tend to not know the evidence

Spine 2009;34:1218–26

In episode 95, Mike and James look at the issue of non-specific low back pain and deal with concepts around diagnosis and we find out that x-rays aren’t that useful but MRI’s in the right patient population can play a role. We then start to look at the available evidence for treatment (massage, acupuncture, spinal manipulation) and at the end Mike tries to give James a two-handed neck massage and in retaliation James does acupuncture on Mike with a harpoon.

Show notes

1) Guidelines on back pain

TOP Back Guideline

American College Guideline

Ann Intern Med 2007; 147:478-91

Ann Intern Med 2007;147:505-14 (meds)

Ann Intern Med 2007;147:492-504 (non-meds)

Summary of guidelines

BMJ 2006; 332:1430-4

Evidence-based Series (non-medication) on Back Pain

Spine 2009, 34:1066-77 and 1078-93 and 1094-1109

2) Imaging – x-ray, CT and MRI

BMJ 2001;322:400-5

Lancet 2009;373:463-72

JAMA 2003;289:2810–8

MRI likelihood ratios

Ann Intern Med 2002;137:586-97

BMJ 2006;332:1430-4

Ann Intern Med 2007;147:478-91

4) Massage

Cochrane 2008; 4: CD001929

5) Acupuncture

Ann Intern Med. 2005 Apr 19;142(8):651-63

Cochrane 2005; 1:CD001351

6) Spinal manipulation

Cochrane 2004; 1: CD000447

In episode 94, we get to yet more listener questions and provide vague, yet deep and thoughtful answers. We talk about the use of benzodiazepines, serotonin syndrome, buspirone, ‘urgent’ hypertension and pontificate even more on low doses. Mike and James realise that while low is often a good way to start, all their podcasts to date start of with high expectations yet end with not much more of an effect than placebo.

Show notes

1) Effects of Treatment on Morbidity in Hypertension – Results in Patients With Diastolic Blood Pressures Averaging 115 Through 129 mm Hg

JAMA 1967;202:1028-34

2) Effect of Propranolol in Mild Hypertension

Lancet 1966;288:1148-50

3) Clopidogrel

See episode 90

In episode 93, we once again get back to listener questions. We explore everything from haloperidol for nausea and vomiting, to statin dosing, ASA in diabetics, and finally Alzheimer's drugs. Towards the end, James and Mike realise that listener questions are too hard and they make up some easy ones of their own yet still struggle.
Show notes

In episode 92, we do a final session with our two family physician friends and colleagues, Mike K and Tina K. We start off with Tina discussing some satisfying evidence for the use of bupropion in women with low sexual desire which causes sexually related personal distress. In the second part Mike K in a slightly less satisfying way  looks at the recent evidence surrounding vascular surgery for a treatment of multiple sclerosis. To conclude this 3-part series we all stop talking, to the satisfaction of all our listeners.

Show notes

1) Bupropion for sex

BJU Int 2010 Feb 11. [Epub ahead of print]

2) Surgery for multiple sclerosis

J Neurol Sci 2009;282:21–7