Assignment: Decision Tree For Neurological And Musculoskeletal Disorders

Posted: February 15th, 2023

Assignment: Decision Tree For Neurological And Musculoskeletal Disorders
For your Assignment, your Instructor will assign you one of the decision tree interactive media pieces provided in the Resources. As you examine the patient case studies in this module’s Resources, consider how you might assess and treat patients presenting symptoms of neurological and musculoskeletal disorders.

To Prepare

· Review the interactive media piece assigned by your Instructor.

· Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.

· Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.

· You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.

Write a 2-page summary paper that addresses the following:

· Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.

· Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources. What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.

· Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.

Use and cite at least 4 sources for the assignment.

Please discuss each medication option listed in Decision Point 1. Why did you not choose the alternative options? What is the mechanism of action for each medication? What are first line FDA approved medications for the disease state?

Case study assigned: YOU PICK

Under Required Media, feel free to go through both interactive scenarios as many times as you would like. Pick ONE to write your paper on and discuss the points above.

http://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_10/index.html

http://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_07/index.html

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To Prepare
• Review the interactive media piece assigned by your Instructor.
• Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
• Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
• You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.
By Day 7 of Week 8-Decision Tree for Neurological and Musculoskeletal Disorders
Write a 1- to 2-page summary paper using this case: Complex Regional Pain Disorder : White male with HIP PAIN that addresses the following:
• 1.Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
• 2.Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
• 3. What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
• 4.Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.
You will submit this Assignment in Week 8.

BACKGROUND

This week, a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high.”

SUBJECTIVE

The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. Over the years, he has had numerous diagnostic tests done (x-rays, CT scans, and MRIs). He reports that about 4 years ago, it was discovered that the cartilage surrounding his right hip joint was 75% torn (from the 3 o’clock to 12 o’clock position). He reports that none of the surgeons he saw would operate because they felt him too young for a total hip replacement and believed that the tissue would repair with the passage of time. Since then, he reported development of a strange constellation of symptoms including cooling of the extremity (measured by electromyogram). He also reports that he experiences severe cramping of the extremity. He reports that one of the neurologists diagnosed him with complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD). However, the neurologist referred him back to his family doctor for treatment of this condition. He reports that his family doctor said “there is no such thing as RSD, it comes from depression” and this was what prompted the referral to psychiatry. He reports that one specialist he saw a few years ago suggested that he use a wheelchair, to which the client states “I said ‘no,’ there is no need for a wheelchair, I can beat this!”

The client reports that he used to be a machinist where he made “pretty good money.” He was engaged to be married, but his fiancé got “sick and tired of putting up with me and my pain, she thought I was just turning into a junkie.”

He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression. He states “you can’t let yourself get depressed… you can drive yourself crazy if you do. I’m not really sure what’s wrong with me, but I know I can beat it.”

During the client interview, the client states “oh! It’s happening, let me show you!” this prompts him to stand with the assistance of the corner of your desk, he pulls off his shoe and shows you his right leg. His leg is turning purple from the knee down, and his foot is clearly in a visible cramp as the toes are curled inward and his foot looks like it is folding in on itself. “It will last about a minute or two, then it will let up” he reports. Sure enough, after about two minutes, the color begins to return and the cramping in the foot/toes appears to be releasing. The client states “if there is anything you can do to help me with this pain, I would really appreciate it.” He does report that his family doctor has been giving him hydrocodone, but he states that he uses is “sparingly” because he does not like the side effects of feeling “sleepy” and constipation. He also reports that the medication makes him “loopy” and doesn’t really do anything for the pain.

MENTAL STATUS EXAM

The client is alert, oriented to person, place, time, and event. He is dressed appropriately for the weather and time of year. He makes good eye contact. Speech is clear, coherent, goal directed, and spontaneous. His self-reported mood is euthymic. Affect consistent to self-reported mood and content of conversation. He denies visual/auditory hallucinations. No overt delusional or paranoid thought processes appreciated. Judgment, insight, and reality contact are all intact. He denies suicidal/homicidal ideation, and is future oriented.

Diagnosis: Complex regional pain disorder (reflex sympathetic dystrophy)

Decision Point One

Amitriptyline 25 mg po QHS and titrate upward weekly by 25 mg to a max dose of 200 mg per day
RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Client comes to the office still using crutches. He states that the pain has improved but he is a bit groggy in the morning
Client’s pain level is currently a 6 out of 10. You question the client on what would be an acceptable pain level. He states, “I would rather have no pain but don’t think that is possible. I could live with a pain level of 3.” He states that his pain level normally hovers around a 9 out of 10 on most days of the week before the amitriptyline was started. You ask what makes the pain on a scale of 1-10 different when comparing a level of 9 to his current level of 6?” The client states, “I’m able to go to the bathroom or to the kitchen without using my crutches all the time. The achiness is less and my toes do not curl as often as they did before.” The client is also asked what would need to happen to get his pain from a current level of 6 to an acceptable level of 3. He states, “Well, that is kind of hard to answer. I guess I would like the achiness and throbbing in my right leg to not happen every day or at least not several times a day. I also could do without my toes curling in like they do. That really hurts.”
Client denies suicidal/homicidal ideation and is still future oriented

Decision Point Two

Continue current medication and increase dose to 125 mg at BEDTIME this week continuing towards the goal dose of 200 mg daily. Instruct the client to take the medication an hour earlier than normal starting tonight and call the office in 3 days to report how his function is in the morning
RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
The change in administration time seemed to help. The client states he is not as groggy in the morning and is able to start his day sooner than before
Client’s current pain level is a 4 out of 10. He states that he is now taking 125 mg of amitriptyline at bedtime.
Client’s has noticed that he is putting on a little weight. When asked, the client states that he has gained 5 pounds since he started taking this medication. He currently weighs in at 162 pounds. He is 5’ 7”. He states that his right leg doesn’t bother him nearly as much as it used to and his toes have only “cramped up” twice in the past month. He states that he is able to get around his apartment without his crutches and that he has even started seeing someone he met at the grocery store. The weight gain seems to bother him a lot and he is asking if there is a way to avoid it

Decision Point Three

Continue the current dose of Elavil of 125 mg per day, refer the client to a life coach who can counsel him on good dietary habits and exercise
Guidance to Student
At this point, the client is almost at his goal pain control and increased functionality. Weight gain is a common side effect with amitriptyline and should be a counseling point at the initiation of therapy. He has a small weight gain of 5 pounds in 8 weeks. A reduction in dose may have an effect on the weight gain but at a considerable cost of pain to the client. This would not be in the best interest of the client at this point. Amitriptyline has a side effect of cardiac arrhythmias. He is not experiencing this at this point. The drug, qsymia contains a product called phentermine which has a history of causing cardiac arrhythmias at higher doses. This product is also only approved for a client with obesity defined as a BMI greater than 30 kg/m2. Your client’s BMI is currently 25.5 kg/m2. He does not meet the definition of obesity but is considered overweight. His best course of action would be to continue the same dose of Elavil, counsel him on good dietary and exercise habits and connect him with a life coach who will help him with this problem in a more meaningful way than a 10 minute counseling session will be able to accomplish.

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Example

Case Study: A Caucasian Man with Hip Pain
NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology
Walden University

Case Study: A Caucasian Man with Hip Pain
“The patient is a 43-year-old white male presents at the office with a chief complaint of pain. He is assisted in his ambulation with a set of crutches. At the beginning of the clinical interview, the client reports that his family doctor sent him for psychiatric assessment because the doctor felt that the pain was “all in his head.” He further reports that his physician believes he is just making stuff up to get “narcotics to get high.” The client reports that his pain began about 7 years ago when he sustained a fall at work. He states that he landed on his right hip. He reports that he does get “down in the dumps” from time to time when he sees how his life has turned out, but emphatically denies depression.” (Laureate Education, 2016a).
Decision #1
My first decision was to start this patient on Amitriptyline 25mg po QHS and titrate upward weekly by 25g to a max dose of 200mg per day (Laureate Education, 2016a). This is a serotonin and norepinephrine/noradrenaline reuptake inhibitor that can be prescribed for neuropathic pain/chronic pain, fibromyalgia and for a wide variety of pain syndromes (Stahl, 2013). It boosts neurotransmitters serotonin and norepinephrine/noradrenaline and presumably desensitizes both serotonin 1A receptors and beta adrenergic receptors (Stahl, 2013). I did not choose Savella because it is a selective serotonin-norepinephrine reuptake inhibitor (SNRI), similar to some drugs used for the treatment of depression and other psychiatric disorders (Wolters Kluwer Clinical Drug Information, 2018b). It is also used for fibromyalgia but I did not feel it was appropriate to start this patient on a medication for psychiatric disorders when he has chronic pain in his hip. I did not choose Neurontin because it is commonly prescribed for neuropathic pain and posttherpetic neuralgia (Stahl, 2013). I did not think it would be an appropriate medication or effectively treat his pain. With this decision I was hoping to have a decrease in his pain.
When he returns in four weeks he is still using his crutches but states his pain has improved and he is groggy in the morning (Laureate Education, 2016a). He reports his pain level is 6 out of 10 and states his acceptable pain level would be a 3(Laureate Education, 2016a). He reports he is able to go the bathroom or to the kitchen without using his crutches all the time and the achiness is less and his toes to not curl as often as they did before (Laureate Education, 2016a). His level prior to starting the medication was 9 out of 10 so there was a slight decrease in his pain but he is still experiencing his toes curling (Laureate Education, 2016a).
Decision #2
My second decision was to continue the current medication and increase dose to 125mg at bedtime this week continuing towards the goal dose of 200mg daily (Laureate Education, 2016a). I would instruct him to take the medication an hour earlier than normal starting tonight and call the office in 3 days to report how his function is in the morning (Laureate Education, 2016a). I did not want to reduce the dose at bedtime and add Biofreeze roll-on because he did have a decrease of symptoms with his current dose and the Biofreeze is a temporary fix. I also chose not to reduce the dose and augment with Neurontin because it does not appear his pain is neurological and he did have a response to his current dose. By changing the medication time but continuing the increase in dose I was hoping for a decrease in his grogginess in the morning and a further decrease in his pain.
When he returns in four weeks the change in administration times seemed to help and he is not as groggy in the morning (Laureate Education, 2016a). He reports his current pain level is 4 out of 10 and he is taking 125mg at bedtime (Laureate Education, 2016a). He has noticed he has gained 5 pounds since he started taking the medication (Laureate Education, 2016a). He states his right leg doesn’t bother him as much as it used to and his toes have only cramped up twice in the past month (Laureate Education, 2016a). He is able to get around his apartment without his crutches but he is asking if there is a way to avoid the weight gain (Laureate Education, 2016a). A common side effect of amitriptyline is weight gain (Wolters Kluwer Clinical Drug Information, 2018a). The only difference between my decision and what I was hoping for was this patient’s 5lb weight gain.
Decision #3
My third decision was to continue the current dose of Elavil of 125mg per day and refer the patient to a life coach who can counsel him on good dietary habits and exercise (Laureate Education, 2016a). According to Laureate Education (2016a), the client is almost at his goal pain control and increased functionality and weight gain is a common side effect and should be a counseling point at the initiation of therapy. Reducing the dose may have an effect on the weight gain but it would be at a cost of pain to the client (Laureate Education, 2016a). I chose not to start this patient on Qysmia because it contains a product that has a history of causing cardiac arrhythmias and Amitriptyline has a side effect of cardiac arrhythmias (Laureate Education, 2016a). The best course of action would be to continue the same dose and counsel him on good dietary and exercise habits and connect him with a life coach (Laureate Education, 2016a). With this decision I was hoping for a therapeutic pain control and helping him to control the weight gain by referring him to a life coach.
Conclusion
When this patient presented it was important to listen to his concerns because other providers believed he was medication seeking. It was important to research each medication prior to prescribing it. I felt the best medication for this patient’s pain was the amitriptyline. Although at first he felt groggy, the administration time change helped with that feeling. He did experience weight gain, but that is a common symptom of this medication. It was important to listen to his concern and refer him to the life coach. I did not want to decrease the dosage of the medication because he was having a response and decrease in his pain.

References
Laureate Education (2016a). Case Study: A Caucasian man with hip pain [Interactive media
file]. Baltimore, MD: Author https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/07/mm/complex_regional_pain_disorder/2.html
Stahl, S. M. (2013). help study bay essential psychopharmacology: Neuroscientific basis and practical
applications (4th ed.). New York, NY: Cambridge University Press.
Wolters Kluwer Clinical Drug Information (2018a). Amitriptyline.
https://www.merckmanuals.com/professional/appendixes/brand-names-of-some-commonly-used-drugs?startswith=a#section_22
Wolters Kluwer Clinical Drug Information (2018b). Milnacipran.
https://www.merckmanuals.com/professional/appendixes/brand-names-of-some-commonly-used-drugs?startswith=m#section_3

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Example 2

A Caucasian Man with Hip Pain.
Student’s Name.
Institution. 
I received a client who complained of pain on the right hip which he had sustained after falling while in his place of work seven years ago. He had numerous x-rays, CT scan and even MRIs tests done on him. None of the doctors he visited had agreed to perform hip replacement citing that he is too young for it. One neurologist suggested that he suffered from a reflex sympathetic syndrome which the family doctor citing there is nothing of such sought. The family doctor referred him to psychiatry. The patient refused the advice of using a wheelchair. He would rather use crutches to walk rather than use a wheelchair. I took the following decisions:
Decision 1
Following the evaluation, i did on the patient. I decided to go with choice 1 amongst the 3 choices. This is because Savella helps in reducing pain to the patient to a manageable level and improved physical activities (Chen, 2013). A combination of Amitriptyline and Neurontin helps to treat mental illness as the patient exhibited some level of depression which had been diagnosed by the neurologist earlier. Anticipated results included reduction of pain in the first week and improved physical activities. However, there was a variation between the expected and actual result. Though the pain had reduced, it was bad during the night. However, on the positive side, the patient sometimes needed not to use crutches to walk.
Decision 2
I prescribed the patient to take Lyrica (pregabalin) 50 mg and Zoloft 50 mg. this option has less side effect as compared choices. The expected results were Lyrica was to target the chemical neural so as to reduce the pain experienced by the patient (Schjøtt, & Bergman, 2014). Zoloft was expected to act as antidepressant so as to improve the chemical balance in the brain through improved communication between nerve cells and central nervous system. However, there was a deviation between the expected results and the observed results. After four weeks the pain had become much worse with a scale of 7-10. The patient was still using crutches to walk. The pain frequently affected the patient during the night. Though the patient denied experiencing depression, he seemed very sad. The patient body seemed not to respond to the prescribed drugs
Decision 3.
I prescribed the patient start tramadol 50 mg and Celexa with a change of Savella to 25 mg in the morning and 50 mg during the night which would later be reduced to 12.5 mg. the reason for choosing this was aided by the fact that the combination of both Savella and tramadol would help reduce pain. Expected result was reduced pain to significant level and Celexa was expected to reduce mental depression (Bar‐Yam, 2016). However, the patient did not respond to the drugs prescribed as the pain seemed to be neuropathic. The patient must be made aware that he must expect some level of pain on a daily basis. The pain may reduce due to the fact that tramadol does not work well with other pain relieving drugs such as Savella.
It’s important to review Ethical issues and consideration when prescribing a patient with a drug (Elwyn, Frosch, Thomson, et al 2012). It’s important to first evaluate the patient thoroughly to avoid the problem of erroneous diagnosis of the patient. It’s also important to review which procedures to use when treating the patient and telling the patient the whole information on his/ her health. For example in our case the client was a pain was neuropathic and it was certain that he would experience some level of pain on a daily base.
In conclusion, the first choice was the better option as the patient stated that pain reduced to a scale of 4-10. He experienced less pain. The other two choices pain did not reduce. This may, however, be attributed it had to eliminate the whole pain. The client was to expect some pain on a daily basis.
 
References.
Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., … & Edwards, A. (2012). Shared decision making: a model for clinical practice. Journal of general internal medicine,
Chen, A. (2013, August). Patient Experience in Online Support Forums: Modeling Interpersonal Interactions and Medication Use. In ACL (Student Research Workshop
Bahmani, M., Rafieian-Kopaei, M., Hassanzadazar, H., Saki, K., Karamati, S. A., & Delfan, B. (2014). A review on most important herbal and synthetic antihelmintic drugs. Asian Pacific journal of tropical medicine
Bar‐Yam, Y. (2016). The limits of phenomenology: from behaviorism to drug testing and engineering design. Complexity, 21(S1),
Levin, G. M., & Ellingrod, V. L. (2012). P-glycoprotein: why this drug transporter may be clinically important. Current Psychiatry, .
Schjøtt, J., & Bergman, J. (2014). Joint medicine-information and pharmacovigilance services could improve detection and communication about drug-safety problems. Drug, healthcare and patient safety,

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Assessing and Treating a Patient with Low Back Pain

Introduction

Low back pain is one of the most common reasons for physician visits and missed work days in the United States (Deyo et al., 2014). Up to 80% of adults will experience low back pain at some point in their lives (Baker, 2022). While most cases of acute low back pain resolve within a few weeks with conservative treatment, some patients develop chronic low back pain lasting more than 12 weeks (Qaseem et al., 2017). This essay examines a case study of a patient presenting with low back pain, the assessment and treatment options considered, and how the treatment decisions align with current evidence-based guidelines.

Summary of Patient Case Study

The interactive case study presents a 45-year old male complaining of low back pain for the past 3 months that has progressively worsened, rating his pain as 8/10. He states the pain does not radiate and nothing seems to improve it. He cannot identify an inciting event or injury. On physical exam, he exhibits tenderness over the lumbar spine and limited range of motion due to pain. Muscle strength and reflexes are normal.

The first decision point is choosing pharmacologic treatment. Options include NSAIDs, muscle relaxants, and opioids. I selected NSAIDs as the first line treatment based on clinical practice guidelines. NSAIDs are recommended as initial pharmacologic therapy due to their efficacy for pain relief and lack of sedation side effects compared to muscle relaxants (Qaseem et al., 2017). Opioids are not recommended for acute or chronic low back pain outside of short-term use for severe pain when other treatments fail, due to their high risk of dependence and addiction (Dowell et al., 2016). NSAIDs such as ibuprofen act by inhibiting prostaglandin synthesis, thereby reducing inflammation and pain (Humphreys, 2017).

The second decision point is whether to order imaging. Options include plain films x-rays, MRI, or CT scan of the lumbar spine. I selected plain films, which can identify fractures or malalignments but have limited utility for assessing soft tissue structures. Evidence-based guidelines only recommend imaging for acute low back pain with signs or symptoms of a serious underlying condition, such as cancer, infection, or cauda equina syndrome (Downie et al., 2022). Most cases of nonspecific low back pain do not require immediate imaging (Baker, 2022). Plain films have lower cost and radiation exposure compared to MRI or CT scans which are reserved for persistent or progressive symptoms (Downie et al., 2022).

The third decision point is referring the patient to a specialist. Options include physical therapy, orthopedics, pain management, and neurosurgery. I selected referral to physical therapy as the next step. Clinical guidelines recommend physical therapy as a first line treatment for chronic low back pain, with proven benefits for reducing pain and improving function (Koes et al., 2010). Referral to a pain specialist or neurosurgeon is not indicated at this time since the patient’s symptoms are not radiating, indicating a likely musculoskeletal rather than neurological etiology. If pain persists after a trial of NSAIDs and physical therapy, additional specialty referrals could be considered.

Evaluation of Decisions

The treatment plan of NSAIDs as initial pharmacologic therapy, plain films x-ray, and referral to physical therapy aligns with current evidence-based practice recommendations for assessment and management of low back pain. The goals of this approach are to provide pain relief, assess for any underlying red flag conditions, improve physical function, and avoid unnecessary tests or medications that could lead to side effects.

The decision to start with NSAIDs follows guidelines to use non-opioid oral medication as first-line treatment for acute and chronic low back pain (Qaseem et al., 2017). NSAIDs are associated with pain reduction, improved function, and return to work compared to placebo, without the risks of sedation or dependence seen with opioids or muscle relaxants (Roelofs et al., 2008). The plain films decision avoids premature advanced imaging but can screen for fractures and instability needing prompt specialist referral (Downie et al., 2022). Referring to physical therapy aims to improve strength, flexibility and pain coping skills, which is shown to reduce recurrence of low back pain episodes (Koes et al., 2010).

The treatment plan matched expectations to provide conservative pharmacological and non-pharmacological options with the least risk of harm and greatest potential benefit based on the current level of symptoms. No imaging or specialist referral red flags were identified that would require veering from the evidence-based pathway. If pain worsened or the patient developed neurological symptoms indicating possible impingement, the plan could be re-evaluated for advanced imaging and potential neurosurgery referral if warranted (Baker, 2022). Overall the assessment and treatment decisions closely followed published practice guidelines with the goal of symptom relief while avoiding unnecessary interventions.

Conclusion

This essay examined a case study of a patient with low back pain, including the rationale behind the diagnostic and treatment plan decisions. The approach focused on NSAIDs, plain films x-ray, and physical therapy referral which are recommended as initial management by evidence-based guidelines. This strategy aims to provide pain relief, assess for underlying causes, improve function, and avoid interventions not currently indicated. The treatment decisions matched expectations to address the symptoms based on their reported duration and severity, while allowing room to escalate care if the problem progresses or the initial plan fails. Following established guidelines can promote optimal quality of care for common conditions like low back pain.

References

Baker, R. (2022). Evaluation of low back pain in adults. UpToDate. https://www.uptodate.com/contents/evaluation-of-low-back-pain-in-adults

Deyo, R. A., Dworkin, S. F., Amtmann, D., Andersson, G., Borenstein, D., Carragee, E., Carrino, J., Chou, R., Cook, K., DeLitto, A., Goertz, C., Khalsa, P., Loeser, J., Mackey, S., Panagis, J., Rainville, J., Tosteson, T., Turk, D., Von Korff, M., & Weiner, D. K. (2014). research essay pro Report of the NIH Task Force on research standards for chronic low back pain. The journal of pain : official journal of the American Pain Society, 15(6), 569–585. https://doi.org/10.1016/j.jpain.2014.03.005

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports, 65(1), 1–49. https://doi.org/10.15585/mmwr.rr6501e1

Downie, A., Williams, C. M., Henschke, N., Hancock, M. J., Ostelo, R. W., de Vet, H. C., Macaskill, P., Irwig, L., van Tulder, M. W., Koes, B. W., Maher, C. G. (2013). Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ, 347, f7095. https://doi.org/10.1136/bmj.f7095

Humphreys, B. K. (2017). Management of chronic low back pain: A mindfulness-based approach to the role of central sensitisation. African Health Sciences, 17(3), 680–689. https://doi.org/10.4314/ahs.v17i3.9

Koes, B.W., van Tulder, M., Lin, C.C., Macedo, L.G., McAuley, J., Maher, C. (2010). An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. European Spine Journal, 19(12):2075-94. https://doi.org/10.1007/s00586-010-1502-y