From the ACP Diabetes Care Guide

Use this calculator tool to determine a Target Heart Rate (THR).

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From the ACP Diabetes Care Guide

A prescription form to provide patients with personalized guidelines for the aerobic exercise they have chosen.

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From the ACP Diabetes Care Guide

Medical Nutrition Therapy

• The Plate Method
• Healthy Food Choices
• Basic Carbohydrate Counting
• Advanced Carbohydrate Counting
• Helping Patients Succeed with Meal Planning

Physical Activity

• Lifetime Physical Activity Model
• 10,000 Steps
• Planned Aerobic Exercise Programs
• Anaerobic Exercise Programs
• Helping Patients Succeed with Exercise Plans
  • What are some guidelines I can give patients to help them exercise safely?
  • How should I tell my patients to manage hypoglycemia during exercise?
  • What should I ask my patients at each visit to assess how they are doing with regard to physical activity?
  • Can I provide tips to help patients stay more faithful to their exercise plans?

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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The American College of Physicians currently considers patients with a body mass index (BMI) >30 as obese, and those with a BMI between 25 and 29.9 as overweight.

The recently published Dietary Guidelines for Americans 2005 recommend at least 60 minutes per day of moderate activity for the prevention of weight gain and up to 90 minutes per day of moderate activity for weight reduction.

Physical activity and fitness reduce morbidity and mortality for coronary artery disease, hypertension, obesity, diabetes, and osteoporosis.

Note: Subscription to MKSAP 14 is required to view this material. For more information, visit www.acponline.org.

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In a new randomized controlled trial, both aerobic and resistance exercise improved glycemic/blood sugar control in people with type 2 diabetes. The greatest improvements came from combined aerobic and resistance training.

The study included 251 adults, between ages 39 and 70, who were not exercising regularly and had type 2 diabetes. Participants were assigned to one of four groups: performing 45 minutes aerobic training three times per week, 45 minutes of resistance training three times per week, 45 minutes each of both three times per week, or no exercise.

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SAN FRANCISCO - Diabetes and testosterone studies topped the news at ENDO 08, the Endocrine Society's 90th annual meeting held last week. Among the research of interest to internists:

• Women with type 2 diabetes and heart disease get less intensive medical treatment for, and have poorer control of, these two conditions than men. In a study of nearly 45,000 diabetics, the comorbid women were 44% more likely than the comorbid men to have high LDL, but 15% less likely to get lipid-lowering medication. The women were also 19% more likely to have uncontrolled hypertension, and 15% more likely to have poor long-term control of their blood glucose levels. The findings may explain why death from heart disease has decreased among diabetic men in the past 25 years, but hasn't decreased for diabetic women, the study's lead author said.
• For obese and overweight men with type 2 diabetes, moderate fitness levels lowered the risk of all-cause death by 40%-50% during an average follow-up of seven years. By measuring peak metabolic rate during a standard treadmill exercise tolerance test, researchers classified fitness levels as low, moderate or high. Moderate fitness reduced death risk by 40% in healthy-weight and overweight men, and 52% in obese men, while high fitness level reduced death risk by 60% in healthy-weight men, and 65% in overweight men. The results suggest all diabetics, regardless of weight, should achieve and maintain at least a moderate fitness level, a study co-author said.

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Question
In patients with chronic noncancer pain (CNCP), are opioids more effective than placebo or other analgesics for relieving pain and improving functional outcomes?

Conclusions
In patients with chronic noncancer pain, weak and strong opioids are more effective than placebo for relieving pain and improving functional outcomes, although they are less effective than other analgesics for improving functional outcomes. Strong opioids are more effective than other analgesics for relieving pain.

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Question
In patients with unilateral sciatica, do lumbar epidural corticosteroid injections (ESIs) reduce symptoms and pain?

Conclusion
In patients with unilateral sciatica, lumbar epidural corticosteroid injections provided only short-term relief of symptoms and pain.

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Question
What is the relative effectiveness of yoga classes, exercise classes, and a self-care book for chronic low-back pain (LBP)?

Conclusion
Yoga improved function and reduced symptoms in chronic low-back pain more than a self-care book at 26 weeks; yoga reduced symptoms, but did not improve function more than exercise.

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Questions

Conclusions
Exercise therapy is effective in improving function and reducing pain in patients with chronic low-back pain. Exercise therapy is not better than no treatment or placebo or other conservative treatment for subacute or acute back pain. Individual components of exercise therapy programs make important contributions to improvements in pain and function. The most effective strategies are individually designed, supervised, and high-dose ( 20 h) and have additional conservative therapy.

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Question
In patients with nonspecific back pain associated with 1 day's absence from work, what variable or set of variables best predicts the 2-year work disability status?

Conclusions
In patients with nonspecific back pain associated with 1 day's absence from work, the best, although limited, prediction of the 2-year work disability status was obtained with 7 baseline variables.

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Question
What is the effect of different firmnesses of mattresses on the clinical course of chronic, nonspecific, low-back pain and disability?

Conclusion
In patients with chronic, nonspecific low-back pain, medium-firm mattresses reduced pain-related disability more than firm mattresses, but did not affect pain while lying in bed or on rising.

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Question
In patients with back pain, how do different classes of antidepressants compare for reducing pain and improving functional status?

Conclusions
Tricyclic or tetracyclic antidepressants are moderately effective for reducing pain in patients with chronic low-back pain. Antidepressants that do not inhibit norepinephrine reuptake show no benefit for pain relief or functional status.

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Recommendation 1:

Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).

Recommendation 2:

Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence).

Recommendation 3:

Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).

Recommendation 4:

Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).

Recommendation 5:

Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course, advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).

Recommendation 6:

For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.

Recommendation 7:

For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

* This paper, written by Roger Chou, MD; Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Donald Casey, MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Shekelle, MD, PhD; and Douglas K. Owens, MD, MS, was developed for the American College of Physicians' Clinical Efficacy Assessment Subcommittee and the American College of Physicians/American Pain Society Low Back Pain Guidelines Panel. For members of these groups, see end of text. Approved by the American College of Physicians Board of Regents on 14 July 2007. Approved by the American Pain Society Board Executive Committee on 18 July 2007.

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Background:

Many nonpharmacologic therapies are available for treatment of low back pain.

Purpose:

To assess benefits and harms of acupuncture, back schools, psychological therapies, exercise therapy, functional restoration, interdisciplinary therapy, massage, physical therapies (interferential therapy, low-level laser therapy, lumbar supports, shortwave diathermy, superficial heat, traction, transcutaneous electrical nerve stimulation, and ultrasonography), spinal manipulation, and yoga for acute or chronic low back pain (with or without leg pain).

Data Sources:

English-language studies were identified through searches of MEDLINE (through November 2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4). These electronic searches were supplemented by hand searching of reference lists and additional citations suggested by experts.

Study Selection:

Systematic reviews and randomized trials of 1 or more of the preceding therapies for acute or chronic low back pain (with or without leg pain) that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction.

Data Extraction:

We abstracted information about study design, population characteristics, interventions, outcomes, and adverse events. To grade methodological quality, we used the Oxman criteria for systematic reviews and the Cochrane Back Review Group criteria for individual trials.

Data Synthesis:

We found good evidence that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation are all moderately effective for chronic or subacute (>4 weeks' duration) low back pain. Benefits over placebo, sham therapy, or no treatment averaged 10 to 20 points on a 100-point visual analogue pain scale, 2 to 4 points on the Roland–Morris Disability Questionnaire, or a standardized mean difference of 0.5 to 0.8. We found fair evidence that acupuncture, massage, yoga (Viniyoga), and functional restoration are also effective for chronic low back pain. For acute low back pain (<4 weeks' duration), the only nonpharmacologic therapies with evidence of efficacy are superficial heat (good evidence for moderate benefits) and spinal manipulation (fair evidence for small to moderate benefits). Although serious harms seemed to be rare, data on harms were poorly reported. No trials addressed optimal sequencing of therapies, and methods for tailoring therapy to individual patients are still in early stages of development. Evidence is insufficient to evaluate the efficacy of therapies for sciatica.

Limitations:

Our primary source of data was systematic reviews. We included non–English-language trials only if they were included in English-language systematic reviews.

Conclusions:

Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. For acute low back pain, the only therapy with good evidence of efficacy is superficial heat.

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Background:

Medications are the most frequently prescribed therapy for low back pain. A challenge in choosing pharmacologic therapy is that each class of medication is associated with a unique balance of risks and benefits.

Purpose:

To assess benefits and harms of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, benzodiazepines, antiepileptic drugs, skeletal muscle relaxants, opioid analgesics, tramadol, and systemic corticosteroids for acute or chronic low back pain (with or without leg pain).

Data Sources:

English-language studies were identified through searches of MEDLINE (through November 2006) and the Cochrane Database of Systematic Reviews (2006, Issue 4). These electronic searches were supplemented by hand searching reference lists and additional citations suggested by experts.

Study Selection:

Systematic reviews and randomized trials of dual therapy or monotherapy with 1 or more of the preceding medications for acute or chronic low back pain that reported pain outcomes, back-specific function, general health status, work disability, or patient satisfaction.

Data Extraction:

We abstracted information about study design, population characteristics, interventions, outcomes, and adverse events. To grade methodological quality, we used the Oxman criteria for systematic reviews and the Cochrane Back Review Group criteria for individual trials.

Data Synthesis:

We found good evidence that NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain) are effective for pain relief. The magnitude of benefit was moderate (effect size of 0.5 to 0.8, improvement of 10 to 20 points on a 100-point visual analogue pain scale, or relative risk of 1.25 to 2.00 for the proportion of patients experiencing clinically significant pain relief), except in the case of tricyclic antidepressants (for which the benefit was small to moderate). We also found fair evidence that opioids, tramadol, benzodiazepines, and gabapentin (for radiculopathy) are effective for pain relief. We found good evidence that systemic corticosteroids are ineffective. Adverse events, such as sedation, varied by medication, although reliable data on serious and long-term harms are sparse. Most trials were short term (≤4 weeks). Few data address efficacy of dual-medication therapy compared with monotherapy, or beneficial effects on functional outcomes.

Limitations:

Our primary source of data was systematic reviews. We included non–English-language trials only if they were included in English-language systematic reviews.

Conclusions:

Medications with good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain). Evidence is insufficient to identify one medication as offering a clear overall net advantage because of complex tradeoffs between benefits and harms. Individual patients are likely to differ in how they weigh potential benefits, harms, and costs of various medications.

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