THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S HEALTH PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[10:46 am, 21/10/2025] PPM 1: @PPM3 do you remember the low back ache patient you published with Amy Price here? 👇
Which we appear to have cited in our latest paper by @PPM4 @PPM5 and you
[10:57 am, 21/10/2025] PPM 1: http://ejpch.org/ejpch/article/view/766
[2:53 pm, 21/10/2025] PPM 1: Questions for the patient advocate.
Please describe your patient's sequence of events that led to the current problems. Please begin the sequence of events from the time your patient had absolutely no problems at all.
Please describe your patient's hourly routine over 24 hours when he was perfectly alright
Next please describe what happened to his hourly 24 hour routine once the disease took hold on his life
Please mention specifically which part of the patient's hourly routine was disrupted
What are the patient's current requirements from us like if we had to give him a single medicine which problem would they prefer it to address?
[2:54 pm, 21/10/2025] PPM 6: Sir, is the patient he or she?
[3:16 pm, 21/10/2025] PPM 1: She but our template hasn't been updated!
I'll update it ASAP
[3:38 pm, 21/10/2025] PPM 3: Yes sir
[3:40 pm, 21/10/2025] PA: She is a student preparing for exams, so she is leading a sedentary lifestyle.
She did not have any issues with backache before that.
But after doing yoga for 14 days, a sharp pain started in her left hip joint.
She consulted the doctor after suffering for 2 weeks.
The doctor ordered an X-ray and advised bed rest and to avoid sitting for long hours.
He also prescribed a few painkillers, which she refused to take.
The pain got worse, and her lower back also started to ache.
So she consulted the same doctor again.
The doctor advised an MRI, which showed some disc bulge.
He again prescribed painkillers and advised bed rest, limiting sitting for long hours. Her pain started in June, and it hasn’t reduced till now.
She still finds it difficult to sit and immediately lies down to ease her pain.
Now the pain is in two places both at the left hip joint and in the lower back.
The low back pain is more compared to the hip joint pain since she stopped yoga.
Her usual daily routine during preparation was:
Waking up at 6 a.m.
Yoga for 1 hour
Meditation (30 mins)
Breakfast at 9 a.m.
Study session (sitting)
Lunch at 1 p.m.
Study session till 5 p.m. (sitting)
Break
Walking from 5:30/6 till 7 p.m.
Dinner at 8:30 p.m.
Study session (sitting)
Sleep by 11 p.m.
After 2 weeks of yoga, she stopped it as advised by her orthopedic doctor.
The constant pain in the hip joint slowly reduced, but the lower backache didn’t.
The major change in her daily routine is not being able to sit upright for longer periods,
which has hindered her preparation.
She can’t even sit and eat for 30 minutes; she has to take a break and lie down to ease her lower backache.
Current requirements: Finding what actually caused her pain and how she can reduce it without painkillers, and how to live with the pain if it can’t be treated,
since it has persisted from June till today.
[4:00 pm, 21/10/2025] PPM 6: What is she studying?
[4:10 pm, 21/10/2025] PA: she completed Her BTech
[4:12 pm, 21/10/2025] PPM 6: In the above description it is mentioned that she is preparing for exams. Hence the question please? What exams is she preparing for?
[4:12 pm, 21/10/2025] PA: GATE
[4:21 pm, 21/10/2025] PPM 1: That case was also about a student studying for his exams and having severe low back ache?
Let me see if I can get the full text of that article
[4:22 pm, 21/10/2025] PPM 6: Can I talk to the patient once?
[4:30 pm, 21/10/2025] PPM 1: 👆I just checked that case report within @PPM3 article and even @PPM7 was one of the team members at that time more than a decade ago, who's input is recorded in the published version!
[4:40 pm, 21/10/2025] PA: Sure
Not sure if the PDF is accessible there and I have extracted the bits relevant here. Even that patient was of the same age preparing for exams, only difference is he was MBBS preparing for MD entrance exams! @PPM3 do you have any follow up of that patient and what happened to his backache?👇
2012-13:
History:
26 y/o M, doctor currently on preparatory leave for postgraduate entrance examinations presents with moderate-severe back-pain.
History of present illness:
Pain started insidiously 10 previous and is localized to the lower cervical-upper dorsal paravertebral region on the right side.
Spasmodic pain, with constant dull aching (rated by 4/10) exacerbating to spikes, (rated 7-8.10) described as “severe” and restricting activity. Pt reports no loss in power or sensation in any dermatome and no restrictions in movement of the RUL.
Patient notes his BP increases from a baseline of 140/100 to 190/100 accompanied by profuse sweating during severe pain. Pain is worse in morning or after lying down and in c/o soreness scapular region. Patient sees other identifiable triggers in terms of physical exertion or mental stress. Patient reports the problem has surfaced intermittently for 3 years. The first episode lasted 8-10 days and was similar in severity.
Physical and mental stressors were present including a hectic posting in internship and accidental needle prick with subsequent Post Exposure Prophylactic regimen. Pain was similar with radiation and limited motion in his right arm.
He presently notes bilateral difficulty in turning the head to either side or shifting positions while at rest. He was prescribed intramuscular Piroxecam and with temporary recovery after 10 days. Piroxecam did leave him with severe gastritis. Milder episodes resolved spontaneously in 2-3 days with only k 4-5g/day of Paracetamol. Frequency of such episodes was once in every 4-5 months.
Current Medications for the pain:
Paracetamol – 5g/day
Baclofen – 30mg/d
Alprazolam – 1mg/d
Myoril [thiocolcicoside] 3g/d
Outcome
Reports little-no pain relief on current medications, physiotherapy caused pain, it was discontinued after one session
Co-morbid conditions:
Hypothyroid with Thyroid replacement therapy (200μg).
Euthyroid as of 3 months ago
Borderline Hypertensive – baseline is 130/100
Lifestyle factors:
Sedentary, 14-15 hours/day deskwork
Sleeps 6 hours/d (spaced over 4-5 hours in the night and 1-2 hours in the afternoon). He reports no difficulty in falling asleep.
Normal appetite, no allergies mentioned
No h/s/o gastritis is present
Additional investigations:
MRI scheduled (today/tomorrow)
A first response from a similar patient and health professional advised the following:
“It is an interesting story and as often there may be obvious and obtruse causes. The obvious causes could include poor workstation ergonomics and postural control - this would lead to an insidious, recurrent and persistent problem that will initially respond to NSAIDS. - whilst it sounds simplistic I am being serious - this is a very common cause of these sad stories and requires quite careful and expert physio/occupational therapy to retrain habits, with ergonomics training. Infection (TB) should have presented itself more floridly by now - neoplasm would be low in the list - a scan would settle those issues.
Here's the obtruse cause - I do have a habit of getting them - so here goes:
The pain may well represent Levator Scapulae spasm and some pain in the Rhomboids and possibly retroscapular bursitis - these often happen together and would explain the dynamic component of the pain as well as its burning nature. It is very persistent and very troublesome.
Discuss this with the radiologist who might have some reading to do about views - special CT projection often helps.
P.S. Baclofen sometimes weakens muscles and perpetuates the problem - regular low dose Diazepam and topical NSAIDs may be better and safe enough - I found Diclofenac very helpful and I can use it for 2-3 weeks before my gastric mucosa tells me to stop for a while. Physiotherapy will help but it has to be a specialist in shoulder girdle issues.”
AP, a clinical psychologist responded to this case as follows:
“Please add the qualifier I am not a medic:
What does the MRI look like? It likely shows a slight narrowing at c6-7 and L5-6 with some dehydration of disk height or/and bulges. Assuming no infection is present, it seems that he has a cervical facet injury and the ligaments in the cervical area are loose which triggers spasm, inflammation and nerve pain. I would try adding low dose gabapentin with the baclophen. If the Myoril is not working could it be dropped? His thyroid may need some more time to stabilize before his blood pressure comes down. He needs specialized instruction on mobilizing his facet joints, physical therapy to strengthen the stabilizing muscles in the cervical area. He may also benefit from doing nerve glides.
I advise he set his phone timer to go off every hour while studying and that he get up, change position, take a short walk as sitting is the most difficult posture with neck or back injury. I recommend ergonomically supportive sitting and sleeping conditions. If the neck is painful it can help to roll up a towel for underneath the neck for support. Alternating heat/ice can reduce inflammation and kick-start blood flow circulation.”
(At this juncture we received a note from the patient: “The pain has been a little debilitating....I must say 75mg (or 112.5mg) of Tramadol helps with the pain temporarily. Thanks so much for forwarding this email to the UDHC network. I can see how this is therapeutic”).
A response from DP, a consultant spinal surgeon in the UK, was as follows:
“Difficulty in turning neck during acute exacerbation suggests paravertebral muscles spasm relieved by IM piroxicam
Pain worse on lying down - can mean several nonspecific things ranging from simple facet syndrome to lesions involving bone/pedicle of Vertebral body.
BP rises and pt has profuse sweating. This could be a response to pain alone. Does he have a history of neuro-endocrine disorder?
Baclofen & alprazolam - completely inappropriate for neck/dorsal pain - should NEVER have been prescribed in a 26 yr old for such back-pain alone
Could not move his right arm during a previous episode. Was this simply related to generalized severe neck pain or an actual motor weakness? How long did this last for? If extended genuine arm problem - I would suspect pathology in the cervical spine and not lower down.
Suggest getting a plain X-ray of his neck and upper dorsal spine to assure alignment is satisfactory, and pedicle and VB endplates are intact. Is his CRP, WCC, ESR and chest X-ray satisfactory?
An MRI of cervicothoracic spine should be performed to exclude degenerative causes as well as infective/benign oncological causes. You mention he is borderline hypertensive. Although very rare, I have had one young patient with metastatic pheochromocytoma to C-spine which we wrote up - so I would do the necessary tests to exclude this.”
PJ, a hospitalist from Boston, Massachusetts advised:
“Sounds like wry neck to me. Sleep supine with thin pillow. Helps my episodes (doctor as patient). Would not have ordered MRI unless fever or motor/sensory abnormality. Agree with DP about medication choice (especially for a student preparing for exam!). Try hot pack and topical NSAIDs.”
The next response received was from GJ, a Consultant Rehabilitation Specialist:
“The rule out is Pott's spine although non-progressive course for 3 years goes against. Elevated BP may be involvement of autonomic nervous system in cervicodorsal region and if so an opinion for stellate ganglion procedure may be obtained from pain clinic. Autonomic dysreflexia in spinal injuries have similar features. There is a chance of spinal SOL (prolapsed disc too). Look for neurocutaneous markers. Very rare may be tumors of the autonomic sensors. Anyway, MRI from a good center should help and should not be delayed. X-ray is also must before getting MRI.”
MRI findings became available and suggested:
“Features of early degeneration with posterior bulge of c5-c6 and c6-c7 i.v.discs seen causing mild pressure on thecal sac and on exiting recess. Posterior bulge of c4-c5 i.v.disc is also seen. Mild left sided scoliotic tilt is noted. Dorsal spine, i.v.disc and dorsal cord do not show any significant abnormalities.”
RR, a consultant radiologist opined that the report was normal for practical purposes.
MM, a physician-scientist from Vellore, India, suggested the study of 2 systematic reviews [11,12] to explore therapeutic options.
RPPM1 replied:
“Summarizing for the benefit of our global audience, your first link which is a Cochrane review on vitamin D in adult chronic pain tells us that the evidence is not yet robust.
The second Cochrane review also tells us that evidence for mobilization of chronic neck pains is even less robust. As is customary with many Cochrane reviews they end on the note that more research is needed. So on one hand in India we see this wave of Vitamin D intervention in chronic pain and yet the evidence is not robust.”
SB, a physician and managing director of a healthcare IT consultancy, shared a few anecdotes in his email:
“1. A doctor's Malady: We had a surgeon, who was a bit too knife-happy, operating 6 days a week from morning till late evening. Rarely used to do OPD (juniors did it; Post-op occasional. Most time spent in OT). Came with medium depression and backache of dorso-cervical area.
After due deliberation and investigation, it was felt he rarely exposed himself to Sun.
Prescription: Sunlight and injection of Vitamin D uneventful recovery occurred in 3 days.
2. I suffered from similar almost symptoms while preparing for PG exams. Severity became severe enough to need 10 days of bed-rest and injections of muscle relaxants and painkillers. I am just trying to underline the contribution of mental stress, which easily exacerbates or sometimes mimics physical aberration. Similar aberrations can be benign and asymptomatic in existing population but in presence of mental stress, become problematic.
3. Over the years, many a physician has realized that it is not always the best practice to follow the best practice guidelines.”
AP, in her next email, added inputs based on personal experiences:
The methods of measuring pain are variable and subjective. So here is my subjective opinion to add to the mix. Vitamin D is cheap so why not? For me this works best when Vitamin C and K and calcium are added plus it is important to have magnesium and potassium in balance. As for diet, low glycemic higher protein makes a difference with good quality fruits and vegetables. I found electronic acupuncture (releases adenosine) to be helpful, Manual manipulation although not curative can be effective when combined with cervical exercise and nerve glides. Sacroiliac mobilization and strengthening/stretching exercises also help. LLLT cold laser is good for inflammation for some people but not for others, borrow one and try it rather than invest. I use a veterinarian model. Alternating hot and cold packs and using Epsom salts provide short-tern relief. Massage and TENS provide short term-relief. Walking, swimming, biking and core exercises help if done on a regular basis.
Prolotherapy was effective for increasing mobility and reducing pain in the cervical and sacroiliac regions but was useless for low back/shoulder areas. I had minimally invasive back and neck surgery this helped a lot as it took pressure off the nerves, my only regret was I did not do it sooner. I agree with SB in that mental stress is a factor. For this I do variable heart rate training, which calms my CNS and brings it back from fight/flight mode and then the muscles relax and I sleep better which allows my body to consolidate healing mechanisms. Posture training can make a difference as can good shoes and a memory foam mattress.
SB also added Jacobson’s progressive relaxation technique in the list of beneficial exercises if the etiopathogenesis was stress related.
Thematic summary of the UDHC approach:
In all the 3 representative cases, presented above, the primary information (with identifiers removed as per international confidentiality norms) was received from the patients, either directly or through the moderator. Apart from the history and the investigation findings, the patients shared their...
[4:44 pm, 21/10/2025] PPM 1: Thanks
[4:44 pm, 21/10/2025] PPM 1: Do you recall a few similar PaJR patients with low backache?
[4:46 pm, 21/10/2025] PPM 8: No sir, but today I spoke with a similar patient.
Main matching point in above paper and him is Sedentary, 14-15 hours/day deskwork
[5:00 pm, 21/10/2025] PPM 8: Sharing some thought. Is there something already available as self care management plans for various illnesses like this?
Patient Information
- Pain is sure, either take pain of investing time in exercise or take pain of weak back muscles.
- exercise is not enough if lifestyle is sedentary. Add frequent breaks for stretching.
- Recurrence is easy and common if physical activity is not maintained.
- it's mostly a lifestyle disease.
Self Management
Quick Relief Protocol
- pain relieving gels, massage, sleep
Prolonged Relief Protocol
- walking - 30 min., stretching - hourly, weight control - reduce truncal obesity, exercise- strengthen back muscles.
Recurrence Prevention
- Strong back muscles
- Proper sleep
To track self care and get better advice - track / journal
- sleep hours approx
- walking duration
- stretching (3-4 times a day)
- exercise (even thrice a week is good)
- pain intensity day by day
Pain killer - SOS with local doctor advice.
[5:03 pm, 21/10/2025] PPM 8: How this patient is doing his/her care management? How's regularity?
[5:06 pm, 21/10/2025] PPM 8: Can we make individualized self care / treatment plan for back pain for the patients according to their preferences and ask them to track?
[5:07 pm, 21/10/2025] PPM 8: Anything risky here that may harm disc buldge patients?
[5:07 pm, 21/10/2025] PPM 8: May be the type of exercises done is important.
[5:09 pm, 21/10/2025] PPM 8: https://www.nature.com/articles/s41598-024-68192-2
[5:09 pm, 21/10/2025] PPM 8: "Clinical relevance of combined treatment with exercise in patients with chronic low back pain: a randomized controlled trial"
[5:34 pm, 21/10/2025] PPM 8: Image - Lumbo-pelvic core stabilization training program exercise and volume.
[7:51 pm, 21/10/2025] PA: one more key history point she Mentioned
she used to have restricted mobility of her left hip joint for
past few yrs (aprox 4yrs )
after doing that 2 week yoga her mobility increased but pinpoint pain started
after stopping yoga pain slowly reduced
now she again have restricted mobility of her left hip joint
And pain and click sound on excess walking or on playing (Badminton) for long hours
[7:58 pm, 21/10/2025] PPM 1: This is very helpful information. Thanks.
Morning PaJR journal club:
[21/10, 17:03]hu1: Good evening.
For the low backache case, is it possible that it is just the calcium deficiency, and a sprain in the back due to yoga worsened it , because during exam season I had a similar backache and it was very severe , wouldn't calcium supplementation help in this case....
[21/10, 17:06]hu2: So in evidence based medicine we start with this question and then start looking for similar reports and scientific studies where it was proven that calcium deficiency can cause this which can then be treated by calcium replacement. Do search and let me know
[22/10, 09:08]hu1: Good morning, I was wondering that why would a normal deficiency based case report be published in any journal? If you may guide me more on this I'd be really grateful....
[22/10, 09:29]: https://pubmed.ncbi.nlm.nih.gov/34041094/
[22/10, 09:30]: I could not find any evidences of lower back pain related to calcium deficiency there are are multiple studies in relation with vit d deficiency....
[22/10, 09:39]: https://pubmed.ncbi.nlm.nih.gov/36514480/
[22/10, 09:47]: https://pubmed.ncbi.nlm.nih.gov/34704712/
[22/10, 10:10]hu2: Yes but in these studies how did they establish a causal correlation between vitamin D deficiency and low backache?
[22/10, 10:13] hu1: In some of them they did...
[22/10, 10:17) hu2: Please analyse how they did
Let's start the analysis with one and then proceed one by one
[22/10, 10:26]hu1: Sir this study had 376 patients who had a mean sun exposure time of 2hours , out of the 302 has significantly lower(how low?not mentioned) vitamin d levels....in conclusion they say :there is a high probability of correlation between chronic lower back pain and vitamin d levels but the deficiency levels do not determine how severe the pain is....
[22/10, 10:27]hu2: How many of the 376 patients had low backache and how many didn't?
Let's find out more about their backache than jump to their vitamin D levels
[22/10, 10:30]hu1: All had chronic lower back pain sir...
[22/10, 10:34]hu2: Alright all had low backache and many had low vitamin D levels but we need to also check a cohort of no low back ache who could alsi have low vitamin D levels?
In india I find most of our patients are overtested for vitamin D without any backache due to unscrupulous corporate packages and I hardly see any patient with or without backache who may have normal vitamin D levels in India!
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