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Guideline for the Evidence-Informed Primary Care Management of Low Back Pain These recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making. Guideline Disease/Condition(s) Targeted Category Specifications Acute and sub-acute low back pain Prevention Chronic low back pain Diagnosis Acute and sub-acute sciatica/radiculopathy Evaluation Chronic sciatica/radiculopathy Management Treatment Intended Users Primary health care providers, for example: family physicians, osteopathic physicians, chiro- practors, physical therapists, occupational therapists, nurses, pharmacists, psychologists. Purpose To help Alberta clinicians make evidence-informed decisions about care of patients with non- specific low back pain. Objectives • To increase the use of evidence-informed conservative approaches to the prevention, assessment, diagnosis, and treatment in primary care patients with low back pain • To promote appropriate specialist referrals and use of diagnostic tests in patients with low back pain • To encourage patients to engage in appropriate self-care activities Target Population Adult patients 18 years or older in primary care settings. Exclusions: pregnant women; patients under the age of 18 years; diagnosis or treatment of specific causes of low back pain such as: inpatient treatments (surgical treatments); referred pain (from abdomen, kidney, ovary, pelvis, bladder); inflammatory conditions (rheumatoid arthritis, ankylosing spondylitis); infections (neuralgia, discitis, osteomyelitis, epidural abscess); degenerative and structural changes (spondylosis, spondylolisthesis, gross scoliosis and/or kyphosis); fracture; neoplasm; metabolic bone disease (osteoporosis, osteomalacia, Paget's disease). Introduction This guideline has been adapted from seven "seed" guidelines referenced as G1 through G7 published between 2003 and 2006 for prevention, acute and subacute, and chronic low back pain (Appendix E. "Seed" Guideline References). The most common type of low back pain is non-specific, which occurs in approximately 90% of cases and has no identifiable cause. Between 49% and 90% of people in developed countries will experience at least one episode of low back pain during their lifetime.1-5 Low back pain is most common among the working population, particularly men, with peak incidence occurring in people aged between 25 and 64 years.5 Back pain usually resolves within 2 weeks. TOP is grateful to various sources including the Institute of Health Economics, the Alberta Heritage Foundation for Medical Research and Alberta Health Services - Calgary Health Region. For other guidelines or companion documents, please refer to 1 the TOP Website: www.topalbertadoctors.org Low Back Pain However, 20% to 44% of patients will experience further episodes within a year, and over three quarters will have a reoccurrence at some point in their lives. A small minority of patients (2% to 7%) will develop chronic low back pain.5, 6 A similar prevalence and clinical course for low back pain is reflected in Canadian data.7, 8 A recent survey9 of 2400 individuals revealed that the lifetime prevalence of back pain in Alberta and Saskatchewan was 83.8%, with 61.8% of respondents reporting back pain in the last year. The management of low back pain can be complex and costly. In Alberta and Saskatchewan, close to 40% of patients with back pain seek help from a healthcare provider.9 Primary care physicians undertake the initial evaluation in 65% of low back pain cases and are often the sole provider for these patients.1,10 Thus, primary care practitioners play an important role in the management of patients with low back pain. Interventions Prevention of Occurrence and Recurrence of Low Back Pain and Practices Patient education Manipulative treatment Considered Physical activity Mattresses Shoe insoles/orthoses Furniture - chairs Lumbar supports/back belts Risk factor modification Acute and sub-acute Low Back Pain (duration less than 12 weeks) Diagnostic triage Narcotic analgesics Emergent cases Spinal manipulation Cases requiring further evaluation Multidisciplinary treatment programs Referral Back schools Psychosocial risk factors Traction Laboratory testing Massage therapy Reassessment of patients whose Transcutaneous Electrical Nerve Stimulation (TENS) symptoms fail to resolve Diagnostic imaging Information and reassurance Oral and epidural steroids Cold packs or heat Bed rest Advice to stay active Acupuncture Return to work Therapeutic exercise Analgesia Chronic Low Back Pain (duration more than 12 weeks) Diagnostic tests Muscle relaxants Laboratory testing Antidepressants Self-management programs Opioids Physical exercise and therapeutic exercise Multidisciplinary treatment programs Active rehabilitation Prolotherapy Massage therapy Epidural steroid injections Acupuncture Behavioural therapy/progressive muscle relaxation TENS Referral Non-steroidal anti-inflammatory drugs Spinal manipulation (NSAIDs) 2 Low Back Pain Appendices Appendix A: Red and Yellow Flags Appendix B: Medication Table Appendix C: Key Guideline Definitions Appendix D: Evidence Source Appendix E: "Seed" Guideline References Reference List Companion There are six companion documents to this guideline which are available on the TOP website: Documents For Clinicians (1) Primary Care Management of Low Back Pain – An Evidence Informed Guideline Summary (2) Yellow Flags: Clinical Assessment of Psychosocial Yellow Flags What can be done to help somebody who is at risk (3) Canadian National Opioid Guideline (Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain) endorsed by the College of Physicians and Surgeons of Alberta (CPSA) Coming Soon (4) Primary Care Management of Low Back Pain - An Evidence Informed Guideline Background Document (supporting documents and process description) Coming Spring 2009 For Patients (1) Patient information sheets (acute low back pain and chronic low back pain) (2) Patient brochure Coming Spring 2009 Recommendations Summary of criteria to determine the categorization of recommendations: Do • The Guideline Development Group (GDG) accepted the original recom- mendation, which provided a prescriptive direction to perform the action or used the term "effective" to describe it. • The GDG supplemented a recommendation or created a new one, based Notes: on their collective professional opinion, which supported the action. • Statements in italics relate to harm. These statements Not • The GDG accepted the original recommendation, which provided a pre- were sourced from the Recommended scriptive direction "not" to perform the action; used the term "ineffective" recommendations or to describe it; or stated that the evidence does "not support" it. elsewhere in the "seed" • The GDG supplemented a recommendation or created a new one, based guidelines on their collective professional opinion, which did not support the action. • It is recognized that not all recommended treatment Do Not Know • The GDG accepted the original recommendation, which did not recom- options are available in all mend for or against the action or stated that there was "no evidence", ? communities "insufficient or conflicting evidence", or "no good evidence" to support • See Appendix D for its use. Evidence Source • The GDG supplemented a recommendation or created a new one, based on their collective professional opinion, which was equivocal with respect to supporting the action. 3 Low Back Pain Evidence Source Systematic Review - SR Randomized Control Trial - RCT Non-Randomized Trial - NRT Guideline - G Expert Opinion - EO Prevention Summary of Recommendations: Prevention of Occurrence and Recurrence of Low Back Pain Recommendation Evidence Source Patient Education Practitioners should provide information or patient education material on back pain prevention and care of the healthy back that emphasizes patient responsibility and workplace ergonomics. (See the companion document -Patient brochure.) The evidence is unclear on what quantity, intensity, or media is optimal for delivering this information. (See the companion documents - patient information sheets [acute low back pain and chronic low back pain] and patient brochure which are available on the TOP website.) Practitioners should emphasize that acute low back pain is nearly always benign and generally resolves within 1 to 6 weeks. Patient information and educational material based on a biomedical or biome- chanical model (anatomical and "traditional" posture information) can convey negative messages about back pain and is not recommended. SR (G2 & G5) Physical Activity Physical activity is recommended. There is insufficient evidence to recommend for or against any specific kind of exercise, or the frequency/intensity of training. SR (G5) Shoe Insoles / Orthoses The use of shoe insoles or orthoses is not recommended for prevention of back problems. RCT (G5) ? Lumbar Support / Back Belts Neither lumbar supports nor back belts appear to be effective in reducing the incidence of low back pain. RCT (G3) ? Manipulative Treatment No evidence was found to support recommending regular manipulative treatment for the prevention of low back pain. RCT (G5) 4 Low Back Pain Prevention Recommendation Evidence Source ? Mattresses There is insufficient evidence to recommend for or against any specific mattresses for prevention of low back pain. RCT (G5) ? Furniture - Chairs There is insufficient evidence to recommend for or against any specific chairs for prevention of low back pain. NRT (G5) ? Risk Factor Modification There is no good evidence for or against risk factor modification (e.g., smoking cessation, reduced alcohol consumption, weight reduction) for the prevention of low back pain. SR (G3) Acute & Subacute Summary of Recommendations: Acute and Sub-acute Low Back Pain Recommendation Evidence Source Diagnostic Triage The first qualified practitioner with the ability to do a full assessment (i.e., history- taking, physical and neurological examination, and psychosocial risk factor assessment) should assess the patient and undertake diagnostic triage. (See Appendix A for summary of red and yellow flags and companion documents, "Clinical Assessment for Psychosocial Yellow Flags" and "What can be done to help somebody who is at risk?", available on the TOP website.) If serious spinal pathology is excluded, manage as non-specific low back pain as per the reassessment and treatment recommendations below. SR (G2 & G4) Emergent Cases Patients with red flags (See Appendix A for red flag definitions) indicating a high likelihood of serious underlying pathology should be referred for immediate evaluation and treatment to an appropriate resource depending on what is available in your region (e.g., emergency room, relevant specialist.) EO (G2) Cases Requiring Further Evaluation Schedule an urgent appointment with a physician if any of the red flags are present. (See Appendix A for red flag definitions.) EO (G2) 5 Low Back Pain Acute & Subacute Recommendation Evidence Source Referral Patients with disabling back or leg pain, or significant limitation of function including job related activities should be referred within 2-6 weeks to a trained spinal care specialist such as a physical therapist, chiropractor, osteopathic physi- cian or physician who specializes in musculoskeletal medicine. Consult or refer to a spinal surgeon if the patient has neuromotor deficits that persist after 4 to 6 weeks of conservative treatment or sciatica for longer than 6 weeks with positive straight leg raise. EO (G2) Psychosocial Risk Factors Primary care evaluation should include assessment for psychosocial risk factors ('yellow flags') and a detailed review if there is no improvement. (See Appendix A for summary of yellow flags and companion documents, "Clinical Assessment for Psychosocial Yellow Flags" and "What can be done to help somebody who is at risk?", available on the TOP website.) Psychosocial risk factors (yellow flags) include fear, financial problems, anger, depression, job dissatisfaction, family problems, or stress. SR (G2 & G4) Laboratory Testing If cancer or infection is suspected, order the appropriate blood tests. In the absence of red flags, no laboratory tests are recommended. EO (G2) Reassessment of Patients Whose Symptoms Fail to Resolve Reassess patients whose symptoms are not resolving. Follow-up in one week if pain is severe and has not subsided. Follow-up in three weeks if moderate pain is not improving. Follow-up in 6 weeks if not substantially recovered. If serious pathology (red flag) is identified, consider further appropriate management. Identify psychosocial risk factors (yellow flags) and address appropriately. (See Appendix A for definitions of red and yellow flags and companion documents "Clinical Assessment for Psychosocial Yellow Flags" and "What can be done to help somebody who is at risk?" for chronicity and increased disability, available on the TOP website.) G (G2 & G4) Information and Reassurance Educate the patient and describe the benign long-term course of low back pain. Provide education materials that are consistent with your verbal advice, to reduce fear and anxiety and emphasize active self-management. (See the companion document - Patient Information Sheet.) NRT (G2 & G4) 6 Low Back Pain Acute & Subacute Recommendation Evidence Source Cold Packs or Heat In the first 72 hours recommend cold packs (ice), after that, alternate cold and heat as per patient's preference. Heat or cold should not be applied directly to the skin, and not for longer than 15 to 20 minutes. Use with care if lack of protective sensation. EO (G2) Advice to Stay Active Patients should be advised to stay active and continue their usual activity, including work, within the limits permitted by the pain. Physical exercise is recommended. Patients should limit/pace any activity or exercise that causes spread of symptoms (peripheralization). Self-treating with an exercise program not specifically designed for the patient may aggravate symptoms. SR (G2 & G4) Return to Work Encourage early return to work. Refer workers with low back pain beyond 6 weeks to a comprehensive return- to-work rehabilitation program. Effective programs are typically multidisciplinary and involve case management, education about keeping active, psychological or behavioral treatment and participation in an exercise program. Working despite some residual discomfort poses no threat and will not harm patients. SR (G2) Analgesia Prescribe medication, if necessary, for pain relief preferably to be taken at regular intervals. First choice acetaminophen; second choice NSAIDs. Only consider adding a short course of muscle relaxant (benzodiazepines, cyclobenzaprine, or antispasticity drugs) on its own, or added to NSAIDs, if acetaminophen or NSAIDs have failed to reduce pain. Serious adverse effects of NSAIDs include gastrointestinal complications (e.g., bleeding, perforation and increased blood pressure). Drowsiness, dizziness and dependency are common adverse effects of muscle relaxants. (See Medication Table in Appendix B.) SR (G4 & G7) 7 Low Back Pain Acute & Subacute Recommendation Evidence Source Narcotic Analgesics There is evidence that the effect of opioid or compound analgesics is similar to NSAID treatment of acute low back pain. Oral opioids may be necessary to relieve severe musculoskeletal pain. It is preferable to administer a short-acting agent at regular intervals, rather than on a pain-contingent basis. Ongoing need for opioid analgesia is an indication for reassessment. In general, opioids and compound analgesics have a substantially increased risk of side effects compared with acetaminophen alone. (See Medication Table in Appendix B.) SR (G7) Spinal Manipulation Patients who are not improving may benefit from referral for spinal manipulation provided by a trained spinal care specialist such as a physical therapist, chiropractor, osteopathic physician or physician who specializes in Musculoskeletal (MSK) medicine. Risk of serious complication after spinal manipulation is low (estimated risk: cauda equina syndrome less than 1 in one million). Current guidelines contraindicate manipulation in people with severe or progressive neurological deficit. SR (G4) Multidisciplinary Treatment Programs Encourage early return to work. Refer patients who have difficulty returning to work to a multidisciplinary treatment program. SR (G4) Back Schools Back schools are not recommended for treatment of acute low back pain. Back schools are programs of variable duration and intensity that include education about the anatomy and function of the back as well as training on specific therap- eutic exercises. SR (G4) Traction Do not use traction. Traction has been associated with significant adverse events. Passive treatment modalities such as traction should be avoided as mono-therapy and not routinely be used because they may increase the risk of illness behaviour and chronicity. The following adverse effects from traction were reported: reduced muscle tone, bone demineralization, and thrombophlebitis. SR (G4 & G7) 8 Low Back Pain Acute & Subacute Recommendation Evidence Source Massage Therapy Massage therapy is not recommended as a treatment for acute low back pain. SR (G4) Transcutaneous Electrical Nerve Stimulation (TENS) TENS is not recommended for the treatment of acute non-specific low back pain. SR (G4) Diagnostic Imaging For non-specific acute low back pain (no red flags), diagnostic imaging tests, including X-ray, CT and MRI, are not indicated. In the absence of red flags, routine use of X-rays is not justified due to the risk of high doses of radiation and lack of specificity. SR (G4) Oral and Epidural Steroids Oral Steroids Do not use oral steroids for acute non-specific low back pain EO (G2) Epidural Steroids Do not use epidural steroid injections for acute non-specific low back pain without radiculopathy. It is reasonable to use epidural steroid injections for patients with radicular pain for greater than 6 weeks who have not responded to first line treatments. Adverse effects are infrequent and include headache, fever, subdural penetration and more rarely epidural abscess and ventilatory depression. SR (G4) Bed Rest Do not prescribe bed rest as a treatment. If the patient must rest, bed rest should be limited to no more than 2 days. Prolonged bed rest for more than 4 days is not recommended for acute low back problems. Bed rest for longer than two days increases the amount of sick leave compared to early resumption of normal activity in acute low back pain. There is evidence that prolonged bed rest is harmful. SR (G2, G4 & G7) ? Acupuncture The evidence does not allow firm conclusions about the effectiveness of acupuncture. SR (G7) 9 Low Back Pain Recommendation Evidence Source ? Therapeutic Exercise There is insufficient evidence to recommend for or against any specific kind of exercise, or the frequency/intensity of training. Clinical experience suggests that supervised or monitored therapeutic exercise may be useful following an individualized assessment by a spine care specialist. For patients whose pain is exacerbated by physical activity and exercise, refer to a physical therapist, chiropractor, osteopathic physician, or physician who specializes in MSK medicine for therapeutic exercise recommendations. Patients should discontinue any activity or exercise that causes spread of symptoms (peripheralization). Self-treating with an exercise program not specifically designed for the patient may aggravate symptoms. SR (G2 & G4) Chronic Summary of Recommendations: Chronic Low Back Pain Recommendation Evidence Source Diagnostic Tests In chronic low back pain, X-rays of the lumbar spine are very poor indicators of serious pathology. Hence, in the absence of clinical red flags spinal X-rays are not encouraged. More specific and appropriate diagnostic imaging should be performed on the basis of the pathology being sought (e.g. DEXA scan for bone density, bone scan for tumors and inflammatory diseases). However, lumbar spine X-rays may be required prior to more sophisticated diagnostic imaging, for example prior to performing a CT or MRI scan. In this case, the views should be limited to anterior-posterior (AP) and lateral (LAT) without requesting oblique views. Oblique view X-rays are not recommended; they add only minimal information in a small percentage of cases, and more than double the patient's exposure to radiation. NRT (G2) Laboratory Testing If cancer or infection is suspected, order the appropriate blood tests. In the absence of red flags, no laboratory tests are recommended. EO (G2) 10 Low Back Pain Chronic Recommendation Evidence Source Self-management Programs Where available, refer to a structured community-based self-management group program for patients who are interested in learning pain coping skills. These programs are offered through chronic disease management and chronic pain programs. Self-management programs focus on teaching core skills such as self monitoring of symptoms to determine likely causal factors in pain exacerbations or amelio- rations, activity pacing, relaxation techniques, communication skills, and modi- fication of negative 'self talk' or catastrophizing. These programs use goal setting and 'homework assignments' to encourage participants' self confidence in their ability to successfully manage their pain and increase their day-to-day functioning. Most community-based programs also include exercise and activity programming that are also recommended. Where structured group programs are not available, refer to a trained professional for individual self-management counselling. G (G6) Physical Exercise and Therapeutic Exercise Patients should be encouraged to initiate gentle exercise and gradually increase their exercise level within their pain tolerance. Sophisticated equipment is not necessary. Low cost alternatives include unsupervised walking and group exercise programs such as those offered though chronic disease management programs. The outcome for group exercise is likely better in terms of peer support, giving people improved confidence and empowering patients to manage with less medical intervention. If exercise persistently exacerbates their pain, patients should be further assessed by a knowledgeable physician to determine if further investigation, medications, other interventions, and/or consultation are required. The exercise program should also be assessed by a knowledgeable physical therapist or qualified exercise specialist if the exercises exacerbate the patient's pain. Some studies reported mild negative reactions to the exercise program such as increased low back pain and muscle soreness in some patients. SR (G1 & G6) 11 Low Back Pain Chronic Recommendation Evidence Source Active Rehabilitation Active rehabilitation program includes: • Education about back pain principles • Self-management programming (see Self-management Programs recommendation) • Gradual resumption of normal activities (including work and physical exercise) as tolerated • Therapeutic exercise - there is strong evidence that therapeutic exercise is effective for chronic low back pain. There is no conclusive evidence as to the type of therapeutic exercise that is best. A client-specific, graded, active, therapeutic exercise program is recommended SR (G2) Massage Therapy Massage therapy is recommended as an adjunct to an overall active treatment program. SR (G6) Acupuncture Acupuncture is recommended as a stand-alone therapy or as an adjunct to an overall active treatment program. No serious adverse events were reported in the trials. The incidence of minor adverse events was 5% in the acupuncture group. SR (G6) TENS The research evidence does not support the use of TENS as a sole treatment for chronic low back pain. However, clinical experience suggests that TENS may be useful in select patients for pain control to avoid or reduce the need for medications. A short trial (2 to 3 treatments) using different stimulation parameters should be sufficient to determine if the patient will respond to this modality. Skin irritation is a common adverse event. SR (G6) Acetaminophen and Non-steroidal Anti-inflammatory Drugs (NSAIDs) Acetaminophen and NSAIDs are recommended. No one NSAID is more effective than another. NSAIDs are associated with mild to moderately severe side effects such as: abdom- inal pain, diarrhea, edema, dry mouth, rash, dizziness, headache, tiredness. There is no clear difference between different types of NSAIDs. (See Medication Table in Appendix B.) SR (G6) 12 Low Back Pain Chronic Recommendation Evidence Source Muscle Relaxants Some muscle relaxants (e.g., cyclobenzaprine) may be appropriate in selected patients for symptomatic relief of pain and muscle spasm. Caution must be exercised with managing side effects, particularly drowsiness, and also with patient selection, given the abuse potential for this class of drugs. (See Medication Table in Appendix B.) SR (G6) Antidepressants Tricyclic antidepressants have a small to moderate effect for chronic back pain, at much lower doses than might be used for depression. Possible side-effects include drowsiness and anticholinergic effects. (See Medication Table in Appendix B.) SR (G6) Opioids Long-term use of weak opioids, like codeine, should only follow an unsuccessful trial of non-opioid analgesics. In severe chronic pain, opioids are worth careful consideration. Long acting opioids can establish a steady state blood and tissue level that may minimize the patient's experience of increased pain from medication withdrawal experienced with short acting opioids. Careful attention to incremental changes in pain intensity, function, and side effects is required to achieve optimal benefit. Because little is known about the long-term effects of opioid therapy, it should be monitored carefully. Opioid side-effects (including headache, nausea, somnolence, constipation, dry mouth, and dizziness) should be high in the differential diagnosis of new complaints. A history of addiction is a relative contraindication. Consultation with an addictions specialist may be helpful in these cases. Consult the Canadian National Opioid Guideline (Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain) endorsed by the CPSA. Coming Soon. (Also see Medication Table in Appendix B.) SR (G6) Multidisciplinary Treatment Program Referral to a multidisciplinary chronic pain program is appropriate for patients who are significantly affected by chronic pain and who have failed to improve with adequate trials of first line treatment. Get to know the multidisciplinary chronic pain program in your referral area and use it for selected cases of chronic low back pain. SR (G6) 13 Chronic Recommendation Evidence Source Prolotherapy Prolotherapy is only appropriate in carefully selected and monitored patients who are participating in an appropriate program of exercise and/or manipulation/ mobilization. The most commonly reported adverse events were temporary increases in back pain and stiffness following injections. Some patients had severe headaches suggestive of lumbar puncture, but no serious or permanent adverse events were reported. SR (G6) Epidural Steroid Injections For patients with leg pain, epidural steroid injections can be effective in providing short-term pain relief. Transient minor complications include: headache, nausea, pruritis, increased pain of sciatic distribution, and puncture of the dura. (See Medication Table in Appendix B.) SR (G6) Behavioural Therapy / Progressive Muscle Relaxation Where group programs are not available, consider referral for individual cognitive- behavioural treatment provided by psychologist or other qualified provider. SR (G6) Referral Refer patients with severe persistent disability who have not responded to an exercise-based active rehabilitation program to interdisciplinary rehabilitation, a multidisciplinary chronic pain program or a physiotherapy clinic with consultation services. G (G2 & G6) ? Spinal Manipulation There is insufficient evidence to recommend for or against spinal manipulative therapy. SR (G6) 14 Appendix A Red and Yellow Flags Low Back Pain Red Flags Definitions (adapted from G2, G4) EMERGENCy - referral within hours URGENT - referral within 24 - 48 hours SOON - referral within weeks While patient is waiting to be seen by specialist: general advice is analgesia, rest and activity avoidance. Advise patient that tests are needed to clarify the diagnosis but that the results may be inconclusive. • Cauda Equina Syndrome - (sudden onset major bladder or bowel symptoms, perineal numbness) - EMERGENCy referral to ER • Severe unremitting (non-mechanical) worsening of pain (at night and pain when laying down), consider infection/tumor – URGENT referral to ER for pain control – will need prompt investigation • Significant trauma – consider fractures – check for instability and refer URGENTLy to spinal surgery • Weight loss, fever, history of cancer/HIV – consider infection/tumor – refer URGENTLy for MRI Scan and to spinal surgery • Use of IV drugs or steroids – consider infection/compression fracture – URGENT referral to spinal surgery • Patient over 50 (if first ever episode of serious back pain) – refer SOON for prompt investigation/spinal surgery • Widespread neurological signs – consider infection/tumor/neurological disease – refer SOON to neurology/spinal surgery/investigate further Yellow Flags14 Yellow Flags indicate psychosocial barriers to recovery that may increase the risk of long-term disability and work loss. Identifying any Yellow Flags may help when improvement is delayed. There is more about "Clinical Assessment of Psychosocial Yellow Flags" and "What can be done to help somebody who is at risk?" in the companion documents to this guideline, which are available on the TOP website". Yellow Flags include: Yellow flag Intervention Belief that pain and activity are harmful Educate and consider referral to active rehab 'Sickness behaviours' (like extended rest) Educate and consider pain clinic referral Low or negative moods, social withdrawal Assess for psychopathology and treat Treatment beliefs do not fit best practice Educate Problems with claim and compensation Connect with stakeholders and case manage History of back pain, time-off, other Follow-up regularly refer if recovering slowly claims Problems at work, poor job satisfaction Engage case management through disability carrier Heavy work, unsociable hours (shift work) Follow-up regularly refer if recovering slowly Overprotective family or lack of support Educate patient and family 15 Contra-indications/ Pain Type Medication Dosage Range Side Effects Ongoing monitoring Precautions Acute low back 1st line - Acetaminophen Up to 1000 mg QID (max of 4000 mg / day) Negligible See Acetaminophen below pain or flare-up nd 2 line – Ibuprofen Up to 800 mg TID (max of 800 mg QID) See NSAIDs below See NSAIDs below of chronic low These are time limited strategies NSAIDs Diclofenac Up to 50 mg TID back/spinal pain typically several days to a week and Add: Cyclobenzaprine for 10 to 30 mg per day; Greatest benefit seen within rarely up to a month Sedation, dry mouth Related to the TCAs but without robust prominent muscle spasm one week; therapy up to 2 weeks may be justified evidence to support long term use Monitor judiciously If taking controlled release (CR) See opioids below See opioids below See opioids below opioids add a short-acting opioid or increase CR opioid by 20 - 25% Chronic low 1st line Up to 1000 mg QID (max of 4000 mg / day) Liver disease. Negligible Primarily liver toxicity with long term, back/spinal Acetaminophen Concomitant long term use with high dose consumption. Increased pain15 NSAIDs may inc. risk of ulcers (sug- risk of high BP associated with long gest max 3000 mg/day) term use 2nd line Ibuprofen Up to 800 mg TID (max of 800 mg QID) Primarily GI, possible fluid Patients may need gastric protection NSAIDs Elevated risk of GI complications; retention or CNS effects with a PPI. coagulation defects such as dizziness or Monitor for CV risk factors and renal Diclofenac Up to 50 mg TID fatigue at higher doses function if long term use Appendix B Medication Table 3rd line Codeine 30 to 60 mg every 3 to 4 hours 10% of patients do not respond to Constipation, nausea, Monitor constipation Weak CR Codeine CR codeine - 50 to 200 mg Q8h, may also be codeine CNS side effects Opioids given Q12h 4th line - Tramadol* Slow titration; max of 400 mg/day, short acting Slow titration then convert to a CR Dizziness, drowsiness, Hepatic and/or renal dysfunction form is only in combination with acetaminophen product. Possible loss of analgesia asthenia, gastrointestinal or pre-existing seizure risk 16 Note – Monitor for total combined daily acet- when combined with high dose opioid. complaints aminophen dose Caution if adding to TCAs or SNRIs OPIOIDS Neuropathic pain 5th line Morphine sulfate 15 to 100 mg BID Assess addiction potential Anticipate constipation Pain, function, behaviour Strong Hydromorphone HCl 3 to 24 mg BID Use an opioid agreement and nausea; treat ac- Monitor for end-of-dose failure; some Opioids Observe and assess for a cordingly patients may require Q8h dosing (CR) Oxycodone HCl 10 to 40 mg BID-TID dose-response relationship CNS side effects. Consider Tricyclics also 3rd line – see Fentanyl patch 25 to 50 µg Q3days Tolerance occurs Neuropathic 1st or Amitriptyline 10 to 100 mg HS Start low & go slow; Drowsiness, Precautions in patients with pre- pain if co- 2nd line TCAs have positive effects on sleep anti-cholinergic effects existing cardiac abnormalities and Nortriptyline emergent with Tricyclics architecture glaucoma fewer adverse effects musculoskeletal complaints15,16,17 1st or 2nd line Gabapentin: 100 mg HS up to a suggested Significant renal impairment requires Sedation, dizziness and Occasional renal function tests Anticonvulsants (Gabapentin or maximum of 1200 mg TID. Higher doses have dose adjustment other CNS side effects Pregabalin*) been used Slower titration required for pregabalin * NOTE: Tramadol and Pregabalin are NOT currently covered by Alberta Blue Cross. Pregabalin: 75 to 300 mg BID; may need to start @ 25 mg for elderly or sensitive patients 3rd line - Add opioids or tramadol See opioids or tramadol as above See opioids or tramadol as above See opioids or tramadol See opioids or tramadol as above as above Sleep Amitriptyline 10 to 100 mg take 2+ hours before bed time Dosing should be individualized Drowsiness, Precautions in patients with pre- disturbance and concurrent mood disturbances anti-cholinergic effects existing cardiac abnormalities and Low Back Pain accompanying treated glaucoma chronic pain15,18 Trazodone 25 to 100 mg HS Drowsiness, dizziness Excessive sedation Mirtazapine 15 to 45 mg HS Drowsiness, inc. appetite, Excessive sedation, weight gain dizziness Appendix C Key Guideline Definitions Low Back Pain Definitions Acute and sub-acute low back pain: Duration less than 12 weeks (adapted from Chronic low back pain*: Duration more than 12 weeks 11-13, G5) Non-specific low back pain: Pain, muscle tension, or stiffness that occurs between the rib cage and the inferior gluteal folds, with or without leg pain (sciatica), and has no identifiable cause Prevention of occurence of low back pain: Reduction of the incidence (first-time onset) of low back pain or the risk of new cases appearing, i.e. primary prevention Prevention of recurrence of low back pain: Reduction of the occurrence of a new episode of low back pain after a symptom-free period in patients who have previously experienced low back pain, i.e., secondary prevention Spinal care specialist: A physical therapist, chiropractor, osteopathic physician or physician who specializes in musculoskeletal medicine *Two seed guidelines, G2 and the G1 defined chronic pain as ≥6 weeks' duration. 17 Low Back Pain Appendix D Evidence Source The Evidence Source provides information on the "seed" guideline(s) that were used to develop the Alberta guideline recommendations. The Evidence Source also provides information on the design of the study that was referenced in the "seed" guideline in support of the recommendation. The following evidence sources were considered: • Systematic review (SR): as cited by the "seed" guideline(s) or identified from supple- mentary literature search from January 2000 to August 2007 required by the Ambassador Guideline Development Group (GDG) • Randomized controlled trial (RCT): as cited by the "seed" guideline • Non-randomized trial (NRT): in the form of non-systematic/narrative review, non- randomized comparative study, and case series study, as cited by the "seed" guideline • Guideline (G): as cited by the "seed" guideline Expert opinion (EO): after examining the individual studies cited by the "seed" guideline(s) or additional SRs on low back pain as identified by supplementary literature search from January 2000 to August 2007, the original recommendation was rejected and a new one was drafted based on the collective expert opinion of the Ambassador GDG. When no evidence was provided by the "seed" guideline in support of the recommendation, the supporting evidence for that recommendation was labeled as expert opinion (by the authors of the "seed" guideline). When the evidence cited by the "seed" guideline(s) was from SR(s) and studies of other design (i.e. RCT, NRT, or guideline) only SR is listed as the source. When no SR was referenced in the "seed" guideline, the evidence source was indicated in the following order: RCT, or NRT, or guideline, or expert opinion. The same classification for the evidence source was applied when multiple "seed" guidelines were used to inform one recommendation. Each recommendation in the Alberta guideline came from one or more "seed" guideline(s) accepted, supplemented, or changed and was based on additional evidence, and/or consensus of expert opinion. 18 Appendix E "Seed" Guideline References Low Back Pain The guidelines are not presented in any specific order. G1, G2, etc., are randomly assigned and for the purpose of organization only G1 Mercer C et al. Clinical guidelines for the physiotherapy management of persistent Low Back Pain (LBP), part 1: exercise. Chartered Society of (UK) Physiotherapy, London. 2006. Available for purchase. G2 Institute for Clinical Systems Improvement (ICSI). Adult low back pain. Bloomington (MN). 2006 September. (USA) Last accessed online May 7, 2008. G3 U.S. Preventive Services Task Force. Primary Care Interventions to Prevent Low Back Pain: Brief Evidence Update. February 2004. Agency for Healthcare (USA) Research and Quality, Rockville, MD. Last accessed online May 7, 2008. G4 van Tulder M et al. on behalf of the COST B13 Working Group on Guidelines for the Management of Acute Low Back Pain in Primary Care. European (Europe) Guidelines for the Management of Acute Nonspecific Low Back Pain in Primary Care. 2004. Last accessed online May 7, 2008. G5 Burton AK et al. on behalf of the COST B13 Working Group on Guidelines for Prevention in Low Back Pain. European Guidelines for Prevention in (Europe) Low Back Pain. November 2004. Last accessed online May 7, 2008. G6 Calgary Health Region. Chronic Pain Management. Guidelines for Primary Care Practice in the Calgary Health Region. October 2005. (Canada) Regional Pain Program. Low Back Pain. Evidence-based Clinical Practice Guidelines for Primary Care Practice in the Calgary Health Region. Chronic Pain Services in the Community: Supporting Primary Care. September 19, 2006. Last accessed online May 7, 2008. G7 Australian Acute Musculoskeletal Pain Group. Evidence-based Management of Acute Musculoskeletal Pain. Acute Low Back Pain. Chapters 4 & 9, pg (Australia) 25-62 and 183-188. 2003. Last accessed online May 7, 2008. 19 Reference List Low Back Pain 1. Devereaux MW. Low back pain. Primary Care: Clinics in Office Practice 2004;31(1):33-51. 2. Margarido MS, Kowalski SC, Natour J, Ferraz MB. Acute low back pain: diagnostic and therapeutic practices reported by Brazilian rheumatologists. Spine 2005;30(5):567-71. 3. Nyiendo J, Haas M, Goldberg B, Sexton G. Pain, disability, and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians. J Manipulative Physiol Ther 2001;24(7):433-9. 4. van Tulder M, Koes B, Bombardier C. Low back pain. Best Practice & Research Clinical Rheumatology 2002;16(5):761-75. 5. Woolf AD, Pleger B. Burden of major musculoskeletal conditions. Bulletin of the World Health Organization 2003;81(9):646-56. 6. Koes B, van Tulder M, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332:1430-4. 7. Moulin DE, Clark AJ, Speechley M, Morley-Forster PK. Chronic pain in Canada- prevalence, treatment, impact and the role of opioid analgesia. Pain Research & Management 2002;7(4):179-84. 8. Schopflocher D. Chronic pain in Alberta: a portrait from the 1996 National Population Health Survey and the 2001 Canadian Community Health Survey. Edmonton, Alberta: Alberta Health and Wellness; 2003. 9. Gross DP, Ferrari R, Russell AS, Battié MC, Schopflocher D, Hu RW, et al. A population- based survey of back pain beliefs in Canada. Spine 2006;31(18):2142-5. 10. Bishop PB, Wing PC. Compliance with clinical practice guidelines in family physicians managing worker's compensation board patients with acute lower back pain. Spine J 2003;3(6):442-50. 11. Manek NJ, MacGregor AJ. Epidemiology of back disorders: prevalence, risk factors, and prognosis. Curr Opin Rheumatol 2005;17(2):134-40. 12. Woolf AD, Pleger B. Burden of major musculoskeletal conditions. Bull World Health Organ 2003;81(9):646-56. 13. University of Michigan Health System. Acute low back pain. Ann Arbor (MI): University of Michigan Health System; 2003 Apr. (Rev. Apr. 2005). Last accessed May 7, 2008. 14. Kendall NAS, Linton SJ & Main CJ (1997). Guide to Assessing Psycho-social Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. Accident Compensation Corporation and the New Zealand Guidelines Group, Wellington, New Zealand. (Oct, 2004 Edition). Last accessed May 7, 2008. 15. Adapted from G6 by a subcommitttee of the Guideline Development Group (GDG) in consultation with pharmacutical experts who were not part of the GDG. 16. Chou R and Hoyt-Huffman L. Medications for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guidelines Ann Intern Med. 2007; 147:505-514 17. Dworkin RH, O'Connor AB, Backonja M et al. Pharmacologic management of neuropathic pain: Evidence-based recommendations Pain 132 (2007) 237-251 18. Moulin DE, Clark AJ, Gilron I et al. Pharmacological management of chronic neuropathic pain – Consensus statement and guidelines from the Canadian Pain Society. Pain Res Manage 2007; 12(1):13-21 19. Lynch ME and Watson CPN. The pharmacotherapy of chronic pain: A review. Pain Res Manage 2006; 11(1):11-38 20 Low Back Pain Toward Optimized Practice (TOP) Program Arising out of the 2003 Master Agreement, TOP succeeds the former Alberta Clinical Practice Guidelines program, and maintains and distributes Alberta CPGs. TOP is a health quality improvement initiative that fits within the broader health system focus on quality and complements other strategies such as Primary Care Initiative and the Physician Office System Program. The TOP program supports physician practices, and the teams they work with, by fostering the use of evidence-based best practices and quality initiatives in medical care in Alberta. The program offers a variety of tools and out-reach services to help physicians and their colleagues meet the challenge of keeping practices current in an environment of continually emerging evidence. To Provide Feedback The TOP Program encourages your feedback. If you need further information or if you have difficulty applying this guideline, please contact:: Toward Optimized Practice Program 12230 - 106 Avenue NW EDMONTON, AB T5N 3Z1 T 780. 482.0319 TF 1-866.505.3302 F 780.482.5445 E-mail: firstname.lastname@example.com Low Back Pain, 2009 21
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Ure Museum of Greek Archaeology
Ure Museum of Greek Archaeology
University of Reading
Department of Classics
Humanities Building
0118 378 6990
0118 931 6661
The Ure Museum started life in the 1920s as a small collection of fragmentary pottery by the first Professor of Classics at the University, Percy Ure. It has now grown due to the generosity of various donors, and is recognised as the fourth largest collection of Greek ceramics in Britain.
The museum has recently undergone a massive renewal and artefacts are now displayed thematically.
It is located on the Whiteknights campus at the University of Reading, where there are also several other important museums.
Venue Type:
Mon-Fri 0900-16.30
Closed: Sat and Sun,
Easter, Christmas, New Year and public holidays. For further information and closures please refer to our website at: www.reading.ac.uk/ure
Free admission
There is a small charge to cover the cost of materials for some events.
Additional info
The Ure Museum offers taught education sessions on Greeks and Egyptians to Key Stage 2.We also offer tailored workshops for GCSE and A-level groups on a variety of themes. For further information, or to discuss your requirements, please contact Jennifer Allison on 0118 378 6990 or refer to our website: www.reading.ac.uk/ure
The collection primarily consists of material from the Greek and Græco-Roman civilisations of the Mediterranean, most notably Greek and Etruscan ceramics. Other objects used by these civilisations are also on display, for example musical instruments, broze and copper artefacts and jewellery.
There is also a small collection of beautiful early Egyptian Byzantine textiles. These are not on display, but can be brought out on request.
The museum also houses an exciting collection of Egyptian antiquities, including a funeral boat and a mummified cat's head.
Collection details
Archaeology, Costume and Textiles, Decorative and Applied Art, Design, Music, Weapons and War, World Cultures
Key artists and exhibits
- Ancient
- Funeral Boat
- Greek
- Egyptian
- Graeco-Roman
- Aulos
- Musical Instruments
- Ceramics
- Pottery
- Vases
- Textiles
Pick Up a Pot!
- 9 April 2015 2-4pm
Join us at this Easter holiday activity to handle some real Ancient Greek pots, learn about the different styles and designs and have a go at making your own pot to take home!
Booking is essential.
Events are suitable for children aged 6 - 12. Children must be accompanied by an adult throughout the session.
Each session costs £3 per child to cover materials, while the accompanying adult is free.
For further information or to book a place on one of the sessions, please contact the Education Officer by phoning 0118 378 6990 or emailing email@example.com
Suitable for
- 11-13
- 7-10
£3 per child to cover the cost of materials
Ancient Greek Experience
A schools programme based on the National Curriculum guidelines for Key Stage 2. Children get the rare opportunity to handle Greek artefacts and discuss their form and function. Children develop their analytical and investigative skills by looking in detail at Greek pottery. Children also get to try out their acting skills as they recreate scenes from some of our pots!
- Ure Museum of Greek Archaeology
How to obtain
This session is available on Tuesdays and Thursdays for two available sessions. The sessions run between 10-12 and 12.30-2.30. Please book a session by emailing the museum.
Ancient Egyptian Experience
A schools programme based on the National Curriculum guidelines for Key Stage 2. This is a 2-hour session based on learning about various aspects of ancient Egyptian life through looking at objects in our collection. Children develop their investigative and analytic skills by looking in detail at Egyptian artefacts. Children explore mummification and the afterlife and look at what they would choose to take with them in to the underworld.
- Ure Museum of Greek Archaeology
How to obtain
This session is available on Tuesdays and Thursdays for two sessions. Sessions run between 10-12 and 12.30-2.30 on these days. Please book by emailing the museum.
- About
- | Collections
- | Events
- | Resources
- | Map

subset: commoncrawl


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WGWE's 1st Annual Polar Plunge
Read More
Take the Plunge! … Take the Challenge!
The 1st Annual WGWE Polar Bear Plunge will be held on Saturday April 18th from 11:30 – 1:30 at Allegany State Park, Red House area. The Challenge is On! WGWE wants YOU to put a team in the Plunge … all proceeds benefit Seneca Nation of Indians "Seneca Strong" – the campaign against drugs and alcohol.
It's simple. Grab your co-workers, people who belong in a group or organization – organize a team. Then have each team member get pledges, with $25 minimum pledge per person – to support their "Polar Plunge" efforts. All money raised will benefit SNI Seneca Strong.
On Plunge day, April 18th, registration opens at 10:30 a.m. Captains of your team should collect Team Members' pledge sheets and money and turn in at registration desk. Each participant must register to participate.
Just contact Katie at WGWE, 716-945-5801; email: email@example.com or facebook/WGWE105.9FM. Register your team. Get your Polar Pledge packet with rules and pledge sheets.
WGWE's Polar Bear Plunge is being co-sponsored by Seneca Salamanca Chamber of Commerce & Allegany State Park.
TAKE THE PLUNGE! Challenge Others To Do the Same! Please see attached forms for full rules and forms.


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Liebherr LTM1030/2 - Euro Gras Colors
- Sold for: Start FREE Trial! or Sign In to see what it's worth.
- Item Category:
- Source: Proxibid, Inc.
- Sold Date: Jul 29,2006
- Channel: Auction House
Conrad Model 2088-45 - Custom Factory Paint - 1:50 Scale - New in Box
Items in the Worthopedia are obtained exclusively from licensors and partners solely for our members' research needs.


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The couple reportedly dated while shooting Employee of the Month together--and guests at Prince's latest show were left in no doubt the pair is still close.
According to witnesses, Simpson and Cook sat next to each other on a sofa, often talking into each other's ear over the music.
A source tells Life & Style magazine, "They were laughing, joking and hanging out. They practically spent all night together, dancing and touching each other."
Simpson has recently been dating bluesman John Mayer, but their romance has reportedly ended.
COPYRIGHT 2007 WORLD ENTERTAINMENT NEWS NETWORK LTD. All Global Rights Reserved.


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Other Views: A long overdue thank-you
It came as a surprise to many that the Standing Rock Sioux Tribe contributed more native code talkers than any other in service to their country in wars overseas. The tribe recently honored the 45 soldiers who served as code talkers in World War I and the one who served in World War II. They all are long dead now, some killed on the battlefield.
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LOOKING for: Vegetable Stock Recipe-(repeat with subject changed
Sorry, I didn't post this properly the first time. I am looking for a recipe, not providing one for vegetable stock.
I would like something with quantities spelled out rather than "a little bit of this and that". Also, keeping it simple and limiting the different ingredients would be nice. It seems that so many recipes require two cups of chicken stock. That is what I want to use this for consistently.
Maybe a combination of potatoes, leeks, onions and parsely? Of course I can try this out but I was hoping someone had something they used that they thought was foolproof?
I've also thought of just using white wine wherever chicken stock was called for but I did this on one recipe and it didn't taste that great. I'm not sure it was the stock or something else. Maybe I should have diluted with water?
Would love to hear if someone has a "rule of thumb" for using a substitution for stock that allows them not to have to go to a lot of trouble. By not being a lot of trouble, I mainly mean that they can use stuff out of their pantry or standard produce that most people have if they cook a fair amount.
I don't like to use packaged stuff so I want to avoid the vegetable bouillon route if possible.
I posted elsewhere on this forum, what I found, i.e. "Leek Broth" which suits my needs quite well.
Here is a link that might be useful: Where I posted the recipe for Leek Broth


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Petrou's clandestine travels in Iran and his visits with that country's diverse and far-flung underground of brave democrats, intellectuals and dissidents provide an exceedingly rare insight into the workings of the Khomeinist police state... But it's Petrou's dispatches from the front lines of the "first war" of the book's title, the freedom struggle that Canadians usually call the "war in Afghanistan," that lend the book its heft.(Ottawa Citizen)


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Greystone Cellars Wine Deluxe Duet
Ships Mon, Mar 30
Add to Wish List
Chardonnay and Cabernet Sauvignon from Greystone Cellars, made by the Culinary Institute of America, are paired perfectly with a crate full of sweet and savory bites.
Wine Gift Set Includes:
- Greystone Cellars Chardonnay:
Along with aromas of golden apple and succulent melon, this Chardonnay has apple and mineral flavors and a round, juicy texture.
- Greystone Cellars Cabernet Sauvignon:
Garnet in color, with aromas of tart cherries, caramel and coffee. Flavors are spicy with black pepper and cinnamon tightly woven through the Bing cherry core.
- 4 oz Sonoma Jacks Original Cheese
- 5 oz Beef Summer Sausage
- 2 oz Three Pepper Water Crackers
- 2 oz Spanish Manzanilla Olives
- 5 oz Nunes Farms Spicy Cocktail Almonds
- 2 oz Beth's Chocolate Chip Cookies
- 1.75 oz Napa Mustard
- Festive Greet Sheet
- Greystone Cellars Chardonnay:
Pursuant to state laws in New York, gifts that contain both food and wine will be sent in two separate packages.
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Back Home » Luxury Hotels UK Search » England Luxury Hotels » Central England Luxury Hotels » Worcestershire Luxury Hotels » Worcester Luxury Hotels » Stanbrook Abbey » Make Booking Stanbrook Abbey hotel
Stanbrook Abbey hotel
Jennett Tree Lane, Callow End, Worcester, Worcestershire, WR2 4TY
Take a trip to the Malvern Hills and you'll come across the wonderfully grand, historic former monastery Stanbrook Abbey. Built on the order of Benedictine nuns back in 1871, the building's Gothic Revival Tower is a famous local landmark trumpeting its prominent place in the history of Roman Catholic architecture in the UK. The monastery's interior has been transformed to create incredibly grand and decorous public halls and dining areas ideal for weddings and large corporate functions. As yet, the only accommodation is a five bedroom Georgian manor house with sumptuous fittings and en-suite bathrooms but another 52 rooms are in the pipeline for 2014 plus all the facilities you'd expect from a five star hotel such as swimming pool, spa, tennis courts and outdoor dining area.
Stanbrook Abbey is part of the following Editors' Picks:
The Top Ten Resplendent Wedding Venues by Liz Coggins
"Nestling beneath the Malvern Hills Stanbrook Abbey with its majestic cloisters is a heavenly setting for a wedding. A former monastery is grand in every sense of the word with Gothic wallpapers and décor, impressive carvings and stained glass. There are stunning gardens overlooking a lake and its lavishly decorated Great Hall, the former chapel ,can only be described as absolutely amazing."
Places to Stay & Visit in WorcestershirePlaces to Stay & Visit in or near Worcester
Official Photos
Traveller Photos
Information on Stanbrook Abbey hotel , Jennett Tree Lane , Callow End , Worcester
|No. of bedrooms:
Total: 5
Types of room: 5 luxurious bedroom suites, available in a Georgian Manor House.
|Room rates guide:
Single from: £125.00
Double/Twin from: £175.00
Suites from: £250.00
Room with Breakfast
|General info:
Credit Cards Accepted: Amex, Delta, Mastercard, Maestro/Switch, JCB, Visa
When Closed: 5th to 18th January 2015
Child Friendly: Children of all ages welcome
Dog Friendly: No
Romantic Details: Own Manor House; Bride's Manor, private orchard, maze, private lake, Honeymoon suite, Bell Tower with views over Worcestershire and the Malvern Hills
Smoking Permitted: Yes (outside only)
Wheelchair Access: Yes
Accreditation: Trip Advisor Certificate of Excellence 2014
|Room facilities:
TV, alarm clock, Free Wi-Fi internet access, Luxuriously furnished, Luxury toiletries
|General facilities:
22 Acres of picturesque grounds ideal for Team building, Dining - The Bistro and The Clarence Room, Library, piano bar, champagne bar, Wedding receptions, Multiple and diverse function and event meeting rooms, Diverse ground floor event space with natural daylight, Chapel, Heli-pad
|Indoor activities:
Library, piano bar, champagne bar, own chapel
|Outdoor activities on site:
Clay pigeon shooting, Cycling, mountain biking, Walking, Hiking, Scrambling, Trekking in the Malvern Hills
|Activities nearby:
Croquet lawn, Golf, Historic tours, Horse riding
|Local directions:
|Directions from the M4 motorway (London into Wales): Exit the M5 at junction 7 onto the A44. At the roundabout, take the first exit onto Crookbarrow Way (A4440). Pass through two roundabouts remaining on A444. Turn left onto Malvern Road (A449). Bear left onto Upton Road (B442). Turn right on to Jennett Tree Lane and take an immediate left onto the driveway of Stanbrook Abbey.
Nearest major city:
Nearest major airport:
Nearest railway stn:
Worcester (6 miles)
Birmingham (21 miles)
Worcester Foregate Street (4 miles)
Special Offers
To add a special offer email alert, click here.
Mad Hatters Tea Party at Stanbrook Abbey (send email about this offer) (telephone about this offer)
Thu 12 Mar 2015 – Sun 05 Apr 2015
Mad Hatters Tea Party at Stanbrook Abbey, nr Worcester
Saturday 4th April, 2pm onwards
Join us in the beautiful surroundings of Stanbrook Abbey for an Afternoon Tea with a difference! With a Mad Hatters Tea Party theming and a few surprises in store, you're in for a real treat!
Just £30 pp
Easter at Stanbrook Abbey (send email about this offer) (telephone about this offer)
Tue 24 Feb 2015 – Tue 07 Apr 2015
Easter break on 3rd – 5th, or 4th – 6th April.
Spend Easter Weekend at the beautiful Stanbrook Abbey, a stunning Grade II listed Pugin abbey near Worcester. The stately home boasts in its majestic splendour with every aspect of service designed for your ultimate comfort and indulgence.The perfect break for your Easter Weekend.
Just £148 pp based on 2 people sharing.
Cabaret Evening (send email about this offer) (telephone about this offer)
Tue 24 Mar 2015 – Fri 17 Apr 2015
Friday 17th April, 7pm onwards
Enjoy a spectacular evening of dining, cabaret, singing and dancing at the beautiful Stanbrook Abbey. You are welcomed with a chilled glass of champagne and canapés. Sit down for a delicious 4 course meal and enjoy an evening of cabaret. After the entertainment, it's time to party into the small hours.
Just £99 pp OR BOOK BEFORE 31ST MARCH FOR JUST £79
Gospel Lunch (send email about this offer) (telephone about this offer)
Thu 12 Mar 2015 – Mon 20 Apr 2015
Sunday 19th April, between 1pm and 3.30pm
Join us at the beautiful Stanbrook Abbey for a spectacular Gospel Lunch. Enjoy a delicious 3 course meal in the Thompson Dining Hall, prepared and cooked for you by our talented chefs, and hear the award-winning ACM Gospel Choir in the Callow Great Hall.
Just £49 pp
St George's Afternoon Tea (send email about this offer) (telephone about this offer)
Thu 12 Mar 2015 – Fri 24 Apr 2015
Thursday 23rd April, 2pm onwards
Join us at Stanbrook Abbey for an Afternoon Tea with a difference! With a St George's Day 'Street Party' theming and a few surprises in store, you're in for a real treat!
Just £30 pp
Get Active at the Abbey (send email about this offer) (telephone about this offer)
Thu 15 Jan 2015 – Wed 01 Jul 2015
2 Nights at Stanbrook Abbey
The perfect break for those looking for an action packed few days with superb dining options in a stunning country setting near Worcester.
Breakfast & Lunch
Wine Tasting
Gourmet Dining Experience
Activities, Entertainment & more
Choose from the following dates:-
13th April – 15th April
25th May – 27th May
29th June – 1st July
Just £195 pp
Dinner & Tour by Candlelight (send email about this offer) (telephone about this offer)
Thu 12 Mar 2015 – Thu 30 Apr 2015
Thursday 30th April, to be seated for 7.30pm
Join us at Stanbrook Abbey for a sumptuous 3 course meal. Each course will be elegantly served in the Thompson Dining Hall, which will be lit by candlelight only. The evening will also include a fascinating guided tour of the Abbey, providing you with the history of this incredible location.
Just £55pp
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Grim Harvest: Climate Change Sweeps Iowa Farms (Op-Ed)
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17 July 2014, 12:51 PM ET
Climate Records Shattered in 2013
The planet shattered several climate records in 2013, from greenhouse gases to roasting Arctic heat to extreme storms, a newly released report on the state of the global climate says.
16 July 2014, 08:02 PM ET
Extreme Weather Disrupts U.S. Farms: Real Climate Change Stories | Video
Ray Gaesser has been farming in Iowa for over 35 years has been seeing an huge surge in extreme events over the past few years. Excess moisture has led to disease in his crops.
16 July 2014, 07:45 PM ET
Wet Get Wetter & Dry Get Dryer: Climate Change Story | Video
The lead author on the National Climate Assessment's Climate Science chapter Don Wuebbles presents the scientific observations of changing climate.
16 July 2014, 02:02 PM ET
World's Biggest Fish Seek New Home
Whale sharks -- the world's largest fish -- are appearing more frequently near the Azores islands, due to climate change, a new study finds.
16 July 2014, 11:20 AM ET
Six Months In and Sizzling California Sets Record
January-June 2014 was the warmest first half to a year ever in California, helping fuel the state's drought.
16 July 2014, 07:26 AM ET
Radar Images Show Human Footprint Claims More of Earth
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Human Footprints: Tracking Development From Space
New radar imagery shows human impacts on Earth, including sprawling urban cities and rural landscapes.
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text:
Hang tight!
Recipe by frady02
"These festive hardboiled eggs are fun and easy to make. Sure to be a hit at any Halloween party."
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hard-boiled eggs, peeled and halved
1/4 cup
mayonnaise, or as needed
1 teaspoon
red food coloring, or as needed
1 teaspoon
blue food coloring, or as needed
1 teaspoon
black food coloring, or as needed
How cool are these. Thank you frady. I made these for a party. The only difference is that I made the filling with sriracha sauce, Dijon and mayonnaise. This made the filling orange. You can make black food coloring by mixing equal parts red, blue and yellow. The pumpkin in the middle is made of Boisin cheese. Form two pkgs of boisin into a ball. Add the face (made out of pepperoni) and roll it in finely shredded cheddar. The stem is made out of the top of a red pepper and the horns are thai chillies.
2 Ratings
* Percent Daily Values are based on a 2,000 calorie diet.
Spooky Halloween Eyes
Serving Size: 1/24 of a recipe
Servings Per Recipe: 24
Amount Per Serving
Calories: 55
Calories from Fat: 40
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text:
The largest India ETF, WisdomTree's EPI, is outperforming the leading country specific BRIC ETFs in the marketplace in 2012. EPI has benefited from a variety of positive developments in India this year including a decrease in inflation, a stabilization of the rupee's value, a renewed interest by foreign institutional investors and the possibility of interest rate cuts. Here's a performance chart of the leading country specific BRIC ETFs in 2012.
Source: Stockcharts.com
While all BRIC ETF products have turned in positive results this year, India has likely risen the most due to its steep losses in 2011 when it trailed all BRIC markets. Here's a performance chart of EPI over the last year displaying its roller coaster ride.
Source: Yahoo Finance
Despite India's strong 2012 recent rally, it is still in negative territory over the last 12 months and is second place to the Russia ETF, RSX, for worst performance.
Maxing out the ETF performance comparison period to four years, shows India crushing Russia and beginning to gain ground on the largest China ETF, FXI. The Brazil ETF, EWZ, has a clear lead - despite its negative total return.
Source: Stockcharts.com
Going forward India will need to see interest rates subside from current 8.5% levels, oil prices significantly moderate and foreign investment continue to be robust for its 2012 performance rebound to continue against the other BRIC nations. If some or all of these factors happen then India stands to benefit from another potential advantage versus other BRICs in 2020: the world's largest population.
Disclosure: I have no positions in any stocks mentioned, and no plans to initiate any positions within the next 72 hours.


text:
A gorgeous dessert white, now showing some maturity, with butter, spice, salted caramel and mulled citrus flavors. It all hangs together beautifully on the supple texture, its acidity well-integrated, with a long, satisfying aftertaste. Drink now through 2025.
(6/ 2010)
Below is a listing of the wine review scores we frequently reference in our notes. While these sources remain an excellent source of information, we always recommend that you trust your own palate. Scores in these publications often represent the personal taste of an individual critic, which may not always coincide with your own. We have a huge team of excellent wine professionals that can match wines you've had in the past with new arrivals that meet your flavor profile.
The item you have chosen is not in stock in our retail stores or within our main
2009 Királyudvar Pezsgo Tokaji Sparkling Wine
2004 Feiler-Artinger Pinot Cuvee Ruster Ausbruch (375ml)
2005 Château Dereszla Tokaji Aszú 6 Puttonyos (500ml)
2000 Tokaj Classic Winery Tokaji Aszu 6 Puttonyos (500ml)
2000 Château Dereszla Essencia Tokaji (250ml)


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6:42 pm
Wed May 29, 2013
Proposed Springfield Budget Includes Casino Payments
By Paul Tuthill
The mayor of Springfield Massachusetts has proposed what he characterizes as a " hold the line" budget for next year.
The $571.8 million dollar budget proposed by Mayor Domenic Sarno preserves city jobs while raising spending by less than 2 percent.
Two of the city's ten branch libraries would close, but library hours and staffing would increase elsewhere throughout the system. The budget is balanced thanks to $5 million dollars from MGM Resorts that was part of a casino development deal. If the casino project falls through, Sarno warns the city faces more than 100 layoffs and massive cuts in services…


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FCPA Compliance and Ethics Report-Episode 144-SEC Enforcement of the FCPA, Part I
FCPA Compliance and Ethics Report-Episode 142-Reflections on the Goodyear FCPA Enforcement Action
FCPA Compliance and Ethics Report-Episode 141-Pi Day and Compliance Programs
African Law Firms & Foreign Counterparts Navigate 'Tense' Relationship
FCPA Compliance and Ethics Report-Episode 140-Leona Lewis
FCPA Compliance and Ethics Report-Episode 139-Amy Lilly, President of GHBER
FCPA Compliance and Ethics Report-Episode 138, Tribute to Mr. Spock and Strict Liability for Internal Controls Under the FCPA
FCPA Compliance and Ethics Report-Episode 137, interview with Loren Steffy
FCPA Compliance and Ethics Report-Episode 136, Joel Borgquist, President of Etik
FCPA Compliance and Ethics Report-Episode 135, Kevin Brady on the process of sales for the compliance practitioner
FCPA Compliance and Ethics Report-Episode 134, Judge Rakoff, Judge Leon and their comments on DPAs, with the FCPA Professor
FCPA Compliance and Ethics Report-Episode 133, The Oscars and Compliance, Part V with Jay Rosen
FCPA Compliance and Ethics Report-Episode 132-Adam Turteltaub and SCCE Europen Compliance and Ethics Institute
FCPA Compliance and Ethics Report-Episode 131, The FCPA Professor Takes a Look Back at 2014
FCPA Compliance and Ethics Report-Episode 130, The Oscars and Compliance, Part IV with Jay Rosen
FCPA Compliance and Ethics Report Episode 129-Judge Rakoff, Judge Leon and Individual Prosecutions Under the FCPA
Global Growth: A Prime Opportunity for the Middle Market
Is the Patent Litigation Boom Coming to an End?
Dentons Dacheng Deal Done: Will BigLaw Follow Suit?
FCPA Compliance and Ethics Report-Episode 125, The Oscars and Compliance, Part II with Jay Rosen
In yet another recent case involving the intersection of CERCLA and state law, the United States District Court for the Eastern District of Washington held that CERCLA legislatively displaced federal common law public...more
A little like one of those peanut-shaped asteroids, today's post cobbles together a couple of recent developments that, other than having relevance to the FDA, do not have all that much in common....more
On February 6, 2015, the U.S. Securities and Exchange Commission (SEC) imposed sanctions against four China-based accounting firms for their refusal to surrender documents in conjunction with an investigation of potential...more
Expanding the reach of the federal displacement doctrine and the U.S. Supreme Court's decision in AEP v. Connecticut, a federal district court for the first time held that the Comprehensive Environmental Response,...more
In an Order of Settlement released February 6, 2015, the SEC agreed to stay the administrative action against the Chinese affiliates of the "Big Four" accounting firms for refusing to turn over their audit work papers...more
The SEC and the PRC based affiliates of five major accounting firms entered into a settlement of proceedings initiated over the failure to produce audit work papers for issuers with substantial operations in China. The...more
President Obama wants to go where the Supreme Court refused to tread. As part of his cybersecurity and privacy initiatives, which we discussed last week, the President would strengthen the federal anti-hacking provisions of...more
The Law of the Republic of Kazakhstan "On introduction of amendments and additions to certain legislative acts on subsoil use matters" No. 271-V 3PK was adopted on 29 December 2014 and, save for the specified provisions,...more
Japan Airlines Activities For US Government Cannot Infringe -
In IRIS CORP. v. JAPAN AIRLINES CORP., Appeal No. 2010-1051, the Federal Circuit affirmed a decision to dismiss due to a conflict of laws.
IRIS owns...more
The Employment Appeal Tribunal (EAT) has today handed down judgment in the closely observed holiday pay appeals in Bear Scotland v Fulton and Baxter, Hertel (UK) Ltd v Wood and others; and Amec Group Ltd v Law and others (the...more
Last year in AMP v Myriad Genetics, the U.S. Supreme Court concluded that isolated, naturally occuring DNA are not patent eligible, which caused considerable consternation in the biotech community. However, this does not...more
The "Myriad-Mayo" patent subject matter eligibility guidance issued March 4, 2014 reflects the USPTO's interpretation of Supreme Court cases interpreting and applying 35 USC § 101 to claims involving laws of nature, natural...more
In This Issue:
- Russia's Second Renewable Energy Auction Gives Both Glimmer of Hope and Cause for Concern
- Tanzania Publishes First Draft of a Long-Awaited Local Content Policy
- New York's Highest...more
In Actavis Group HF v. Eli Lilly & Co. the UK High Court has granted a declaration of non-infringement in the UK, France, Italy and Spain. A jurisdictional challenge in relation to the French, Italian and Spanish...more
In a decision that has long been awaited by the industry and the legislator alike, the European Court of Justice ruled today, 12 June 2014, on the question to what extent two conflicting regulatory frameworks within one...more
Kate Hodgkiss, Partner in the Edinburgh office, comments: The European Court of Justice (ECJ) has today handed down judgment in a case which could mean that employers face huge liabilities for claims for holiday pay. The...more
The equipment finance industry breathed a sigh of relief when Federal legislation was enacted in 2005 preempting state laws imposing vicarious liability on lessors of motor vehicles. That relief may have been premature if the...more
The progress of the European Financial Transaction Tax (the "FTT") towards becoming law in eleven participating Member States of the European Union overcame another hurdle on 30 April 2014 with the Court of Justice of the...more
On April 28, 2014, a Massachusetts federal court granted dismissal of a proposed class action alleging that Raytheon violated Kuwaiti law by failing to pay overtime to employees working in Kuwait on federal defense contracts....more
The United States Supreme Court has held that arbitrators, not courts, bear the primary responsibility for interpreting and applying a local litigation requirement of an investment treaty between the United Kingdom and...more
The question of who is a U.S. person has always been relevant for tax purposes because it determines who is subject to (a) U.S. income, gift and estate tax, (b) filing Foreign Bank Account Reports (FBARs), and (c) the ''exit...more
The recent decision in Secretary of State for Health and others v Servier Laboratories Ltd and others;; National Grid Electricity Transmission plc v ABB Ltd and others [2013] EWCA Civ 1234, concerned an appeal by two...more
The recent Australian opposition decision of Merial Limited v Zoetis LLC [2013] APO 59 highlights the differences between the Australian and New Zealand patent offices in the construction of "kit" claims in relation to the...more
This alert reports a French case that relates to a hedge fund registered in the Cayman Islands, the investment agreement of which was governed by Cayman law, and where the actions complained about (withdrawing from the fund)...more
On 30 September 2013, the President signed Federal Law No. 260-FZ amending Part III of the Civil Code of the Russian Federation.
The Law is the sixth set of amendments to the Russian Civil Code within the civil law...more
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Chicago Hardy Fig - what to do for winter
Hi there,
I have a detached garage which I think gets pretty cold (Ontario) as it's unheated, so I'm not sure if that's safe for my fig tree. This is it's first season, almost 3 feet tall, with a few fig buds on it. I've read that it's not good to bring it indoors. Anyone have experience with this?
There is a radio garden program from California, Farmer Fred. He has a blog and web site and radio program as I mentioned. Why I mention him to you Ukulele Lady is that he has had a program on fruit tasting recently ANd figs in particular I didn't know there where so many figs in existence.
If you put Farmer Fred on your internet yu might be able to find the program Was interesting reading and his show is very good.
Did you pick your name, by chance form a Bette Middler song called Ukulele lady. Is one of my favourite songs.
I am in Ontario as well Barrie. ANd have an unheated garage I do keep my chrysanthemums in there and some other things that will overwinter
Some things do make it in there and others do not Dahlias and Canna lily for sure do not
I always plan every fall to put the big pots in there and make an enclosure within the garage to maybe give a few more degrees of warmth but never get around to doing so.
I have a Chicago Hardy Fig. I live in Plattsburgh NY, zone 4b to 5. I overwintered mine in my unheated basement last year. It is an old house with a stone basement. My fig did great down there. I probably brought it out too early. I noticed it had fat leaf buds in early April and brought it up to my sunroom. I had mites on the leaves by the time I could safely move it outside. Next year I will keep it in the dark a couple of more weeks. Hope this helps, and good luck,


text:
Peoples Church holds open house
The Peoples Church held an open house and community meal Tuesday afternoon. Families could be involved in several art projects and help raise a teepee. Shown above Diane Pitman brought her tools and extra bike parts to help the area youth with their bicycle repairs. She teaches Kasey Whitfield and Leonard Bellanger how to fill their tires with air and simple bike maintenance.
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text: Just kidding. My wife and I ate here when it first opened about 10 years ago and we were not impressed. That is not the case now, this place is wonderful! The service is great, the food is terrific and the prices are more than reasonable. I heartily recommend that if you're looking for Middle... read more


text:
Earn 50 Birchbox points for every friend that purchases a subscription.
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Store this 50 ml bottle in your drawer to unwind at night, and keep the matching 8.8 ml size in your purse to relax during your hectic days.
The Harvey Prince perfume fan favorite makes a calming return
Harvey Prince
Availability: In stock
Take a deep breath and relax with this sophisticated scent, which helps us tap into our inner New Age gurus. Harvey Prince designed the mood-elevating blend of exotic essences and oils to counteract stress and keep us zen throughout the day. It's the fragrance equivalent of yoga class.
The light, clean fragrance features top notes of purifying sandalwood, refreshing grapefruit, and sensual Egyptian myrrh. Subtle cues of golden amber, incense, and star jasmine turn each spritz into a mini aromatherapy break.
Spritz onto your pulse points like your wrists and neck whenever you need to take a time out. Follow with a cup of tea for extra credit.
Alcohol Denatured (40B), Fragrance, Water, Hexyl Cinnamal, Butylphenyl Methylpropional, Hydroxycitronellal, Geranoil, Linalool, Citronellol, Cinnamyl Alcohol
I love it so much I bought it the day after I got it as a sample!
Yogini has a light fresh scent (almost citrus like on me) that is perfect for day-time wear. This is staying in my purse for all-day touch ups.
I have enjoyed all the perfume samples I get in my monthly boxes, but not this one. Smell is too musque or something, just not my thing.
The perfume is exactly as described, like a Yoga class. The smell is great for day to day, but I have found that is is SUCH great refresher for when I come back from the office after a lunch sweat sesh. Nice Job guys!
Did not like the smell of this at all. Was overpowering and not feminine at all. I prefer a softer sweeter or clean smell.
I really like this product and use it several times a week. I recommend this amazing product for anyone looking for a good smell.
Loved the scent!!! I will be adding this to my collection! Its light and airy, and perfect for anyone on the go.
smells super girly, yet not too heavy or floraly. it is a good scent for someone my age without smelling like cheap bath and body works but then again not an old lady at a perfume counter
Very nice fragrance. It's very light and subtle- not at all overwhelming. Very fun and flirty and perfect for spring!
I really enjoyed this scent. It was warm, comforting, and not overpowering. I would wear this in the summertime and spring.


text: MeritDirect to manage PennWell contact lists Published on September 09, 2013. 0 Reprints Reprints Ad Age Reports Resource Guide B-to-B Marketing Fact Pack From spending trends to the biggest marketers and agencies, this handy guide gives you the lay of the b-to-b land. Learn more Rye Brook, N.Y.—Database marketing company MeritDirect will manage the sales contact lists of PennWell Corp. Statlistics formerly managed those lists. PennWell publishes 130 print and online magazines and newsletters and conducts more than 60 conferences and exhibitions in addition to other services. Its brands cover industries including aerospace and defense, dental, electronics, lighting, and oil and gas. In this article: BtoB Advertisement Read These Next Tumblr's First CMO Stephanie Dolgins Will Also Oversee Its Media Deals Tim Peterson on 03.30.2015 69 0 Chevy Liked Its Truck Effort So Much, It's Taking It National Mike Colias on 03.30.2015 40 0 L'Oreal's Chief Digital Officer on Programmatic Plans, Startups and Org Charts Jack Neff on 03.30.2015 467 0 Comments (0)


text:
Type: Posts; User: Eddysx
Used to click threads like this one and see some round. Thick. Solid piece of ass.
Left disappoint
Working full time ATM and for the dispatch job, 40+ hrs per week is guaranteed
I know my location says Vegas but I'm n a small little island in AK. With my current job I get more action than the cops around here
Currently working as homeland safety/security. Jobs fun. Get to go out on my own and deal with ppl and other bs all day but underpay. Dispatch sits on chair all day with little to no outside comm....
Sup misc, any of you have had any experience in that field before?
- op wants to be a cop but can't cuz 20 yo
- op talks to Sargent and was advised to apply for dispatch then move over...
The interview sucked. Atleast for me as I had no experience. 3 interviews with sht ton of questions and aptitude and scenario tests
Actually under pay for how much I work. Brb 12 hrs/day 7/days a week
But no one lifts In tmisc...
46k + /year
Before tax obv
Tfw sitting around all day scaling sloots passing by
Very clean m8
At work/training rn misc. Bored as hell
Go go
sup brahs
no. finger fak a girl 5'3 can barely fit 2 fingers. srs
couldn't stand my roommate so I jizzed on his beanie that he wears everyday.... srs
repped... lols
I make 2.2k a month
2 cars paid off
don't live with parents
hi op
u dun goofed op
das it mane
Sexor night: was gonna go downtown... Pulled down her leggings when the smell punched me right In the face. Paused and looked at her vagine for second. She goes "what's wrong?" I said nooooo


text:
Willows reopens with bang
Tucked away in a dense pocket of vegetation across the Yazoo-Mississippi Delta levee, two mechanized traps sit fully loaded, waiting for the operator to launch a seemingly endless cache of clay disks into the sky.
"Pull," commands a shooter, looking down the barrel of a Beretta 12-guage as a bright orange clay pigeon arches high in the air from behind the limb of a wild pecan. Reaching its apex, the clay shatters into dozens of pieces as a rattling "boom" pierces the air.
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Now, I write e-books and happy to say, the year is 2013, and I will continue as long as I can. I hope that when you purchase one of my books. My belief is you will enjoy the stories that I produce. I write like there is no tomorrow, so you will get my very best every time out.
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I am a self-employed grandmother looking for an honest gentleman that is interested in companionship and long term relationship. I am not wanting a quick one night stand. I will not tolerate dishonesty, had enough of that previously. I do have baggage, everyone at my age has some, but mine is on wheels and easily managed.
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—% Match
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61 • Cheney, WA • Woman
I'm looking for
- Men
- Ages 56–68
- Near me
- Who are single
- For new friends, long-term dating, short-term dating
My details
- Last online
- Mar 2
- Orientation
- Straight
- Ethnicity
- White
- Height
- 5′ 5″ (1.65m)
- Body type
- Rather not say
- Diet
- Mostly anything
- Smokes
- No
- Drinks
- Rarely
- Drugs
- Never
- Religion
- Christianity, and somewhat serious about it
- Sign
- Virgo, and it's fun to think about
- Education
- Graduated from two-year college
- Job
- Other
- Income
- Rather not say
- Status
- Single
- Type
- —
- Offspring
- Has kids, but doesn't want more
- Pets
- Likes dogs and has cats
- Speaks
- English (Fluently)
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My self-summary
Write a little about yourself. Just a paragraph will do.
What I'm doing with my life
Don't overthink this one; tell us what you're doing day-to-day.
I am enjoying getting to know the real me again as well as watching my grandchildren grow and develope. I love the sea shore and am planning on taking more trips to the ocean.
I'm really good at
Go on, brag a little (or a lot). We won't judge.
I have been told that I am a good listener and loyal friend. I try not to give advice but am willing to share my experience and my shoulders for someone to cry on. I have a logical mind and can figure things out.
Favorite books, movies, shows, music, and food
Help your potential matches find common interests.
I like mysteries eg; JD Robb, JA Jance, Steven King, Sue Garwood, etc. Favorite movies include Fiddler on the Roof, Shirley Valentine, Oh brother where art thou. Saw Fiddler on the Roof and The Lion King when the stage play came to Spokane, they were fantastic. I occasionaly go to the plays in Cheney. I like pretty much all music except Rap , don't understand it. My favorite food is fried chicken, home fried not KFC, Mexican, Italian, Steaks etc. Too many to list.
The six things I could never do without
Think outside the box. Sometimes the little things can say a lot.
My Lord, My freedom, my family, my friends, my faith, my love of life.
I spend a lot of time thinking about
Global warming, lunch, or your next vacation… it's all fair game.
how I can better my life and stay out of other people's affairs.
On a typical Friday night I am
Netflix and takeout, or getting your party on — how do you let loose?
out with my brothers having dinner and touching base.
The most private thing I'm willing to admit
I'm an empty essay… fill me out!
I am afraid of what will be.
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