Abstract: Keightly, Jenny In 1994, at the age of 26, Mrs. A underwent a tibialis anterior decompression at her left ankle for persisting lower leg pain related to tibialis anterior tendinopathy. Prior to the development of the tendinopathy she had been undergoing training for a half marathon. Following the surgery, the pain only worsened and she experienced twelve months of severe pain, swelling, coldness and tightness of the left ankle which eventually settled as she worked with her musculoskeletal physician using multiple methods such as counter-irritation, gradually increasing movement in the ankle, choosing supportive shoes and medication. Mrs. A believes medication was never very helpful and is averse to using any.
Abstract: Eivers, Tore Lateral hip pain is a common presentation in general practice and for those practising musculoskeletal medicine. The potential causes can be quite varied. Amongst the most common are referred pain from the lumbosacral spine and sacroiliac joints, hip joint, and disorders of the muscles and tendons inserting near or around the greater trochanter of the femur. The latter can be associated with collections of fluid within one of the many bursae that lie between and around these tendons and so the term "trochanteric bursitis" has been commonly used to describe the pathological entity responsible for the resulting pain. There is a growing awareness however, that the primary pathology is unlikely to be of the bursa but rather tendinopathy more akin to the rotator cuff tendinopathies of the shoulder. The term 'greater trochanteric pain syndrome' is perhaps a more apt description and what has been more commonly used in the recent literature.
Abstract: Vivian, David Canal stenosis is the narrowing of the canal through which the spinal cord and nerves travel. The spinal canal can be congenitally narrow, and whatever its original state, it tends to narrow further over time because of trauma and degeneration. This structural change can be a cause or a contributor to a patient's symptoms, but it is frequently present in the asymptomatic population. Lumbar canal stenosis (LCS) can cause symptoms, particularly lower extremity pain and/ or numbness, and neurogenic intermittent claudication (NIC), and perhaps low back pain.
Abstract: This review updates part of an earlier Cochrane review on 'Pregabalin for acute and chronic pain in adults' (Moore 2009), and considers only fibromyalgia pain. Antiepileptic drugs have been used in pain management since the 1960s. Pregabalin is an antiepileptic drug also used in management of chronic pain conditions, including fibromyalgia. Pain response with pregabalin is associated with major benefits for other symptoms, and improved quality of life and function in people with chronic painful conditions.
Abstract: Sandhu, Karan KG, a 55yo male presented to his general practitioner following a two-day history of moderate intensity low back pain that initially occurred during a cricket match. The patient was not experiencing any other associated symptoms and there were also no previous episodes of similar pain. On examination, he demonstrated restricted range of motion (secondary to pain) on lumbar flexion and extension. All remaining movements were within normal ranges and he also exhibited a normal straight leg raise.
Abstract: Vivian, David Coccygeal pain (also known as coccydynia and coccygodynia) refers to pain derived from the coccyx. The term defines a symptom rather than a diagnosis.
Abstract: Mathew, Ronnie Musculoskeletal pain is the third most common cause for presentation to a General Practitioner (GP). Of these presentations, shoulder pain is among the most common. Indeed, up to 95% of those with shoulder pain are treated at the primary care level.
Abstract: Kanji, Giresh; Menhinick, Peter Previous trials to assess the efficacy of lumbar traction for back pain have been methodologically flawed. To avoid these shortcomings, we conducted a randomised controlled trial in which high-dose traction was compared with sham traction. The sham traction was given with a specially developed brace that tightens in the back during traction. To the patient, the experience is that of traction. The patients and outcome assessor were blinded for the assigned treatment. 151 patients with at least six weeks of non-specific low back pain were randomised. Intention to treat analysis showed no differences between the groups on all outcome measures (patients' global perceived effect, severity of main complaints, functional status and pain); all 95 confidence intervals included the value zero. The number of withdrawals from treatment, loss to follow-up, and protocol deviations was low. Consequently, the per-protocol analysis showed results similar to the intention to treat analysis. Subgroup analyses did not show any group for which traction might seem promising. Our data do not support the claim that traction is effective for patients with low back pain.
Abstract: Kanji, Giresh; Menhinick, Peter This pilot study for a randomised clinical trial compares the effect of high-dose continuous lumbar traction and low-dose continuous lumbar traction on the magnitude and rate of recovery for patients with low back pain. A motorised traction force of 44% of the body weight was applied in the treatment group (n=13) and of 19% in the control group (n=12). Both groups were comparable before randomised treatment allocation. The patients were blinded successfully. The results for most outcome measures favoured high dose traction, treatment versus control group: 64% v 34% at five weeks, and 45% v 25% at nine weeks. These results are clinically substantial but do not reach statistical significance (95% confidence intervals include zero). Due to the small number of patients this study lacks power, therefore the 95% confidence intervals are very wide. With 50 patients in each group the 95% confidence intervals at five weeks would have excluded zero.
Abstract: Kanji, Giresh; Menhinick, Peter Low back pain (LBP) poses a significant problem to society. Although initial conservative therapy may be beneficial, persisting chronic LBP still frequently leads to expensive invasive intervention. A novel non-invasive therapy that focuses on discogenic LBP is Intervertebral Differential Dynamics Therapy (IDD Therapy, North American Medical Corp. Reg U.S.). IDD Therapy consists of intermittent traction sessions in the Accu-SPINA device (Steadfast Corporation Ltd, Essex, UK), an FDA approved, class II medical device. The intervertebral disc and facet joints are unloaded through axial distraction, positioning and relaxation cycles. The purpose of this study is to investigate the effect of IDD Therapy when added to a standard graded activity program for chronic LBP patients. In a single blind, single centre, randomized controlled trial; 60 consecutive patients were assigned to either the SHAM or the IDD Therapy. All subjects received the standard conservative therapeutic care (graded activity) and 20 sessions in the Accu-SPINA device. The traction weight in the IDD Therapy was systematically increased until 50% of a person's body weight plus 4.45 kg (10 lb) was reached. The SHAM group received a non-therapeutic traction weight of 4.45 kg in all sessions. The main outcome was assessed using a 100mm visual analogue scale (VAS) for LBP. Secondary outcomes were VAS scores for leg pain, Oswestry Disability Index (ODI), Short-Form 36 (SF-36). All parameters were measured before and 2, 6 and 14 weeks after the start of treatment. Fear of (re)injury due to movement or activities (Tampa Scale for Kinesiophobia), coping strategies (Utrecht Coping List) and use of pain medication were recorded before and at 14 weeks. A repeated measures analysis was performed. The two groups were comparable at baseline in terms of demographic, clinical and psychological characteristics, indicating that the random allocation had succeeded. VAS low back pain improved significantly from 61 (+/-25) to 32 (+/-27) with the IDD protocol and 53 (+/-26) to 36 (+/-27) in the SHAM protocol. Moreover, leg pain, ODI and SF-36 scores improved significantly but in both groups. The use of pain medication decreased significantly, whereas scores for kinesiophobia and coping remained at the same non-pathological level. None of the parameters showed a difference between the two protocols. Both treatment regimes had a significant beneficial effect on LBP, leg pain, functional status and quality of life after 14 weeks. The added axial, intermittent, mechanical traction of IDD Therapy to a standard graded activity program has been shown not to be effective.
Abstract: Kanji, Giresh; Menhinick, Peter Low back pain is one of the most significant medical and socioeconomic problems in modern society. International guidelines call for evidence-based management for the pain and disability associated with musculoskeletal disorders. The purpose of this randomised controlled trial is to address the question of efficacy and appropriateness of VAX-D (Vertebral Axial Decompression) Therapy, a new technology that has been shown in clinical research to create negative intradiscal pressures, and has been shown to be effective in treating patients presenting with chronic low back pain ( > 3 months duration) with associated leg pain. Successful outcome was defined as a 50% reduction in pain utilising a 10cm Visual Analogue Pain Scale and an improvement in the level of functioning as measured by patient-nominated disability ratings.
Patients were randomly assigned to VAX-D or to TENS which was used as a control treatment or placebo. The TENS treatment demonstrated a success rate of 0% while VAX-D demonstrated a success rate of 68.4% (P PubDate: Fri, 17 Nov 2017 22:20:26 GMT
Abstract: Kanji, Giresh; Menhinick, Peter Purpose: Backache and sciatica due to protuberant disc disease is a major cause of lost working days and health expenditure. Surgery is a well-established option in the management flowchart. There is no strong evidence proving that traction for sciatica is effective. We report a pilot prospective randomized controlled trial comparing inversion traction and physiotherapy with standard physiotherapy alone in patients awaiting lumbar disc surgery. This study sought to study the feasibility of a randomized controlled trial on the effect of inversion therapy in patients with single level lumbar discogenic disease, who had been listed for surgery.
Methods: This was a single centre prospective randomized controlled trial undertaken at the Regional Neurosciences Centre, Newcastle Upon Tyne, UK. It was a prospective randomized controlled trial where patients awaiting surgery for pure lumbar discogenic disease within the ambit of the prestated inclusion/ exclusion criteria were allocated to either physiotherapy or physiotherapy and intermittent traction with an inversion device. Post-treatment assessment made by blinded observers at 6 weeks for various outcome measures included the Roland Morris Disability Questionnaire (RMDQ) Score, Short Form 36 (SF 36), Oswestry Disability Index (ODI), Visual Analogue Pain Score (VAS), magnetic resonance imaging (MRI) appearance and the need for surgery. Avoidance of surgery was considered a treatment success.
Results: Twenty-six patients were enrolled and 24 were randomized [13 to inversion + physiotherapy and 11 to physiotherapy alone (control)]. Surgery was avoided in 10 patients (76.9%) in the inversion group, whereas it was averted in only two patients (22.2%) in the control group. Cancellation of the proposed operation was a clinical decision based on the same criteria by which the patient was listed for surgery initially. There were no significant differences in the RMDQ, SF 36, ODI, VAS or MRI results between the two groups.
Conclusion: Intermittent traction with an inversion device resulted in a significant reduction in the need for surgery. A larger multicentre prospective randomized controlled trial is justified in patients with sciatica due to single level lumbar disc protrusions.
Implications for rehabilitation: Resolution of impairment and disability due to radiculopathy is the aim of any intervention. Avoidance of surgery meant satisfactory resolution of impairment and disability due to radiculopathy. This happened more often in the inversion group to the extent of reaching statistical significance. The 12-point improvement in disability by the Oswestry Disability Index in the inversion group suggests a role for this intervention in disability reduction. Inversion may form part of the conservative rehabilitation of patients with single level unilateral lumbar disc protrusion alongside other forms of physiotherapy. There is a potential secondary impact in the reduction of rehabilitation following surgery.
Abstract: Kanji, Giresh; Menhinick, Peter Background: Effectiveness of inversion traction has been revealed in patients with chronic low back pain (CLBP), however, it is still unknown which angles of inversion traction positively affect patients with CLBP.
Objective: To investigate the angle-effects of inversion traction on pain sensation, lumbar flexibility, and trunk muscles (flexors and extensors) strength in patients with CLBP after an 8 week treatment program.
Methods: Forty-seven women suffering nonspecific CLBP for 23.00 +- 5.45 weeks were included prospectively and randomized into 3 groups: supine group (SG; n = 15), inversion -30 degrees group (I30G; n = 18), and inversion -60 degrees group (I60G; n = 14), respectively. Each group completed a 3-minute 3-set inversion traction protocol at 0 degrees, inverted -30 degrees, or inverted -60 degrees, respectively for 4 days a week during 8 weeks. The outcome measures included rating of pain using the visual analogue scale (VAS), flexibility of lumbosacral joint, and the isokinetic strength of the trunk flexors and extensors at 60 degrees/s.
Results: Pain was significantly improved after 8 weeks. The reductions observed in VAS scores were lower in the I60G compared with the changes in I30G and SG. Significant interaction effects were observed in trunk flexion and extension particularly in the I60G condition. There was also a significant increase in the extensor peak torque of the I60G.
Conclusions: Inversion traction at angle of -60 degrees reduced back pain or discomfort and improved lumbar flexibility and isokinetic trunk extensor strength in patients with CLBP following an 8 week program. Therefore, this treatment modality may be suitable for patient groups of similar CLBP phenomenology.
Abstract: Griffin, Heather Complex regional pain syndrome (CRPS) is a relatively uncommon, but painful and disabling condition. It is characterised by limb pain with sensory, vasomotor, sudomotor, motor and dystrophic changes, usually occurring after injury. The diagnosis can be difficult to make, as it lacks an objective test. The diagnosis is therefore based on clinical findings. The Budapest criteria are the accepted standard for this.
Abstract: Patel, Vinay; Kanji, Giresh Lumbar spine pain is the most common musculoskeletal complaint we see in practice. The disc has been found to be the most common source of lumbar spine pain. A disc prolapse occurs when the nucleus of the disc protrudes through a torn annulus. Disc bulges and prolapses can often cause irritation to an adjacent nerve root, and may cause radicular symptoms down the leg. Disc prolapse is often preceded by actions involving bending and lifting that place some pressure on the disc. The annular ligament is a layered structure and layers may sequentially tear, hence the final force that causes the nucleus to protrude may be minimal such as bending over. Disc prolapse accounts for diminished quality of life, as well as associated costs financially from medical care and lost earnings.
Abstract: McKay, ABreck Academic blindness occurs when researchers and reviewers, believing their confirmation bias, obtain or support further research funding and waste that funding on error laden hypotheses and research programmes. This paper addresses three examples, one internationally recognised whiplash research study and two examples of erroneous internationally recognised chronic low back pain (CLBP) research. The researchers persist in pursuing these false models despite confirmation bias errors being repeatedly demonstrated. The secondary problem of many peer reviewers also blinded by academic and confirmation bias is identified.
The author uses his personal experience, primary care observation, analysis and clinical research of the underlying anatomy, physiology and whole body function models to identify where the errors exist and why they need to be corrected. By considering the results of this primary care research, new and simple explanations for the results seen in whiplash injuries and CLBP can be more readily provided with explanations and managements developed in primary care, and immediately applicable throughout the world.
Further interpretation of the results has led the author to propose a better, simpler hypothesis leading to an understanding of the importance of enthesis damage and periosteal biomechanical injury in the onset and persistence of musculoskeletal pain, fibromyalgia (chronic widespread pain syndrome), chronic low back pain (CLBP), vertebral or bony degeneration and osteophytes, or spur formation visualised on imaging of the spine and other bony tissues.
These identified issues form the often ignored pain elephant in the room. Pain researchers have frequently been enticed by confirmation bias and trapped by fiscal servitude, merely for academic survival. Those asked to peer review appear to have also suffered from similar bias. The author raises the issue of research funds being wasted on programmes involving confirmation bias (confounded by academic blindness) and promulgates a potential method to prevent further inappropriate fund application approval.
Abstract: Chandra, Nathaniel In Australia in 2013, there were an estimated 4.7 million people over the age of 50 with either osteoporosis or poor bone health1. Generally under-diagnosed, osteoporosis was associated with 144 000 fractures in 2013. With the total cost of osteoporosis estimated to be approximately $7.4 billion per year, the burden of the disease and its complications are enormous.
Abstract: du Toit, Paul Francois Background: Total Knee Arthroplasty is a common and costly surgical procedure. The majority of patients have successful surgery and post operative rehabilitation, however, there is a group that fail to gain adequate ROM and develop chronic pain. There have been many studies demonstrating the effect of preoperative pain catastrophising as a predictor of chronic postoperative pain. The aim of this study is to assess the effect of pain catastrophising on functional outcome following total knee arthroplasty.
Methods: 50 patients were included in a study over a period of one year at the Eden Rehabilitation Centre. The patients completed a Pain Catastrophising Scale (PCS) on admission and then their functional outcome was measured on their discharge using ROM, Timed Up and Go (TUG) and Functional Independence Measure (FIM).
Results: There was no statistical evidence that pain catastrophising postoperatively had any effect on functional outcomes. There was, however, a significant difference between the PCS reported by the male patients compared to the female patients. Conclusion: The data from this study does not support the PCS being used post-operatively as a screen for poor functional outcome.
Abstract: McBride, David Carpal tunnel syndrome (CTS) is a condition best described as a 'constellation of symptoms:' a pattern or arrangement which is more complex than most. A CTS patient may therefore present an 'ill structured clinical problem,' the diagnosis of which must be approached with caution, and a thorough understanding of the pathophysiological mechanisms which contribute.
Abstract: Ganderton, Charlotte; Cook, Jill; Docking, Sean; Rio, Ebonie; van Ark, Mathijs; Gaida, Jamie Achilles tendinopathy is commonly encountered in clinical practice yet can be quite difficult to successfully treat. Relative overload is the precursor to most presentations, while systemic conditions can decrease the amount of load that triggers overload. While there is evidence for the use of eccentric exercise, it is not recommended in isolation for most presentations of Achilles tendinopathy as it fails to address strength and kinetic chain deficits, which can leave the individual vulnerable to recurrence. Insertional tendinopathy requires a tailored management that avoids dorsiflexion, as this position compresses the tendon onto the calcaneus.
Purpose: This masterclass summarises the tendinopathy continuum and articulates the authors' clinical reasoning and hands-on experience managing Achilles tendinopathy. We outline graded loading concepts while emphasising that relying on recipes is likely to fail. We also provide a perspective on the role of central pain processing and peripheral input from nociceptive fibres in the context of tendinopathy.
Inplications: Rehabilitation should be tailored to address identified impairments (muscle bulk asymmetries, kinetic chain dysfunction, tolerance of energy storage and release in the Achilles tendon), and progressively work toward movements and activities relevant for the individual's sport or daily activities. Within the three-stage rehabilitation sequence, stage 1 aims to reduce pain and increase calf muscle bulk; stage 2 focuses on improving power within the whole kinetic chain, and movement control during jumping and landing; and stage 3 begins to retrain sport specific load, and carefully introduces movements that require energy storage and release within the tendon.
Abstract: Kanji, Giresh Low back pain is the most common musculoskeletal complaint. In surveys 60 to 69% of 40 year olds have experienced low back pain in the last year with over 80% experiencing low back pain within their lifetime1. The origin of spinal pain has been elusive with many pain textbooks stating that up to 85% of low back pain is of unknown origin. The integration of new technologies such as MRI for spinal pain has not been fully established. This article will attempt to outline pain generators in the lumbar spine to present a model of spinal pain which integrates pathology, neurophysiology and central nervous system pain sensitivity.
Abstract: Krechman, Belinda As a clinician dealing with musculoskeletal pains on a daily basis, patients often have a chief musculoskeletal pain complaint that becomes aggravated by their work situation; daily tasks or ergonomic settings. Office work is dominated by keyboarding while looking at visual display units often in a seated position. Poor sitting postures have been shown to have a strong influence in the development and perpetuation of musculoskeletal dysfunctions (MSD). Work related MSD as a result of prolonged poor sitting postures, means a musculoskeletal complaint that may have been induced by work and also worsens during working hours and days.
Abstract: Kanji, Giresh; Weatherall, Mark; Peter, Raja; Purdie, Gordon; Page, Rachel Objective: Chronic tension-type headache (CTTH) is a chronic syndrome characterized by frequent headache occurring more than 15 days per month. The intensity and duration of headache pain can be very distressing and disabling on an individuals' well-being. The purpose of this study was to examine the applicability of sauna bathing as a new method of treatment for reducing pain in patients with CTTH.
Methods: Thirty-seven people who fulfilled the International Headache Society criteria for CTTH were randomly assigned into two groups. The control group (n = 20) received advice and education while the intervention group (n = 17) received the same advice and attended a sauna regularly for 8 weeks. Reductions in subjective pain were determined using the numerical pain rating scale (NPRS). Disturbance in sleep, depression as assessed by Beckman Disability Index (BDI), and Headache Disability Index (HDI) were measured.
Results: Mean change in headache intensity significantly differed between the sauna and control group by 1.27 (95% confidence interval, 0.48-2.07; F = 10.17; df = 1, 117; p = 0.002). There was no statistically significant change in duration of headache or improvement in sleep, depression, or HDI between the sauna and control groups.
Conclusion: Regular sauna bathing is a simple, self-directed treatment that is effective for reducing headache pain intensity in CTTH.
Abstract: Baster, Thomas Obesity is a common association with the musculoskeletal pain patient and can create significant treatment barriers. The current advice and treatment for obesity is ineffective in most cases. There are probably components in the contemporary food chain that are contributing to the epidemic of obesity. Such components include an excess of omega 6 fatty acids which contain linoleic acid, trans and saturated fats, excess refined carbohydrates, sugar and salt intake. The saturated fats and linoleic acid result in a low grade inflammatory state and activation of the endocannabinoid system that can lead to obesity. Such dietary items should ideally be minimised. Other food items that need to be increased in consumption are those with omega 3 fatty acids, with polyphenols and containing fructans. Exercise is more of a weight maintenance tool. If obesity is addressed as part of a comprehensive approach to a musculoskeletal pain case, the clinical emphasis should be directed towards providing healthy eating advice, as successful weight loss is difficult for most patients.
Abstract: Khor, KE Chronic pain has generally been defined as "pain that persists beyond normal tissue healing time, which is assumed to be about 3 months". It is now well known that the prevalence of chronic pain in Australia is about 20% overall. Of these, 33% of patients experience significant interference of activities of daily living by pain. This high number, coupled with the immense burden of chronic pain, means the management of chronic pain would need to be undertaken at all levels of medical care, mainly at the primary care level and supported by appropriate specialists and secondary and tertiary pain management centres.
Abstract: Bogduk, Nikolai This article continues the consideration of truth in diagnosis by addressing validity. Whereas reliability measures the extent to which two observers agree when using the same test on the same population, validity measures the extent to which the test actually does what it is supposed to do.
Abstract: Brooks, Christine M Age-related decline in lean body mass is often associated with serious functional impairment during the older years. In 1988 Irwin Rosenberg suggested using the term "sarcopenia" to bring attention to the condition and to stimulate research that would provide an understanding of what caused skeletal muscle wasting as one ages. In this paper the medical practitioner is provided with a clinically relevant base of knowledge for counselling older patients about how to avoid or delay the onset of disability due to their gradual reduction in muscle mass as they get older. Six issues are briefly discussed, including how to categorise sarcopenia, progression of sarcopenia throughout the lifespan, impact of an inactive lifestyle, the effect of age on muscle composition, how to detect sarcopenia in the clinical setting, and the effect of exercise interventions. Age-related skeletal muscle decline is often accelerated due to inactivity. Data from master athletes suggest it is possible to slow the progress of muscle wasting through physical activity. Inactivity, on the other hand, accelerates muscle wasting. Resistance training is a useful intervention strategy for the medical practitioner to recommend highly to all patients.
Abstract: Masters, Scott Persistent spinal pain is a common problem in the community, affecting around 10% of the Australian population. It is one of the most common causes of work insurance claims and causes of disability. Care of these people is often left in the hands of primary care health practitioners. These patients often fall outside the scope of specialist care in that they are most commonly suffering from a non-operative, non-rheumatologic condition.
Abstract: Krechman, Belinda The following two case studies from a clinical myotherapy practice are described to distinguish between piriformis syndrome (PS) and lumbar radicular leg pain (sciatica). The differences in etiology and symptoms will be outlined as well as the administered treatments. Patient identity has been changed to preserve confidentiality.
Abstract: Brooks, Christine Review(s) of: Oxford handbook of sport and exercise medicine, 2nd edition, by Domhnall MacAuley, Oxford University Press, Oxford, UK. 2013, 755 pp. ISBN 9780199660155, softcover, New on Amazon for $39 - $60 and used for $22 plus shipping charges, Also available as a eBook.
Abstract: Masters, Scott Review(s) of: Emergencies in sports medicine, by Dr Julian Redhead and Dr Jonathon Gordon, Oxford University Press, Oxford, UK. 2012, Available from Oxford University Press or Amazon for around $47.95 plus shipping.
Abstract: Agraval, Kyal Since early times low back pain with radicular leg pain has been described by medical authorities, including Hippocrates, Schmorl and Dandy. However, the causal relationship between the disc and radicular leg pain was only first clearly made in the seminal article on disc herniation by Mixter and Barr in 1934. Key discoveries in history which helped establish our understanding of discogenic back pain are presented in this article. Method: Using Pubmed a search was undertaken to locate the relevant medical literature. Search terms, including discogenic back pain, discovery of causes of back pain, and historical perspective low back pain, were applied. Articles that seemed to be significant were sourced from the Peninsula Health Library. Any relevant articles that were discovered by cross-reference were also perused where available. Some of the literature was reviewed only in abstract form.
Abstract: Baster, Thomas The endocannabinoid system is an endogenous lipid signalling system in all vertebrates. It has multiple important functions including the modulation of pain and it could have a significant role in the future in the clinical management of both acute and chronic pain. It consists of several receptors and ligands, with the most studied components being the receptors CB1 and CB2 and the endogenous ligands AEA and 2AG.
Abstract: McGrath, Ella; Yelland, Michael; van Driel, Mieke Osteoarthritis (OA) is the most common form of arthritis and is a source of chronic pain, disability and decreased quality of life for many people, particularly adults over 50. It affects more than 1.3 million Australians and affects females to males in a 3 to 1 ratio. Management of OA is a challenge for health care professionals. There are a wide range of management options that have varying levels of evidence for their efficacy. These include exercise, ambulatory aids, weight loss, pharmaceuticals, surgery, intra-articular injections and complementary medicines (CAM). In 2004-5, the Australian Bureau of Statistics National Health Survey (ABS NHS) established that 40% of Australians with OA use pharmaceuticals and 46% use dietary supplements. One of the most common supplements taken in Australia is glucosamine. It is also available in a combination tablet with chondroitin. Twenty six per cent of females and 21% of males with OA in the ABS NHS reported taking glucosamine.
Abstract: Juul-Kristensen, B; Remvig, L; Engelbert, RHH There are no precise prevalence rates of adults with generalised joint hypermobility (GJH), and in a recent review the prevalence for adults varies from 2% to 57% depending on age, gender and ethnic origin. For children the prevalence varies from 7% to 36%, primarily depending on the tests and criteria (especially the cut-off points) used for diagnosing GJH.
Abstract: Lee, MWL; McPhee, RW; Stringer, MD The dermatome is a fundamental concept in human anatomy and of major importance in clinical practice. There are significant variations in current dermatome maps in standard anatomy texts. The aim of this study was to undertake a systematic literature review of the available evidence for the distribution of human dermatomes. Particular emphasis was placed on the technique of ascertainment, the location and extent of each dermatome, the number of subjects studied, and methodologic limitations. Our findings demonstrate that current dermatome maps are inaccurate and based on flawed studies. After selecting the best available evidence, a novel evidence-based dermatome map was constructed. This represents the most consistent tactile dermatomal areas for each spinal dorsal nerve root found in most individuals. In addition to highlighting the orderly arrangement, areas of consistency and clinical usefulness of dermatomes, their overlap and variability deserve greater emphasis. This review demonstrates the validity of an evidence-based approach to an anatomical concept.
Abstract: Koulouris, George; Mehta, Ojas Hrakesh Back pain is an enormous clinical, social and economic problem, with up to 85% of adults experiencing back pain at some stage during in their lifetime.1 Chronic low back pain has many causes that can generally be divided into degeneration of the intervertebral discs (39-42%), facet joints (31%) and sacroiliac joints (18%).2,3 Although disc disease is implicated in all ages, sacroiliac and facet joint arthropathy are more frequently seen in older patients.
Abstract: Murtagh, John As a septuagenarian reflecting on a medical career of over 50 years, I remain firmly convinced of the primary and key role of doctors, especially general practitioners, in physical and procedural musculoskeletal medicine (MSM). During my time in over a decade of rural general practice I said many times that I could not have managed effectively without the knowledge and associated skills of manipulative medicine and all that emanated from it. This conviction and philosophy developed from experiences (outlined in this paper) prior to studying medicine. The journey has been controversial and stressful at times but counterbalanced by the many rewards. My approach has modified over the decades and these changes and the reasons for them will be presented.
Abstract: Taylor, Margaret E Research into prolotherapy continues in several centres and some recent published papers are presented here with comments.
Abstract: Thompson, Grant Greater trochanteric pain syndrome (GTPS) is a common and frequently debilitating condition presenting with pain at or around the greater trochanter, sometimes referring to the lateral hip or lateral thigh. The condition is often chronic.
Abstract: Jensen, Steve Shoulder pain is very common. It has been estimated that approximately 10% of the adult population will experience an episode of shoulder pain in their lifetime, whilst shoulder pain is the third most common musculoskeletal presentation in general practice, after low back and neck pain. It has also been reported that up to 41% may have persistent symptoms at 12 months. The astute clinician needs to be able to differentiate between potential sources of "shoulder" pain, including intrinsic conditions of the shoulder joint complex, the neck and, uncommonly, non-musculoskeletal conditions...This paper provides a summary of available data pertaining to pain referral zones as a result of musculoskeletal conditions which may present as "shoulder" pain.
Abstract: Baster, Thomas J A neurotrophin called nerve growth factor is present in the intervertebral disc in low levels and is upregulated following injury and by inflammation, with an increase in nociceptive neurons. Brain-derived neurotrophic factor is also upregulated by inflammation and this can lead to neo-vascularization and neo-innervation. Whilst glial-derived neurotrophic factor is increased in the dorsal root ganglion following disc inflammation, the implication of this is unclear. Finally a semaphorin known as Sema3A, which has an inhibitory effect on neuron growth, is reduced in the disc following injury and this may tip the balance towards neo-innervation.
Abstract: Mitchell, Bruce; Verrills, Paul; Vivian, David Over the last two decades, the sacroiliac joint (SIJ) has increasingly been recognized as an anatomical source of pain that figures in the differential diagnosis of a patient presenting with low back pain (LBP) and/or buttock pain with or without more distant referred pain.1-7 The SIJ is innervated and thus has the potential to be a source of pain.
Abstract: Brooks, Christine M Core stability training has gained wide acceptance as a treatment for low back pain rehabilitation, maintenance of a healthy back, and improved sport performance. This article examines aspects of core stability/strength exercise program approaches, with a focus on research suggesting that core stability and core strengthening programs are misconceived. It outlines a brief overview of spinal stability research and its application to core stability/strengthening programs within both the rehabilitation and sport performance enhancement sectors and briefly explains why these programs violate essential motor control and training theory principles.
Abstract: Bogduk, Nikolai What medical education did not teach is how to be discerning. Medicine never admitted that its professors might be wrong. It did not teach students how to question the professor. For undergraduate purposes this might be pragmatic. There is so much to learn. We cannot afford the time to question and justify everything, so we have to take what is taught on trust. But in the postgraduate arena these concessions should not apply. Trust can be abused. For new knowledge, serious questions serve to protect kindly but compliant practitioners from gullibility...Many examples might be invoked, but I shall illustrate with two. The first exemplifies simple, forensic, bibliographic enquiry. The second illustrates the application of the rules of biostatistics.
Abstract: Ng, Charlie During 2011-2012, NZAMM has been continuing its cycle of educational activities. Central to this are the musculoskeletal workshops presented around the country by musculoskeletal physicians. Last year's workshop theme was "The Shoulder". The workshops were well received by participants in Rotorua, Wellington, and Auckland. The theme for the 2012 workshops is "Low Back Pain". This along with other topics will be presented at the NZMA GP CME meeting in Rotorua on 7 June 2012 and at other meetings during the year.
Abstract: Harding, Geoff These days I find myself wondering about the state of medicine in Australia, especially that of general practice. Of course, I am no expert on the subject given that I have been in full-time musculoskeletal medicine since about 1989. However, I do read the press and have discussions with colleagues who are in general practice, and I am also privy to the impressions of those patients who come to see me about their musculoskeletal pain problems. There seems to be a paradoxical change underway where, in spite of care plans and improved technology, and the growth of large multi-doctor clinics, many patients are actually feeling depersonalised by the "system".
Abstract: Govind, Jayantilal Stakeholders who have a vested interest in the management of personal injury claims and more so in the management of chronic axial pain coincidentally demonstrated an acute attitudinal change with the publication of the International Association for the Study of Pain's (IASP) monograph on Back Pain in the Workplace. By denying the reality of chronic axial pain, this monograph defined chronic low back pain not as a "medical problem," but as a problem of "activity intolerance".
Abstract: McGuirk, Brian; Ghabrial, YAE; Bogduk, Nikolai General practitioners and the public have the impression that back pain is a condition for which there is a surgical treatment and which, therefore, warrants treatment by orthopedic surgeons. Consequently, patients with back pain constitute a substantial proportion of patients referred to orthopedic outpatients. This load limits the time available for consultants to provide comprehensive and non-surgical care. Meanwhile, evidence-based guidelines for the management of back pain emphasize the need for explanation, assurance, and activation, and the avoidance of passive treatment and the use of investigations. The required management is distinctly medical, and not surgical, in nature. The present study reports the results of an innovation in which a physician was appointed to provide care for patients with back pain referred to orthopedic outpatients.
Abstract: Broadhurst, Norman A; MacLaren, Shane F This is the final report of stage I of the Shoulder Imaging Project financed by the Commonwealth Department of Health and Ageing.
Abstract: Govind, Jayantilal; Bogduk, Nikolai; Lau, P According to the World Health Organization, patients with severe headaches or migraine suffer the same degree of disability as a patient with quadriplegia or dementia. Population-based studies confirm that the impact of severe headaches on the quality of life is substantially burdensome. Severe and persistent pain is often associated with profound personal suffering and the increased risk of suicide is not uncommon. ln the Australian context, headaches generate some two million consultations (13%) annually at a cost of greater than $700 million per annum.
Abstract: Baster, Thomas This paper reviews the current literature relating to the use of anaesthetic blocks and radiofrequency ablation of the rami communicans at the L2 level. It is based on searches of Pubmed and Scirus of keywords "rami communicans", "L2 block", "DRG block L2", "Radiofrequency ablation lumbar back pain", and "lumbar disc innervation" It was prepared with the assistance of the library service at Griffith University.
Abstract: Baster, Thomas Bob (not actual name) aged 48 was not happy, as his chronic low back pain (cLBP) prevented him riding his Harley Davidson motorbike. He had been involved in a serious accident whilst serving in the Armed forces when a heavy tank rear door had struck him, resulting in fractures to his left femur, right femur, dislocated hips and left potts fracture about 20 years previously. He had developed low back pain about eight years ago and had been on the usual treatment circuit: physiotherapy, chiropractic, specialists, acupuncture, and even had tried Blomberg injections.
Abstract: Douglas, William This article outlines the development of the current concept of fibromyalgia syndrome (FMS). It reviews current management strategies and discusses the medicolegal implications associated with FMS. The important, documented psychological associations with FMS have received little recognition by many rheumatologists. Psychological factors are not mentioned in either ACR Criteria. The EULAR 2010 guidelines for management of FMS have brief recognition of this association. Integrating the work done by psychiatry and internal medicine in relation to FMS would only benefit and not disadvantage sufferers with this condition.
Abstract: Cleary, Mike; Ng, Charlie We have been considering our place in the NZ medical system from the point of view of our colleagues in general practice and specialist practice. There has been frustration with the lack of recognition of our existence, experience, and expertise by the Health Workforce tasked with planning for the future of the NZ medical manpower. While we may seethe at this, it seems ignoring musculoskeletal conditions is an international problem with medical school curricula as judged by the recent article in the May 27th NZMJ, called "Basing musculoskeletal curriculum changes on the opinions of practicing physicians" who sought to survey "...practicing clinicians who manage these conditions, to find out their opinions on which disorders they regard as most important. This information will then be used to inform curriculum design." No prizes for guessing which group of practising clinicians was not surveyed! Charlie has sent the Health Workforce person briefed with musculoskeletal education a CV of our organisation and, as I write, I sense that the NZMJ is receiving correspondence on the above article.
Abstract: Harding, Geoff This year we have seen the topic of health raised almost daily in this country. Healthcare costs the community lots of dollars and the politicians are always trying to deal with the ever-increasing drain on the budget. Whilst the focus usually is on hospitals and general practice, there are many other areas where changes are being made.
Abstract: Chow, Roberta T; Johnson, Mark I; Lopes-Martins, Rodrigo AB; Bjordal, Jan M Background. Neck pain is a common and costly condition for which pharmacological management has limited evidence of efficacy and side-effects. Low-level laser therapy (LLLT) is a relatively uncommon, non-invasive treatment for neck pain, in which non-thermal laser irradiation is applied to sites of pain. We did a systematic review and metaanalysis of randomised controlled trials to assess the efficacy of LLLT in neck pain. Methods. We searched computerised databases comparing efficacy of LLLT using any wavelength with placebo or with active control in acute or chronic neck pain. Effect size for the primary outcome, pain intensity, was defined as a pooled estimate of mean difference in change in mm on 100 mm visual analogue scale. Findings. We identified 16 randomised controlled trials including a total of 820 patients. In acute neck pain, results of two trials showed a relative risk (RR) of 1 69 (95% CI 1 22-2 33) for pain improvement of LLLT versus placebo. Five trials of chronic neck pain reporting categorical data showed an RR for pain improvement of 4 05 (2 74-5 98) of LLLT. Patients in 11 trials reporting changes in visual analogue scale had pain intensity reduced by 19 86 mm (10 04-29 68). Seven trials provided follow-up data for 1-22 weeks after completion of treatment, with short-term pain relief persisting in the medium term with a reduction of 22 07 mm (17 42-26 72). Side-effects from LLLT were mild and not different from those of placebo. Interpretation. We show that LLLT reduces pain immediately after treatment in acute neck pain and up to 22 weeks after completion of treatment in patients with chronic neck pain. Funding. None.
Abstract: Choong, Thomas Osteoarthritis is the most common form of arthritis. It affects millions of people in Australia and many more worldwide. Osteoarthritis, at this point in time, has no cure. The significance of this disease is illustrated not only by its prevalence in the community, but also by the impact it has on that community. It affects patients in terms of pain and disability, financial costs, and quality of life. It also imposes a financial burden on all levels of society - the family, local community, business, and government. And its impact is increasing with time in line with the phenomenon of the ageing population.
Abstract: Pietzsch, Tibor Thomas The first record of epidural injections is from France. In 1901 Sicard and Catherine and in 1909 Coussade and Chauffard used epidural injection to relieve back pain. I could find no actual record of what substance they injected, but there is a suggestion, that it was either cocaine or a narcotic.
Abstract: Douglas, Robert Objective. Acute tendinopathy is an injury that is commonly seen in general practice and sports medicine clinics. Management of the condition can be difficult, and has traditionally been limited to rest, NSAIDs, and adjuncts such as ice and physiotherapy. The aim of this study was to determine the efficacy and tolerability of a "polypill" comprising ibuprofen and doxycycline, with adjunctive use of omega-3 fatty acids ("fish oil") and green tea. Method. Patients with symptoms determined to be due to an acute tendinopathy were identified. After informed verbal consent, they were offered treatment with the polypill. Results. Initial review occurred 1-3 weeks after commencement of treatment - 19/20 patients reported an improvement in symptoms at this review. Half of the patients reported resolution of symptoms at five weeks or less. 15 patients (75%) were able to complete their prescribed polypill course. Only two patients (10%) ceased polypill treatment as a result of adverse effects. One patient failed to report any change in symptoms. The median and mode duration of treatment with the polypill was four weeks. Conclusion. The resolution (or improvement) of symptoms in most patients in four weeks or less suggests that the observed effect of the polypill therapy for most patients may be due to the combined anti-inflammatory and analgesic effects of ibuprofen. There may be only a subgroup of patients suffering from an acute tendinopathy for whom the polypill is appropriate treatment. Suggestions are made for areas of further polypill research.
Abstract: Williams, Nefyn H The initial clinical assessment of spinal pain consists of diagnostic triage into (i) serious spinal pathology, (ii) other pathological entities, and (iii) non-specific symptoms. The non-specific group comprises the major burden of spinal illness. There are two broad approaches to the diagnostic challenge of non-specific spinal pain. One approach is to split the group into sub-groups explained by separate pathophysiological abnormalities. The focus of this work is to describe these proposed abnormalities in greater detail and to discover which clinical features distinguish them. The other approach is to lump all of those with non-specific features into one group, and consider the common psychosocial factors that are relevant to the whole group. A variety of pathological and non-pathological models have been proposed. Pathological models include ligament laxity, facet syndrome, discogenic pain, spondylosis, and instability. Non-pathological models include a pain-spasm-pain cycle, muscle inhibition and deconditioning and somatic dysfunction. All of these models are problematic and do not fully account for all of non-specific spinal pain. Another approach is to consider these two different approaches together and to consider this non-specific category as orthogonal dimensions of pathology and dysfunction.
Abstract: Collinson, Gary The last six months has been busy for the officers and executive of the Association. Late in March many months of organization finally came to fruition with the conference "Spine in Action: Low Back Pain - Can Chronicity be Prevented'" This was held at the Rendezvous Hotel in Auckland.
Abstract: Harding, Geoff It has been almost 12 months since the AGM on the Gold Coast and my election as president of the AAMM. I am sorry to say that I had planned to ensure that we had had an issue of the Journal to you long before this. No excuses can be offered except that time seems to be in great demand these days.
Abstract: Watt, PJames Background and purpose. Patients with chronic headache and neck pain often were found to have continuing dysfunction in the cervical spine. The purpose of this study is to determine the effectiveness of a specific mobilization technique, sustained segmental post-isometric relaxation (SSPIR), for treatment of these patients. Subjects. There were 27 consecutive subjects with chronic neck pain. Methods. A specific mobilization technique was used. The technique was repeated at each follow-up, with a specific home-exercise prescribed between consultations. Results. Nineteen patients reported improvement to 85-100% of normal at one-year follow-up. Six relapsed after initial improvement and continued to have pain at one year. None was worse after treatment than at entry. One was lost to follow up. Discussion. The results suggest effectiveness of the treatment but there are significant sources of bias. Conclusion. The apparent effectiveness of this mobilization technique warrants further study. Summary. A case series of 27 consecutive chronic neck pain patients from the author's practice who had symptoms of neck pain or headache for a mean of 40 months were treated on average twice with a specific treatment technique. At telephone follow up, a minimum of a year later, 19 (70%) reported improvement to 85-100% of normal. While the study has a number of potential areas for criticism, the results warrant further investigation.
Abstract: Chou, Roger; Fu, Rongwei; Carrino, John A; Deyo, Richard A Background. Some clinicians do lumbar imaging routinely or in the absence of historical or clinical features suggestive of serious low-back problems. We investigated the effects of routine, immediate lumbar imaging versus usual clinical care without immediate imaging on clinical outcomes in patients with low-back pain and no indication of serious underlying conditions. Methods. We analysed randomised controlled trials that compared immediate lumbar imaging (radiography, MRI, or CT) versus usual clinical care without immediate imaging for low-back pain. These trials reported pain or function (primary outcomes), quality of life, mental health, overall patient-reported improvement (based on various scales), and patient satisfaction in care received. Six trials (n=1804) met inclusion criteria. Study quality was assessed by two independent reviewers with criteria adapted from the Cochrane Back Review Group. Meta-analyses were done with a random effects model. Findings. We did not record significant differences between immediate lumbar imaging and usual care without immediate imaging for primary outcomes at either short-term (up to 3 months, standardised mean difference 0.19, 95% CI -0.01 to 0.39 for pain and 0.11, -0.29 to 0.50 for function, negative values favour routine imaging) or long-term (6-12 months, -0.04, -0.15 to 0.07 for pain and 0.01, -0.17 to 0.19 for function) follow-up. Other outcomes did not differ significantly. Trial quality, use of different imaging methods, and duration of low-back pain did not affect the results, but analyses were limited by small numbers of trials. Results are most applicable to acute or subacute low-back pain assessed in primary-care settings. Interpretation. Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition.
Abstract: McGuirk, Brian; Ghabrial, YAE General practitioners and the public have the impression that back pain is a condition for which there is a surgical treatment and which, therefore, warrants treatment by orthopedic surgeons. Consequently, patients with back pain constitute a substantial proportion of patients referred to orthopedic outpatients. This load limits the time available for consultants to provide comprehensive and non-surgical care. Meanwhile, evidence-based guidelines for the management of back pain emphasize the need for explanation, assurance, and activation, and the avoidance of passive treatment and the use of investigations. The required management is distinctly medical, and not surgical, in nature. The present study reports the results of an innovation in which a physician was appointed to provide care for patients with back pain referred to orthopedic outpatients.
Abstract: Vivian, David Coccygeal pain (also known as coccydynia and coccygodynia) refers to pain derived from the coccyx. The term defines a symptom rather than a diagnosis. Coccydynia was first described by Petit in 1726, as "caries of the coccyx." Understanding of its etiology has varied significantly during its history. At the beginning of the twentieth century, coccydynia was thought to derive from trauma, and coccygectomy was a common procedure. During the early twentieth century coccydynia was understood to be the result of neurosis and hysteria. Coccydynia is now understood to result from a number of specific conditions, but the etiology of many cases remains unknown.
Abstract: Bogduk, Nikolai The fundamental reason I pursue the diagnosis of discogenic pain is that patients have no other valid alternative. Patients with chronic back pain get caught in a circus. They are told that there is nothing wrong with them medically; or they are told something fallacious, such as they once did have nociception, but that has now ceased, and now they have only a "memory" of that pain. Under those conditions, medical treatment will not help, and the only prospect of treatment is behavioural and physical rehabilitation. But that treatment does not work. The patients still have pain. Yet again they are told there is nothing wrong. They failed rehabilitation, and the only recourse is to repeat it.
Abstract: Collinson, Gary The year 2009 has started off fast enough for everyone and it is poignant to think we are already half way though the year. As always, there is so much to do and so little time to do it. The Executive has met regularly and continues to discuss a number of issues that affect the Association and musculoskeletal medicine in New Zealand. The exciting news is that the Department of Orthopaedics and Musculoskeletal Medicine at the Christchurch School of Medicine, University of Otago, has secured a Post-Graduate Masters in Pain Medicine and Management. The convener, Dr Jim Borowczyk, will be offering the program as of 2010. This is a unique and significant achievement that can only enhance the quality of pain management in New Zealand. The Christchurch Department of Orthopaedics and Muscu loskeletal Medicine can now offer a range of post-graduate qualifications from a Certificate, Diploma, and now a Masters in our field of interest and expertise.
Abstract: Oei, Michael As I am approaching the end of my term as president of the AAMM, I am sorry to say that musculoskeletal medicine in Australia as well as world wide has not made any inroads for specialty recognition. Musculoskeletal medicine is going through a difficult time in attracting new members. Unless there is a career path at the end of the training and better Medicare rebates, it will be difficult to entice our younger GP colleagues to commit their time and money to do any MSK postgraduate training. Currently the Association is too small a group to have any real bargaining power with the government policy makers. In order for the government to consider musculoskeletal medicine as an entity, we need to make back pain a national health issue.
Abstract: Govind, J Stakeholders who have a vested interest in the management of personal injury claims and more so in the management of chronic axial pain coincidentally demonstrated an acute attitudinal change with the publication of the International Association for the Study of Pain's (IASP) monograph on Back Pain in the Workplace. By denying the reality of chronic axial pain, this monograph defined chronic low back pain not as a "medical problem" but as a problem of "activity intolerance". Yet paradoxically, the same monograph advocated that the "medical management" should not be "pain contingent" but rather "time contingent". The rationale for this was not articulated, and evidentiary basic science - as one would expect in cardiorespiratory and other medical disorders - was conspicuously absent. The taskforce further recommended that those who fail to achieve restoration of function and return to work were to be reclassified as "unemployed". Despite its irony, it is a sad commentary for the premier scientific body in pain medicine to deny the existence of chronic axial pain, to encourage unemployment and its psychosocial upheavals and for this Task Force to promote itself as a self-appointed surrogate gatekeeper to a non-medical system principally ensconced in claims management, cost containment and cost reduction. (non-author abstract)
Abstract: Wilk, V In an earlier paper the author examined the correlation between lumbar disc morphological changes and pain in the general population. Certain changes in the disc can be seen on MRI that do correlate with pain, but are nonetheless present in significant proportions of the normal population. The author also examined some of the key evidence questioning the validity of provocative discography as the gold standard in diagnosing discogenic pain. The debate on discography continues and whether there is a clinical role for discography. In this article the author examines the principle of provoking pain to make a specific diagnosis. (non-author abstract)
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