Soft tissue, hard tissue - keys to diagnosing and managing musculoskeletal diseases | |
MJA Practice Essentials -- Rheumatology. Peter M Brooks,
editor. Sydney: Australasian Medical |
The burden of
arthritis and musculoskeletal problems is increasing
as the Australian population ages -- even though age itself is an
association rather than a cause. Although more than 10% of general
practitioner consultations relate to musculoskeletal problems,
the emphasis in medical school and postgraduate teaching is hardly
commensurate with the prevalence of these conditions.
So, MJA Practice Essentials -- Rheumatology, which outlines current knowledge and practice of rheumatology, is topical and fills a decided gap in the market. The articles were originally published in the Medical Journal of Australia in 1996-1997. Peter Brooks, the Editor, has deftly chosen the authors, and most have a well justified international reputation for their contributions to our understanding of the multifaceted conditions they are asked to discuss. Evidence-based guidelines are stressed -- the reality is that for some (even common) conditions the list is depressingly short. The emphasis on soft tissue rheumatic complaints and neck and back pain is to be applauded, although with so many conditions some have been ignored or only briefly discussed. Milton Cohen (who has a long term interest in the pathophysiology of pain) courageously states that "Most cervical or lumbar pain is not associated with serious disease". I agree, but the unexpected can still catch us out. Certainly with lumbar pain, "...precise anatomical diagnosis is often not possible", and even magnetic resonance imaging is of no value in routine investigation of back pain. The limitation of imaging in the management of many rheumatic conditions is appropriately stressed. Readers should welcome the model discussion of fibromyalgia by Geoffrey Littlejohn, who convinces us that there is a management strategy for a condition we believe is frequently impossible to treat. As a minor point in the chapter on polymyalgia rheumatica, I would take issue with the recommended starting dose of prednisolone (15 mg per day), as we are dealing with an elderly population taking long term steroids. I find that in many patients the condition can be controlled with a lower dose, and that steroid side effects are significantly related to the initial as well as the cumulative dose of prednisolone. Treatment boxes and algorithms work well in the discussions on rheumatoid arthritis, osteoarthritis, gout and osteoporosis. There is a chapter on the toxicity of antirheumatic drugs -- the long list of potential side effects of non-steroidal anti-inflammatory drugs makes one wonder why they are still so widely used. However, it should be emphasised that serious side effects, apart from those affecting the gastro intestinal tract, are rare. Overall, the style of this publication is reader friendly and the material is up-to-date -- at $19.95 it is extremely good value. Kenneth D Muirden
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