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Musculoskeletal diseases

Musculoskeletal diseases Letters 3 September 2018 Free

Primary care management of non-specific low back pain: key messages from recent clinical guidelines

To the Editor: The recent guideline review by Almeida and colleagues1 coincides with an international call for action to address the burden of low back pain.2 Low back pain is a major societal problem and the number one cause of disability internationally. Recent guidelines prioritise advice, reassurance and self-management as first line care. Implementing these simple, high value interventions is important in populations, such as Aboriginal Australians, where there has been limited previous recognition of low back pain as a problem. A recent systematic review of musculoskeletal pain among Aboriginal Australians3 summarised that the prevalence of low back pain is higher among Aboriginal Australians and has disproportional impacts. Qualitatively, low back pain has multidimensional effects, including functional, cultural and emotional. Access to both primary and specialist level care is lower for some musculoskeletal pain conditions such as osteoarthritis, and there may be parallels for low back pain. Worryingly, there is evidence that the health care that Aboriginal people receive for low back pain is worse than that received by non-Aboriginal Australians, including care with the potential to cause iatrogenic harm. These include higher rates of opioid prescribing and unhelpful low back pain information. Low back pain is associated with a higher number of comorbid health issues, psychological stress and income poverty, and may contribute to the complex milieu of health burden and disadvantage for some Aboriginal communities. The implementation of effective, high value, first line care described by Almeida and colleagues1 is critical for Aboriginal people with low back pain; however, it needs to be adapted so that it is acceptable, accessible and appropriate. For example, advice and education to reassure patients and encourage self-management may need to be supported by culturally appropriate low back pain information. This could include visual, story-based information that has been developed with input from Aboriginal people.4 Implementing successful self-management requires doctors to develop trusting relationships with patients in services that are culturally secure for Aboriginal people. Effective communication is critical.5 The provision of evidence-informed low back pain care to Aboriginal patients requires better recognition of low back pain as a health issue affecting Aboriginal Australians, and a greater understanding of how such care can be best implemented in Aboriginal communities.

Ivan Lin · Donna B Mak · Juli Coffin · Peter O'Sullivan

Endocrinology Letters 20 November 2017 Free

Cortisone injections for tennis elbow should be an “avoid”, rather than a recommended procedure

To the Editor: We are strong supporters of Choosing Wisely, which promotes appropriate use of medical procedures and evidence-based medicine. We bring to your attention an example of a recommendation published in the 2017 edition of the Australian Therapeutic Guidelines for rheumatology,1 which is contrary to level 1 evidence (ie, multiple randomised control trials) and the Choosing Wisely ethos. The guidelines suggest that local corticosteroid injections may be considered for lateral epicondylitis (tennis elbow) and repeated if needed. The recommendation uses the less than prudent justification: “local corticosteroid injection can provide pain relief for 6–12 weeks”.1 There are now at least five high quality randomised control trials of corticosteroid injection for tennis elbow with 6 or more months follow-up, and collectively they show harm of corticosteroid compared with placebo injection or conservative treatment for time periods greater than 3 months. We reference three of these trials,2-4 and others show consistent results. There are no high quality published trials showing benefit of corticosteroid over placebo injection at time periods greater than 3 months, and one review, in fact, showed an association of poorer long term outcome with repeated injections.5 It is not reasonable, nor should it be good clinical practice, to justify a possible medium term harm by reference to a much shorter term benefit. Based on current evidence, corticosteroid injection for tennis elbow should become a Choosing Wisely “avoid” procedure. Practice guidelines such as the Australian Therapeutic Guidelines for rheumatology ought to more carefully consider level 1 evidence to avoid supporting a prevailing traditional treatment option that is not evidence-based. In treatments with potential benefits and harms that have been tested by randomised control trials, recommendations should only support those treatments with a high quality trial evidence of benefits outweighing harms.

John W Orchard · Bill Vicenzino

Tennis Elbow
Medical practices Letters 4 September 2017 Free

A stitch in time: stitching errors in digital radiology

Modern digital radiological techniques include “stitching” together multiple x-ray images. This provides one overall image of the area of interest, such as the entire spine or lower limbs, for deformity assessment. Dedicated software automatically combines separate exposures and allows for overlap. Image acquisition is rapid, minimising patient motion artefact and reducing distortion.1 However, if images are inappropriately put together (digitally stitched), stitching errors may occur with this computer-driven process. If not manually corrected by the radiology technician, the supplied image may hide pathology or give the false impression of abnormality. Four cases of digital stitching error have recently occurred in our tertiary referral paediatric hospital. Digitally stitched x-rays from the lower limbs were obtained for routine assessment of a child with skeletal dysplasia, and fractures of the left tibia and fibula were apparent (Box, A). This did not correlate with the clinical findings, including the child dancing in the waiting room. The radiology department was contacted and they re-issued corrected images (Box, B). Spinal x-rays in two patients after scoliosis surgery incorrectly showed broken surgical rods. In the context of ongoing symptoms, the option of revision surgery was discussed with the family in the first case. Repeat x-rays, obtained as part of the pre-operative planning, showed the rod was in fact not broken. A stitching error was immediately recognised by the spinal surgeon when a second similar case occurred. In a fourth case, comparison of the anteroposterior and lateral views of a child’s spine showed different numbers of vertebrae in the two views (11 vertebrae on the frontal view and 12 on the lateral). Digital radiology is commonplace and allows rapid image acquisition and ease of digital measurement.2 However, technical errors — digital stitching errors — may occur. Although rarely reported, these may be relatively common, with one study identifying stitching errors in 14 out of 86 reviewed scoliosis studies.1 Despite ongoing technological refinements,3 clinicians should always carefully check digitally stitched images: look for soft tissue mismatch, correlate with source images and clinical presentation, and avoid digital stitching in certain patients, such as people with movement disorders. Box – Digitally stitched long leg images of a paediatric patient, showing the stitching error and apparent fracture (A),* and corrected image with resolution of the stitching error and no fracture (B) * Note the mismatched soft tissue shadow (A).

Clare Faurie · Nicole Williams · Peter J Cundy

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