'Red Flags': essential factors in recognizing serious spinal pathology

Integrated Primary Healthcare Opioid Tapering Interventions: A Mixed-Methods Study of Feasibility and Acceptability in Two General Practices in New South Wales, Australia

Introduction

Integrated team-based primary healthcare is well positioned to support opioid tapering for patients experiencing chronic pain. This paper describes the development, implementation and acceptability of a primary healthcare opioid tapering intervention 'Assess Inform Manage Monitor' (AIMM) at two sites.

Methods

AIMM involved GP advice; nurse monitoring and potential engagement with: community pharmacist; psychologist; dietitian and exercise physiologist. Individuals receiving 90 days or more of prescription opioids were eligible. Patient and provider surveys and qualitative interviews were completed.

Results

Of 140 eligible patients, 37 attended during the study period and were invited to participate. Patient post-intervention surveys (n = 8) and interviews (n = 6) indicated the intervention was acceptable, although the perceived value of some of the integrated team was low. GP and practice nurse support was valued. Providers (n = 4) valued team integration. Low weaning readiness was a barrier to engagement by patients and providers.

Key lessons and conclusions

The intervention, whilst conceptually acceptable, was not feasible in its current form. Future efforts to transition patients towards integrated care should retain the practice nurse and place more focus on understanding and reinforcing patients' readiness to wean. Greater inter-professional collaboration may also be needed. Such refinements may advance the cause of opioid reduction in primary care.

Carrying water may be a major contributor to disability from musculoskeletal disorders in low income countries: a cross-sectional survey in South Africa, Ghana and Vietnam

Background

The Sustainable Development Goals include commitments to end poverty, and promote education for all, gender equality, the availability of water and decent work for all. An important constraint is the fact that each day, many millions of women and children, and much less frequently men, carry their household’s water home from off-plot sources. The burden of fetching water exacerbates gender inequality by keeping women out of education and paid employment. Despite speculation about the potential health impacts of fetching water, there is very little empirical evidence. We report the first large study of the health impacts of carrying water on women and children.

Methods

A cross-sectional survey was conducted in South Africa, Ghana and Vietnam during 2012. It investigated water carrying methods and health status. Because areas of self-reported pain were correlated we undertook factor analysis of sites of reported pain, to interpret patterns of pain reporting. Regression analysis using Generalised Estimating Equations (GEE) investigated water carrying as a risk factor for general health and self-reported pain.

Results

People who previously carried water had increased relative risk of reporting pain in the hands (risk ratio RR 3.62, 95% confidence interval CI 1.34 to 9.75) and upper back (RR 2.27, 95% CI 1.17 to 4.40), as did people who currently carry water (RR hand pain 3.11, 95% CI 1.34 to 7.23; RR upper back pain 2.16, 95% CI 1.25 to 3.73). The factor analysis results indicate that factor 1, ‘axial compression’, which is correlated with pain in the head and upper back, chest/ribs, hands, feet and abdomen/stomach, is associated with currently (0.30, 95% CI 0.17 to 0.43) or previously (0.21, 95% CI 0.01 to 0.42) carrying water. Factor 2, ‘soft tissue strain’, which is correlated with pain in the neck, shoulders/arms, lower back and hips/pelvis or legs, is marginally negatively associated with currently (-0.18, 95% CI -0.32 to -0.04) carrying water. The factor ‘axial compression’ was more strongly associated with carrying water containers on the head.

Conclusions

Participants who reported a history of current or past water carrying more frequently reported pain in locations most likely to be associated with sustained spinal axial compression in the cervical region. Given the fact that cervical spinal conditions are globally one of the more common causes of disability, our findings suggest that water carrying, especially by head loading is a major contributing factor in musculoskeletal disease burden in low income countries. Our findings support the proposed indicator for monitoring SDG6.1: “Percentage of population using safely managed drinking water services at home.”

The screening process of a patient with low back pain and suspected thoracic myelopathy: a case report

Background

Thoracic disc herniations are rare and difficult to diagnose. Myelopathy is a potential consequence that can lead to irreversible neurological impairment if not treated appropriately. It is incumbent on all clinicians who see patients with low back pain (LBP) to be aware of such pathologies. This case describes a screening process in the detection of a rare serious spinal pathology and discusses the use of red flags and central nervous system signs and symptoms in the decision leading to immediate referral.

Case Description

The subject in this case was a 69-year-old male referred to physical therapy for the treatment of LBP after having seen two medical doctors. He presented with severe spinal pain with gait disturbance, postural balance deficits and bilateral loss of plantar flexor strength. Decreased sensation in the buttocks and a subtle episode of urinary incontinence were also present.

Outcomes

Based on the results of the history and physical examination, the patient was referred back to his medical practitioner, who ordered magnetic resonance imaging. A thoracic disc herniation associated with spondyloarthritis at T10-11 causing myelopathy was detected, and the patient underwent immediate decompressive surgery. One month following initial evaluation, the patient had completely recovered without any neurological compromise.

Discussion

This case highlights the importance of the screening of serious pathologies and the assessment of central nervous impairments in certain cases of LBP. The integration of a cluster of subjective and physical examination findings led to the prompt referral of this patient for urgent medical attention.

Level of Evidence

4.

Caring for children with physical disability in Kenya: potential links between caregiving and carers' physical health

BACKGROUND

The health of a carer is a key factor which can affect the well-being of the child with disabilities for whom they care. In low-income countries, many carers of children with disabilities contend with poverty, limited public services and lack assistive devices. In these situations caregiving may require more physical work than in high-income countries and so carry greater risk of physical injury or health problems. There is some evidence that poverty and limited access to health care and equipment may affect the physical health of those who care for children with disabilities. This study seeks to understand this relationship more clearly.

METHODS

A mixed methods study design was used to identify the potential physical health effects of caring for a child with moderate-severe motor impairments in Kilifi, Kenya. Qualitative data from in-depth interviews were thematically analysed and triangulated with data collected during structured physiotherapy assessment.

RESULTS

Carers commonly reported chronic spinal pain of moderate to severe intensity, which affected essential activities. However, carers differed in how they perceived their physical health to be affected by caregiving, also reporting positive benefits or denying detrimental effects. Carers focussed on support in two key areas; the provision of simple equipment and support for their children to physically access and attend school.

CONCLUSIONS

Carers of children with moderate-severe motor impairments live with their own physical health challenges. While routine assessments lead to diagnosis of simple musculoskeletal pain syndromes, the overall health status and situation of carers may be more complex. As a consequence, the role of rehabilitation therapists may need to be expanded to effectively evaluate and support carers' health needs. The provision of equipment to improve their child's mobility, respite care or transport to enable school attendance is likely to be helpful to carers and children alike.

Manual correction of an acute lumbar lateral shift: maintenance of correction and rehabilitation: a case report with video

The acute onset lumbar lateral shift, otherwise known as a list or acute scoliosis, is a common clinical observation associated with low back pain. In general orthopaedics, the presence of a lateral shift is associated with a poor prognosis; however, a manual correction method devised by McKenzie is claimed to produce rapid reversal of the deformity and reduction in pain. This single-case report presents the details of the McKenzie Mechanical Diagnosis and Treatment (MDT) management of a major right-sided lateral shift, which includes the manual correction technique, self-correction and management, prophylaxis, pain ablation, and rehabilitation to a high level of athletic function, with long-term follow-up at 9 months. The lateral shift is widely accepted as being associated with disc pathology, but the exact mechanism of shift production remains speculative. hypotheses include muscle spasm, avoidance of irritation of a spinal nerve, and space-occupying or space-deficient disc mechanics. The hypotheses used to explain the lateral shift phenomena are discussed. (Case report is supplemented by video stream, available at jmmtonline.com/).

Changes in bending stiffness and lumbar spine range of movement following lumbar mobilization and manipulation

OBJECTIVE

The purpose of this study was to investigate the effects of lumbar rotational manipulation and lumbar central posteroanterior mobilization on lumbar bending stiffness and flexion and extension range of motion (ROM).

METHODS

A same-subject, repeated-measures, crossover design was used using 32 asymptomatic subjects (16 female and 16 male; mean [SD] age, 25.5 [4.5] years; weight, 65.7 [11.8] kg; and height, 1.70 [0.08] m). Each subject received mobilization or manipulation on 2 different occasions. Bending stiffness was calculated using a 3-point bending model using an electromagnetic tracking device and a force platform; lumbar flexion and extension ROM was measured using an electromagnetic tracking device. All variables were measured pre- and postintervention. Their effect was compared using paired t tests.

RESULTS

Manipulation and mobilization did not significantly alter either bending stiffness or lumbar flexion and extension ROM (mobilization: P = .175, P = .613, and P = .535; manipulation: P = .973, P = .323, and P = .439). Bending stiffness changes were not correlated to changes in ROM (Pearson r for stiffness-flexion = -0.102, P = .586; Pearson r for stiffness-extension = 0.014, P = .941).

CONCLUSIONS

Manipulation and mobilization had no significant effect on bending stiffness or flexion and extension ROM for this group of subjects. Some individual variations in effect were observed.

Medical screening and evacuation: cauda equina syndrome in a combat zone

STUDY DESIGN

Resident's case problem.

BACKGROUND

Cauda equina syndrome (CES) is a rare, potentially devastating, disorder and is considered a true neurologic emergency. CES often has a rapid clinical progression, making timely recognition and immediate surgical referral essential.

DIAGNOSIS

A 32-year-old male presented to a medical aid station in Iraq with a history of 4 weeks of insidious onset and recent worsening of low back, left buttock, and posterior left thigh pain. He denied symptoms distal to the knee, paresthesias, saddle anesthesia, or bowel and bladder function changes. At the initial examination, the patient was neurologically intact throughout all lumbosacral levels with negative straight-leg raises. He also presented with severely limited lumbar flexion active range of motion, and reduction of symptoms occurred with repeated lumbar extension. At the follow-up visit, 10 days later, he reported a new, sudden onset of saddle anesthesia, constipation, and urinary hesitancy, with physical exam findings of right plantar flexion weakness, absent right ankle reflex, and decreased anal sphincter tone. No advanced medical imaging capabilities were available locally. Due to suspected CES, the patient was medically evacuated to a neurosurgeon and within 48 hours underwent an emergent L4-5 laminectomy/decompression. He returned to full military duty 18 weeks after surgery without back or lower extremity symptoms or neurological deficit.

DISCUSSION

This case demonstrates the importance of continual medical screening for physical therapists throughout the patient management cycle. It further demonstrates the importance of immediate referral to surgical specialists when CES is suspected, as rapid intervention offers the best prognosis for recovery.

LEVEL OF EVIDENCE

Differential diagnosis, level 4. J Orthop Sports Phys Ther 2009;39(7):541-549, Epub 24 February 2009. doi: 10.2519/jospt.2009.2999.