Musculoskeletal medicine

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chapter 34 Musculoskeletal medicine

INTRODUCTION AND OVERVIEW

Musculoskeletal medicine (MSM) is that branch of medicine dealing with the conservative management of disorders of the musculoskeletal system, including the muscles, aponeuroses, joints and bones of the axial and appendicular skeletons, and those parts of the nervous system associated with them. These disorders represent the most common cause of disability in most countries across all age groups ¹ and are the third most common reason for presentation to general practice.² The direct and indirect costs of this burden are in the $15 billions per annum.³

Yet, paradoxically, undergraduate and postgraduate education in MSM is at best elementary. The need for MSM training in medical schools and hospitals has been well established.⁴ Currently in Australia there is no public MSM outpatients department (OPD) hospital clinic, which differs from our European and American colleagues, who have vibrant systems in place. For instance, osteopathy and musculoskeletal medicine special-interest doctors are recognised in the United Kingdom, musculoskeletal physicians are recognised in Europe and the United States has osteopathic MDs. Historically in Australia it has been left to the allied healthcare professionals and alternative healthcare practitioners to absorb much of the demand for musculoskeletal (MS) management. The medical profession has been slow to embrace MSM, but has a vital role to play. The optimal management of MSM conditions epitomises the need for an integrated approach from practitioners knowledgeable in the biopsychosocial approach to management. General practitioners with postgraduate MS training can work collaboratively with other healthcare providers to minimise pain and optimise function for patients.

One of the most common MS disorders seen by healthcare practitioners in Australia is spinal pain. Persistent back pain is by far the most common reason for chronic MS patient encounter in Australian general practice, followed by knee, shoulder and neck.⁵

This chapter focuses on the optimal management of spinal pain, although the general principles espoused may be used for all areas of the body.

LOW BACK PAIN

The issue of low back pain (LBP) pervades Western society. Be it through lost work, missed recreation and sporting activities or money spent on prevention or cure, there are few people who have not had dealings with it. Healthcare practitioners have been both blamed for exacerbating its prevalence and given credit for reducing it. It is abundantly covered in the media, and myths circulate swiftly through the populace. This section outlines the evidence on low back pain in a functional fashion.

DEFINITIONS

• Low back pain is pain perceived to be arising from lumbar and/or sacral regions of the spine. It has been defined by the IASP ⁶ as per Figure 34.1. Importantly, low back pain is not perceived to arise from the gluteal, thoracic, loin or groin region, although it may refer into these regions.

• Acute pain is pain that has been present for less than 12 weeks, subacute pain has been present for longer than 5–7 weeks but less than 12 weeks, and chronic (persistent) pain longer than 12 weeks. These terms are common in the research literature and management strategies differ significantly between them.

• Somatic pain is pain arising from noxious stimuli to any of the musculoskeletal components of the body. Studies have shown that the sensitivities of these components are: periosteum > ligament > joint capsule > tendon > fascia > muscle.^7,⁸ Somatic referred pain is pain perceived in a region innervated by nerves other than those that innervate the actual source of pain.⁶ Common examples include buttock and posterior thigh pain referred from the lumbar spine, and knee pain referred from the hip.

• Radicular pain is pain that arises from irritation of a spinal nerve or its roots. Radiculopathy involves conduction block to a spinal nerve or its root, resulting in numbness and/or weakness.⁶ Table 34.1 outlines the differing features of somatic referred pain and radicular pain. Figures 34.2–34.6 show some patterns of referred pain from different vertebral structures. They illustrate the potential of somatic vertebral structures to refer pain to remote areas and thus mimic other pains, such as ‘sciatica’ and visceral pains.

• Hyperalgesia is an increased response to a stimulus that is normally painful. In clinical practice this is commonly seen with persistent pain. It often results in an increase in the referred pain in intensity and area due to central nervous sensitisation.¹⁵ Knowledge of this phenomenon is important in providing patients with a reason for changes in their pain. It is also important for doctors involved in writing reports or assessments, as it invalidates the term ‘non-anatomical’ in describing distribution of pain. This term is often used in medico-legal reports to suggest that an individual’s pain is imaginary or of dubious significance. The use of ‘non-anatomical’ in describing pain should be obsolete in the twenty-first century.

FIGURE 34.1 Pain sites

TABLE 34.1 Somatic versus radicular pain

Somatic referred pain	Radicular pain
Due to spread of pain from deep spinal tissues (including muscles)	Due to chemical or mechanical irritation of nerves
Back pain worse than leg pain, which may be bilateral	Unilateral leg pain worse than back pain
Pain concentrates proximally in buttock and thigh, but may spread below knee	Pain concentrates distally, running into the lower limb, usually extending below the knee
Deep, dull aching, expanding pressure-like quality	Sharp, shooting, electric quality, often deep and superficial
Vague location, varies over time, ill-defined distribution	Pain runs along defined narrow band in dermatome distribution
Poorly defined paraesthesia may be present	Numbness and paraesthesia in dermatomal distribution
Normal reflexes and power (if abnormal, further assessment is needed)	Reflexes may be reduced or absent; motor weakness may be present

FIGURE 34.2 Patterns of referred pain evoked in normal volunteers by noxious stimulation of interspinous ligaments at the segmental levels indicated

(based on Kellgren 1939⁹)

FIGURE 34.3 Patterns of referred pain evoked in normal volunteers by noxious stimulation of interspinous ligaments at the segmental levels indicated

(based on Kellgren 1939⁹)

FIGURE 34.4 Patterns of referred pain evoked in normal volunteers by noxious stimulation of interspinous ligaments at the segmental levels indicated

(based on Kellgren 1939⁹)

FIGURE 34.5 Patterns of referred pain evoked in normal volunteers and in patients by noxious stimulation of the cervical zygapophyseal joints or intervertebral discs at the segments indicated ¹⁰^–¹²

FIGURE 34.6 Various patterns of referred pain produced in normal volunteers or patients by noxious stimulation of lumbar zygapophyseal joints or intervertebral discs ^13,¹⁴

EPIDEMIOLOGY

The lifetime prevalence of acute LBP is about 70%,¹⁶ with the cumulative lifetime prevalence of episodes lasting more than 2 weeks being 14%.¹⁷ In Australia, back complaint is the sixth most common reason for presentation to a general practitioner.²

Data on the natural history of LBP are variable but instructive when closely analysed. A commonly quoted statement is that, with treatment, ‘90% of patients recover within 2 months’.¹⁸ This may be true when follow-up is only for 4 weeks.¹⁸ More-rigorous studies with 12-month follow-up reveal a different picture.^19,²⁰ Around 80% of patients remain disabled to some extent at 12 months, with 10–15% highly disabled. These studies paint a picture of recovery followed by relapse. In general, a patient’s status at 2 months post presentation reflects their status at 12 months.

An Australian study of acute LBP patients without a compensation claim managed with evidence-based guidelines revealed that 70% can expect to recover and stay recovered at 12 months, with a low risk of recurrence.²¹

HISTORY

History-taking primarily allows formulation of a diagnostic framework and assessment of prognosis. It should also be used as a way to gain the patient’s trust and begin the process of education and assurance. A reasonable framework is:

• pain history—use pain chart, VAS, disability, recovergram (see also Ch 38, Pain management)

• red flag check—see Box 34.2

• yellow flag check—see Box 34.3.

BOX 34.3 Yellow flag indicators

Work:

• belief that pain is harmful, resulting in fear-avoidance behaviour

• belief that all pain must be abolished before attempting to return to work or normal activity

• expectation of increased pain with activity or work

• fear of increased pain with activity or work

• belief that work is harmful

• poor work history

• unsupportive work environment

Beliefs:

• catastrophising, thinking the worst

• misinterpreting bodily symptoms

• belief that pain is uncontrollable

• poor compliance with exercise

• expectation of ‘techno-fix’ for pain

• low educational background

Behaviours:

• passive attitude to rehabilitation

• use of extended rest

• reduced activity with significant withdrawal from activities of daily living

• avoidance of normal activity

• impaired sleep because of pain

• increased intake of alcohol or similar substances since the onset of pain

Affective:

• depression

• feeling useless and not needed

• irritability

• anxiety about heightened body sensations

• disinterest in social activity

• over-protective partner/spouse

• socially punitive partner/spouse

• lack of support to talk about problems

(Source: Bogduk 2003²²)

EXAMINATION

Although physical examination of LBP patients will rarely allow a patho-anatomic diagnosis to be made, it remains an extremely valuable tool. Its strength lies in the opportunities it opens (Box 34.4). A confidently performed physical examination in association with meaningful dialogue is an important step in the overall management.

Following the orthopaedic model of ‘look, move and feel’ is the standard approach. Initial inspection allows a record of asymmetry, pain behaviour, gait and skin lesions. A knowledge of surface landmarks (Fig 34.7) adds more meaning to the descriptions. The physician should be alert for pain behaviour from the patient and its interpretation. Importantly, pain behaviour needs to be recognised as the patient’s way of communicating distress. Overt or exaggerated pain behaviour is not a sign of malingering but, rather, a signal for the doctor to explore pain management issues in more depth. This would include psychosocial factors as well as biological.

FIGURE 34.7 Surface anatomy landmarks: iliac crests (IC), posterior superior iliac spines (PSIS). Spinous process of L4 lumbar vertebra lies at or just below the level of the iliac crest. Lumbosacral junction (=) lies 10–15° superiorly and towards the midline from the PSISs. T12 can be located by counting spinous processes back from the lumbosacral junction. T10 is at a line drawn along the 12th rib and continued to the midline to meet its contralateral fellow.

The patient can be moved in all six planes—flexion, extension, lateral flexion left and right, and rotation left and right. Rotation is best performed sitting, to stabilise the pelvis. While the patient is seated, straight leg raising (SLR) and slump testing may be performed (Fig 34.8). With the patient in the supine position, SLR can be assessed as well as leg length. Hip range of movement (ROM) can be assessed, noting that if back pain is reproduced, this is most likely to be from the effects on lumbar/pelvic structures than the hip joint (groin/anterolateral thigh pain). In the prone position, hip extension and hip rotation can be assessed.

FIGURE 34.8 Slump test. The patient sits on the edge of the couch, then in a stepwise fashion, increased stretch is introduced as follows: i) the patient slumps forward, ii) then flexes the neck, iii) then straightens the leg, iv) then dorsiflexes the foot. Purportedly, if any back or leg pain reproduced so far is eased when the neck is then extended, and/or the ankle plantar flexed, then neuromeningeal irritation, rather than hamstring pain, is invoked (adopted from Kenna & Murtagh ²³).

Palpation should be performed systematically through the paravertebral tissues, sacroiliac and gluteal area. Attention should be paid to insertional areas such as the posterior greater trochanter, parasacrally and the posterior superior iliac spine (PSIS). To assess the sacrotuberous and sacrospinous ligament, levator ani and other paracoccygeal structures, per rectum examination will be needed. Note should be made of hyperalgesia, allodynia and abnormal tissue texture.

Special tests of spinal dysfunction have been described for the lumbar and pelvic region, including many labelled as sacroiliac tests. A combination of tests shows best utility regarding sacro-iliac joints (SIJ) dysfunction.²⁴

Examination of the visceral, vascular and neurological systems is determined by the presenting symptoms and history. Neurological examination is only necessary if there is radicular leg pain or neurological symptoms. A quick check of the L5 and S1 myotomes can be performed by asking the patient to stand on their heels, then their toes. The L1–S2 dermatomes are easily checked by touching the centre of the respective zones.

INVESTIGATION

Careful thought is needed before investigating a patient. Concern regarding increasing levels of radiological intervention, especially CT scanning, has become topical.^25,²⁶ The risk of exposure to significant ionising radiation, for questionable clinical benefit along with wasting of limited healthcare resources, should be of concern to the healthcare practitioner and consumer alike. By asking: ‘How will this investigation influence my management, what are the chances of a significant finding and will this test detect it?’, unnecessary tests are likely to be avoided.

Red flag conditions and their appropriate investigations are shown in Table 34.2. Plain films have a reasonable pick-up rate (Table 34.3) but will miss early disease. CT scans have no role in the investigation of somatic low back pain, except in confirmation of pathology indicated by other investigations or the history/examination. MRI scan is the investigation of choice for red flag conditions of the spine and gives the best information about the status of the intervertebral disc (i.e. presence or absence of modic lesions and high-intensity zones).

TABLE 34.2 Appropriate investigations for possible serious causes of acute musculoskeletal pain

TABLE 34.3 Sensitivity ^* and specificity^** of plain films in the evaluation of some pathological causes of back pain

Condition	Sensitivity	Specificity
Malignancy	70%	90%
Osteomyelitis	80–90%	70–90%
Spondylitis	50%	90%

* 100% false negative %

** 100% minus false positive %

Source: Mazanec 1991²⁸

Providing the patient with a proper explanation of the role of the investigation is paramount. This is especially so with radiological investigation, where reported abnormalities are, in most cases, not significant (Table 34.4). However, patients risk being alarmed by being referred for unnecessary investigations and misinterpretation of asymptomatic anatomical abnormalities.²⁹

TABLE 34.4 Spinal disease linked to back pain: prevalence in a primary care population,³⁰^–³³ key historical features and their respective positive likelihood ratios³¹

DIAGNOSIS

A specific patho-anatomic diagnosis will not be forthcoming for the overwhelming majority of LBP patients. In essence, the initial consultation(s) are primarily to exclude red flag diagnosis and estimate the influence of yellow flags on prognosis. The probability diagnosis will be somatic LBP, and in the acute pain situation no further clarification is necessary. Evidence-informed practice has no value from any further subclassification, even though this is common practice in primary care.³⁴ Primary practitioners can reasonably use a benign label (ligament or muscle strain) to help reassure their patients that they have a good prognosis.

In the case of persisting pain, precision diagnosis may be sought. Two structures can be relatively easily blocked by guided anaesthetic blocks: the zygapophyseal joints and the sacroiliac joints. Both have validated protocols that must be followed correctly for accurate diagnosis.^35,³⁶ Radiofrequency neurotomy may be used as a treatment if the blocks are positive.^37,³⁸ The intervertebral disc cannot be specifically blocked, but provocative discography has been used to identify a painful disc. The role of discography has been controversial,³⁹ but it has been used primarily to select patients for fusion surgery.

MANAGEMENT

From the individual patient’s point of view, management must address four key concerns:⁴⁰

The research data are quite clear on the importance of educating low-back-pain sufferers about the nature of their problem, assuring them of the generally good prognosis and encouraging them to stay as active as possible. What is less clear is the best overall combination of other treatments, such as supervised therapeutic exercise, manual therapy, injections, behavioural therapy, workplace intervention a and myriad other interventions. Few studies have tested combinations of treatments or integrative management, most studies comparing monotherapies against standard/minimal care or another monotherapy. The Australian National Musculoskeletal Medicine Initiative ²¹ and Blomberg’s pragmatic trials⁴¹^–⁴⁴ are significant trials that have compared algorithms involving multiple treatments versus standard care. They are informative for an approach to the four concerns above.

• ‘I hurt’—quick control of pain is paramount. Pain is the fifth vital sign and is an independent risk factor for chronicity. At the first consultation, the patient requires a credible, convincing explanation of the cause of their pain. This should be performed after thorough history-taking and examination, which should be thought of by the practitioner as therapeutic. It needs to be couched in language understandable to the lay person. In most cases, when performed confidently this step will allay patients’ concerns regarding their pain and facilitate the other necessary steps in pain management (analgesics, manual therapy, exercises and focal injections).

• ‘I can’t move’—the disability associated with acute low back pain can quickly impair a person’s ability to work, socialise and perform leisure activities. Patients often become too frightened to move, in case they further ‘damage’ their spine. Assurance of the benefits of early mobilisation and the dangers of prolonged rest ⁴⁵ should be incorporated into the explanation of the nature of the patient’s condition. Before leaving the first consultation, the patient should have a sound knowledge of appropriate activity and have a program for pacing activities, maintaining movement and controlling any resultant flare of pain or stiffness. This may involve manual therapy, be it manipulation or an exercise regimen or both.

• ‘I can’t work’—the work domain and low back pain have been the subject of much debate for years. The experience could be summarised thus: ‘If the workplace has a toxic environment, the injured patient is unlikely to return no matter what physical rehabilitation occurs’. Thus the importance of the yellow flag concept as first comprehensively set out in the New Zealand government guidelines.⁴⁶ (See Box 34.3 for yellow flag indicators.) Returning the worker to his or her occupation in some role as soon as practical with acceptance by their supervisors goes a long way to resolving work issues. The worker must be educated in suitable duties and have a non-adversarial environment to return to, for optimal outcomes.

• ‘I’m scared’—the fear associated with low back pain is a leading cause of disability, even though the fears are most often grounded in myth and mistaken beliefs. Open discussion with the patient about their understanding of the cause of the pain, their expectations regarding recovery and their motivation to actively become involve in the recovery process usually help to overcome their apprehension. Rectifying their fears, educating them in coping skills and reassuring them of the good prognosis are all helpful steps. Formal psychological intervention should be sought if this does not occur within the first few visits.

The above musculoskeletal quartet overview gives a useful framework to address all musculoskeletal patients. It may also be used at each presentation.

Initial presentation

• Take a full pain history and record pain and disability (e.g. recovergram, see Fig 34.9).

• Record red and yellow flags.

• Perform an examination as required from the above information. If spinal dysfunctions are present, then manual therapy should be considered.

• Order investigations deemed necessary from red flags.

• Explain the nature of the patient’s condition to them in detail.

• Assure them of the importance of staying active, returning to work and their usual activities, and having a positive outlook regarding recovery. Reassure them that you are available to address any concerns and will review them again soon (this will vary depending on presentation, but is usually a few days to a few weeks).

• Advise them on pain management options (Box 34.5).

• Advise them on ways to maintain movement (Box 34.6).

• Review as necessary. Generally, patients should be followed up until they have recovered (i.e. pain score < 2 visual analogue scale (VAS) and return to full or near full activity).

FIGURE 34.9 Recovergram

BOX 34.5 Pain management options

1. Give a full explanation of the nature of the pain, and assurance regarding the good chance of full recovery.

2. Encourage the patient to stay active, to minimise pain and disability.

3. Time-contingent use of analgesics to control pain, to allow activity and avoid sleep disruption.

4. Use the safest medication at the lowest effective dose. Opioids may be considered in appropriate patients with careful monitoring.

5. Manual therapies should be considered for a trial to relieve somatic dysfunction.

6. Consider neuropathic pain medication if the pain is predominantly neuropathic in origin.

7. Devil’s claw, white willow bark and topical cayeme may all be useful for short-term management.

8. Needling interventions, both dry and wet, may be useful.

9. Guided blocks with a view to radiofrequency neurotomy can be considered in persistent spinal pain.

BOX 34.6 Recommendations for activity and exercise

• Give general advice to stay active, keep flexible and walk without limping.

• The worst thing the patient can do for their back is be too careful.

• Mobilise the spine by gentle activity.

• Build on the patient’s personal preferences for exercise; encourage them to set goals.

• Encourage directional preference—i.e. moving in a direction that either reduces pain or doesn’t cause pain.

• Make every effort to remove fear about low back pain and avoid sickness behaviour.

• Discourage activities involving static work for the back muscles.

• Treat acute attacks of back pain as an acute muscle spasm, with stretching and light activity.

• With respect to lifting, instruct patients:

• to avoid twisting with bending

• to use the thighs with a vertical back for heavy objects

• to use the back and flex it at other times

• not to be afraid to lift.

• Explain:

• that increased tension in muscles, for whatever reason, would increase the pain and thereby add to the problem

• that longstanding pain could create a vicious circle, with chronic pain as a result.

• Stipulate that all patients must mobilise their lumbar spine through light activity.

• It is not necessary to set exercise goals, but provide the patient with guidelines and encourage them to set their own goals.

• Enquire about and redress any misunderstandings about back pain.

• Encourage and help the patient to try to walk as flexibly as possible.

• Prescribe exercise while a significant other is in attendance at the consultation.

• Reinforce instructions at three months and at one year as a minimum.

• There is evidence for the effectiveness of core stability exercises and Alexander technique programs, but selecting appropriate patients can be problematic.^48,⁴⁹

• Remain available to see the patient at their request.

COMPLEMENTARY THERAPIES

Acupuncture

For low back pain

A 2005 Cochrane review ⁵⁰ looked at acupuncture for non-specific low back pain and dry-needling for myofascial pain in the lower back. Thirty-five trials were included in the review. The authors concluded that acupuncture relieves pain and improves function in patients with chronic low back pain, compared with no treatment or sham treatment, and this effect was sustained at short-term, but not long-term, follow-up. Acupuncture as an adjunct to conventional treatments is more effective than conventional treatments alone, although the effects are small. Dry-needling can also be a useful adjunct. However, neither acupuncture nor dry-needling are more effective than other treatments, conventional or ‘alternative’. These findings were confirmed by an independent 2005 meta-analysis of acupuncture for low back pain, which concluded that acupuncture provides short-term pain relief of chronic low back pain.⁵¹ There was insufficient evidence on acupuncture for acute low back pain.

For neck pain

A 2006 Cochrane review ⁵² found 10 trials on acupuncture for chronic neck pain, and none for acute or sub-acute neck pain. The authors concluded that there was moderate evidence that acupuncture is more effective than sham treatments in relieving pain both immediately post-treatment and at short-term follow-up. Limited evidence suggests that acupuncture is more effective than massage in the short term. There is moderate evidence that acupuncture is more effective than waitlist control for neck pain with radicular symptoms, at short-term follow-up.

For lateral elbow pain

A 2002 Cochrane review ⁵³ found four small trials of acupuncture for lateral elbow pain of more than 3 weeks duration, and not due to trauma or systemic inflammation. Two trials, with a total of 130 patients, compared needle acupuncture with sham acupuncture. Acupuncture was found to result in greater relief of pain than sham acupuncture (mean difference 18.8 hours), and was more likely to result in 50% more reduction in pain and overall improvement after 10 treatments. However, these changes were not sustained at medium/long-term follow-up (3–12 months).

The other two trials looked at laser acupuncture versus placebo laser, and needle acupuncture plus B₁₂ injection versus B₁₂ injection alone, and found no differences between acupuncture and control.

The authors concluded that because of the small number of trials, the results should be interpreted with caution, and that there was not enough evidence to determine the role of acupuncture in treating lateral elbow pain.

Since then, two more trials have been published. Tsui and Leung ⁵⁴ in a small uncontrolled trial (n = 20) found that electroacupuncture was superior to manual acupuncture after 2 weeks, and Fink and colleagues⁵⁵ found in a small trial (n = 45) that both true and sham acupuncture resulted in a decrease in pain and improvement in function after 2 weeks, the difference being significantly greater in the true acupuncture group. At 2-month follow-up the true acupuncture group maintained the improvement in function but pain scores had returned to baseline.

These trials suggest that needle acupuncture may have a short-term benefit in lateral elbow pain, but more trials are needed.

• Devil’s claw (Harpagophytum procumbens)—orally has been shown in several double-blind studies to be beneficial for longstanding injuries such as chronic low back pain.^56,⁵⁷ It has been approved for relief of low back pain by ESCOP.⁵⁸ It reduces pain and inflammation and has a chondroprotective effect. It compares favourably with medication such as rofecoxib.^6,⁵⁹ Use cautiously in patients with peptic ulcer, gallstones or pregnancy. Suspend 1 week before major surgery, to avoid increased risk of bleeding.

• Willow bark (Salix alba)—used orally for chronic joint or muscle injuries. A Cochrane review in 2006 ⁶⁰ showed moderate evidence that 240 mg salicin daily reduces pain more than placebo in the short term for acute exacerbations of chronic non-specific low back pain. One RCT⁶¹ found that 39% of those treated with willowbark became pain-free after 4 weeks compared with 6% in the placebo group. Response was achieved after 1 week.

Dose: for acute episodes of non-specific chronic low back pain—willowbark preparations standardised to total salicin content providing 240 mg daily in divided doses.

• Adaptogens are a group of herbs used to boost the body’s response to stress after injury.

• Korean ginseng (Panax ginseng)—used by many athletes to reduce fatigue, improve strength during convalescence, and facilitate rapid recovery from injury. Used mostly in the short term combined with other herbs, and not during acute infections.

• Siberian ginseng (Eleutherococcus senticosus)—more suitable to long-term use. Not for use in acute infections.

• Withania somnifera—suited to recovery period and reducing fatigue associated with overtraining. Has anti-inflammatory activity exerting selective COX-2 enzyme inhibition.⁶²

Topical herbs

• Wintergreen (Gaultheria procumbens)—used topically to increase blood flow to chronic joint and muscle injuries. Its essential oil is methyl salicylate.

• Arnica montana—used topically to help resolve bruising and swelling of acute injuries.

• Comfrey (Symphytum officinale)—used topically for sprains and joint injuries.

FURTHER FOLLOW-UP

• Repeat the first 4 steps above.

• Continue management of yellow flag issues.

• Continue education as to the nature of the problem, and address all the patient’s concerns regarding prognosis, lifestyle and work issues, and management options.

• The first 6–8 weeks of management should result in dramatic improvements in pain and disability. If not, then full reassessment of the patient should be undertaken. This will necessarily involve re-evaluation of the diagnosis and treatment strategies in partnership with the patient.

Algorithms can also provide guidance in management. See the appendix for two useful algorithms and associated outcome studies.

Management of chronic persistent low back pain is beyond the scope of this chapter.

SPONDYLOLYSIS/LISTHESIS

The teenage athlete with LBP presents a special dilemma to the health practitioner—that of potential stress fracture of the pars interarticularis. Practitioners should have a high index of suspicion for this condition, to allow early detection and full bony healing.

EPIDEMIOLOGY

The fetal incidence of spondylolysis has conclusively been shown to be zero. It is only on walking that we see spondylolysis occurring. In a study of 32,600 asymptomatic adults, the prevalence of a pars defect was 7.2%.⁶³ The prevalence has not been shown to be any different in patients suffering from low back pain. There is no significant change in that rate from age 20 to age 80. It is therefore the teenage years that we must be vigilant about, as practitioners.

Most spondylolysis occurs at L5 (85–95%), with most of the rest occurring at the neighbouring L4 (5–15%). There is a strong association with spina bifida occulta.⁶⁴ The young athletic populations are at most risk, with gymnasts, cricketers (fast bowlers), footballers, rowers, weight lifters and throwing track and field athletes at highest risk of symptomatic spondylolysis.

PATHOPHYSIOLOGY AND NATURAL HISTORY

The pars interarticularis is the thinnest part of the vertebra. Repetitive mechanical stress from flexion/extension activity of the lumbar spine is the usual cause of fracture to the pars.

In a 45-year follow-up evaluation of first-grade children with a spondylolytic defect, whether symptomatic or not, subjects with bilateral pars defect had a virtually identical course to that of the general population in terms of disability and pain.⁶⁵ There appeared to be a marked slowing of slip progression with time, and no subject had reached a 40% slip. Importantly, the authors agreed that there was no justification for advising children and adolescents with spondylolysis and low-grade spondylolisthesis not to participate in sport.

A 7–11-year follow-up of symptomatic young athletes with early-detected spondylolysis recorded similar reassuring findings.⁶⁶ Most young athletes conservatively treated will have good functional outcomes at 11-year follow-up. If the pars defect is unilateral, there is a good chance of bony union, but it can take over 3 months.

CLINICAL FEATURES

Pain aggravated by physical activity is the usual presentation of symptomatic spondylolysis. It is usually in the low back and may radiate into the buttocks or proximal thighs. Unfortunately there is no discriminatory symptom or sign for spondylolysis to distinguish it from other causes of mechanical back pain. Reproduction of pain by asking the patient to stand on one leg and hyperextend the lumbar spine is said to be pathognomonic, but no reliability or validity studies have been published.

Most spondylolysis and spondylolisthesis will be asymptomatic. In children, only 13% of individuals with a pars defect have symptoms, and then they usually occur at growth spurts.⁶⁷

IMAGING

To avoid unnecessary radiation, careful thought must be given to ordering radiology. The first rule is not to rush into radiology at the first visit, if there has been no trial of conservative therapy. Most patients suspected of stress fracture are negative to bone scan and X-ray.⁶⁸ If, at the 4–6-week mark, there are no signs of the patient settling, then the first step would be a simple lateral of the spine. If spondylolisthesis is present, then no further radiology is necessary. Once there is a slip present, a bone scan is unnecessary as it means there is no possible chance of bony repair of a spondylolysis. The presence of spondylolisthesis does not imply that it is the cause of the back pain, but it does rule out any need for bracing the spine.

If the lateral is normal, then bypass doing oblique radiographs, as they require a great deal of radiation into the gonadal region for no benefit in decision-making. Either treat the patient on suspicion of spondylolysis or do a bone scan/MRI.

If the bone scan is positive, then CT scan through the particular segment will reveal whether a fracture is present and whether it is complete. This will give an indication of the chance of bony healing. It must be pointed out, however, that bony healing is not necessary to achieve an excellent clinical outcome with full return to activities. With this in mind, a strong case can be made for minimal radiological intervention in these patients.

MANAGEMENT

There are no high-quality controlled trials on treatment for spondylolysis. Most studies are uncontrolled case series involving the use of supervised exercise programs, braces and analgesia. Two studies have shown that specific exercise interventions, alone or in combination with other treatments, have a positive effect on low back pain due to spondylolysis and spondylolisthesis; however, the type of exercise was different in both studies.⁵²

Factors to consider are:

• pain management—this is usually achieved through analgesics, anti-inflammatory agents and avoiding flexion/extension activities; bracing may be considered if pain control proves difficult. Non-pharmacological methods ⁶⁹ are preferable to pharmacological approaches where possible. An integrative interdisciplinary approach to rehabilitation is usually required, particularly in chronic cases.

• mind–body techniques—to assist with pain management

• stability strengthening—biomechanical correction, mobilisation, exercises for flexibility and stability and strengthening, soft tissue massage. There are good theoretical reasons for and some clinical evidence to recommend strengthening lumbar stability exercises for patients ⁷⁰

• massage

• surgery—this is rarely needed and usually only considered if there is neurological compromise.

REFERENCES

1 Giles LC, Cameron ID, Crotty M. Disability in older Australians: projections for 2006–2031. Med J Aust. 2003;179:130-133.

2 Australian Institute of Health and Welfare. General practice activity in Australia 2006–07. Online. Available: http://www.aihw.gov.au/publications/gep/gpaa06-07/.

3 Access Economics. The prevalence, cost and disease burden of arthritis in Australia, Canberra: Arthritis Foundation of Australia, 2001.

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APPENDIX: ALGORITHMS

ALGORITHM FOR MANAGEMENT OF ACUTE LOW BACK PAIN

(Source: McGuirk B, King W, Govind J et al. The safety, efficacy and cost-effectiveness of evidence-based guidelines for the management of acute low back pain in primary care. Spine 2001; 26:2615–2622)

STAYAC ALGORITHM

(Source: Blomberg S. A pragmatic strategy for low back pain—an integrated multimodal programme based on antidysfunctional medicine. In: Hutson M, ed. Textbook of musculoskeletal medicine. Oxford University Press; 2005:1–20)

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Musculoskeletal medicine

INTRODUCTION AND OVERVIEW

LOW BACK PAIN

DEFINITIONS

EPIDEMIOLOGY

HISTORY

EXAMINATION

INVESTIGATION

DIAGNOSIS

MANAGEMENT

Initial presentation

COMPLEMENTARY THERAPIES

Acupuncture

For low back pain

For neck pain

For lateral elbow pain

Glucosamine and chondroitin

Nutrition

Herbal treatments

Topical herbs

INITIAL FOLLOW-UP

FURTHER FOLLOW-UP

SPONDYLOLYSIS/LISTHESIS

EPIDEMIOLOGY

PATHOPHYSIOLOGY AND NATURAL HISTORY

CLINICAL FEATURES

IMAGING

MANAGEMENT

APPENDIX: ALGORITHMS

ALGORITHM FOR MANAGEMENT OF ACUTE LOW BACK PAIN

STAYAC ALGORITHM

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