Musculoskeletal ultrasound - used to best advantage.

BACKGROUND: Effective management of both acute and chronic musculoskeletal pain revolves around a good history and physical examination, as well as a more detailed knowledge of anatomy than is required in other related medical disciplines. Imaging - if indicated - should not be looked upon as the panacea for problem solving but needs to be considered in the light of what a particular modality is best designed to do. OBJECTIVE: In the practice of cost effective medicine, a specific imaging modality must be chosen on the basis that it is the best economically to provide the information sought which in turn allows the formulation of an appropriate management plan. DISCUSSION: Ultrasound imaging has many advantages over other modalities for assessing musculoskeletal dysfunction. The major advantages are no radiation, 'real time' allows visualisation of functioning tissue, and it is the gold standard for assessing tendons. The most expensive or latest imaging modality is not always the most appropriate.

Chronic low back pain. What are the treatment options?

BACKGROUND: Chronic low back pain is a relatively common occurrence in general practice and there is much that the family doctor can do to help. OBJECTIVE: An important aspect of the management is to be able to identify red and yellow flag conditions which, if undiagnosed, can become a serious health risk. DISCUSSION: Being aware of the possibility that red and yellow flag conditions exist alerts the practitioners to which questions to ask and what the management might be. Patients suffering benign low back pain can be helped to cope by the use of several easily implemented modalities.

Pain provocation tests for the assessment of sacroiliac joint dysfunction.

A double-blind trial was carried out to determine the sensitivity and specificity of three commonly used pain provocation tests for sacroiliac joint dysfunction. The trial involved 40 patients, all of whom reported pain when they were subjected to each of the three tests. Half of the patients (20) had the symptomatic sacroiliac joint injected with 4 ml of 1% lignocaine, whereas the other 20 patients received 4 ml of normal saline to the painful joint. The level of pain produced by each of the three tests was assessed pre- and posttest injection using a visual analogue scale of 0-100. If the pain could be suppressed by 70% with injection of either normal saline or 1% lignocaine into the symptomatic sacroiliac joint under image intensification, the test was considered to be positive for pain arising from the sacroiliac joint. None of the patients receiving normal saline had their pain suppressed to any significant degree, whereas those patients receiving 1% lignocaine had their pain suppressed sufficiently for the three pain provocation tests to have a specificity of 100% for each test and a sensitivity range of 77-87%. This study indicates that the three tests, when used in combination, have a high predictive value for pain arising from the sacroiliac joint.

Effective treatment of low back pain in pregnancy.

OBJECTIVE: To assess the possible cause of low back pain in pregnancy and develop a management program. METHOD: All women attending a rural general practice for antenatal care were asked about back pain. They were tested for pain of lumbar and sacroiliac origin and if positive were treated with mobilising technique and home exercise. RESULTS: Of the 20 patients identified as having low back pain, the iliolumbar ligament was identified in three while the sacroiliac joint was suggestive in the remainder. After three visits 15 had no pain and the rest had more than a 50% improvement in their pain. CONCLUSION: Low back pain in pregnancy is likely to be due to sacroiliac dysfunction which can be significantly improved with mobilisation.

Sacroiliac dysfunction as a cause of low back pain.

The diagnosis of sacroiliac dysfunction cannot be assessed by the usual movements of the lumbar spine; namely, extension, flexion and lateral flexion. Many patients complaining of lower back pain have good lumbar mobility. If this is so, careful attention must be given to other structures in the region capable of causing lower back pain, including the sacroiliac joints (SIJs).