The therapeutic management of back pain with and without sciatica in the emergency department: a systematic review.

INTRODUCTION: An increasing number of patients are attending the Emergency Department (ED) with back pain with or without sciatica. There is evidence to suggest that medical management is varied and inconsistent. OBJECTIVE: The purpose of this study was to review the literature to determine the evidence base for the therapeutic management of adults presenting with back pain with or without sciatica in the ED. METHODS: A systematic review of the literature included the therapeutic management of patients presenting in the ED. Articles published in peer review journals in English language up to August 2018 were searched for in the following data-bases: MEDLINE, EMBASE, SCOPUS, CINAHL, ZETOC, PubMed, The Cochrane Library (Cochrane Database of Systematic Reviews), Web of Science, Open Grey and ETHOS. A narrative synthesis approach was followed. RESULTS: Twenty two studies, including 17 randomised control trials, one randomised control pilot study, two cohort studies, one cohort pilot study and one retrospective audit were included. The Downs and Black methodological quality scores ranged from 16 to 31 with a mean score of 24 out of a possible 32. CONCLUSION: Evidence suggests that Naproxen alone should be considered as first line management in cases of back pain without sciatica. Intra-venous corticosteroids should be considered in the management of cases of severe sciatica. More high quality trials are needed to determine an evidence-based management protocol for the treatment of acute low back pain in the ED, specifically focusing on non-pharmacological management and the first line management of patients presenting with LBP with sciatica. Systematic Review Registration Number PROSPERO CRD42016042087.

Is there an association between back pain and stress incontinence in adults with cystic fibrosis? A retrospective cross-sectional study.

BACKGROUND: Back pain and stress urinary incontinence (SUI) are common in adults with cystic fibrosis (CF). This study aimed to establish whether there is an association between back pain, lung function and stress urinary incontinence and its relative risk. METHOD: This was a cross-sectional, retrospective analysis of the Manchester Musculoskeletal Screening Tool (MMST) data. It includes pain, (Short Form McGill Pain Questionnaire (SF-MPQ and VAS)) and International Consultation on Incontinence Short Form (ICIQ-UI-SF) measures. Associations were tested using Spearman's rank correlation coefficient. Relative risk of developing symptoms was calculated the sig level was p=0.05. RESULTS: ICIQ-UI-SF was associated with back pain (SF-MPQ) (Rho=0.32, p<0.001) and pain (VAS) (Rho=0.23, p<0.01). RR of developing SUI with back pain was 2; RR of developing back pain with SUI was 1.3. CONCLUSIONS: An association is indicated between back pain (SF-MPQ and VAS), and SUI in adults with CF. This information is important when developing management strategies in the CF population.

What Are the Predictors of Altered Central Pain Modulation in Chronic Musculoskeletal Pain Populations? A Systematic Review.

BACKGROUND: Altered central pain modulation is the predominant pain mechanism in a proportion of chronic musculoskeletal pain disorders and is associated with poor outcomes. Although existing studies predict poor outcomes such as persistent pain and disability, to date there is little consensus on what factors specifically predict altered central pain modulation. OBJECTIVES: To review the existing literature on the predictive factors specifically for altered central pain modulation in musculoskeletal pain populations. STUDY DESIGN: This is a systematic review in accordance with supplemented PRISMA guidelines. METHODS: A systematic search was performed by 2 mutually blinded reviewers. Relevant articles were screened by title and abstract from Medline, Embase, PubMed, CINAHL, and Web of Science electronic databases. Alternative sources were also sought to locate missed potential articles. Eligibility included studies published in English, adults aged 18 to 65, musculoskeletal pain, baseline measurements taken at the pre-morbid or acute stage, > 3-month follow-up time after pain onset, and primary outcome measures specific to altered central pain modulation. Studies were excluded where there were concurrent diseases or they were non-predictive studies. Risk of bias was assessed using the quality in prognostic studies (QUIPS) tool. Study design, demographics, musculoskeletal region, inclusion/exclusion criteria, measurement timelines, predictor and primary outcome measures, and results were extracted. Data were synthesized qualitatively and strength of evidence was scored using the grading of recommendations, assessment, development, and evaluations (GRADE) scoring system. RESULTS: Nine eligible articles were located, in various musculoskeletal populations (whiplash, n = 2; widespread pain, n = 5; temporomandibular disorder, n = 2). Moderate evidence was found for 2 predictive factors of altered central pain modulation: 1) high sensory sensitivity (using genetic testing or quantitative sensory tests), and 2) psychological factors (somatization and poor self-expectation of recovery), at a pre-morbid or acute stage baseline. LIMITATIONS: At the times of the article publications, the current definitions and clinical guidelines for identifying altered central pain modulation were not yet available. Careful interpretation of the information provided using current knowledge and published guidelines was necessary to extract information specific to altered central pain modulation in some of the studies, avoiding unwarranted assumptions. CONCLUSIONS: Premorbid and acute stage high sensory sensitivity and/or somatization are the strongest predictors of altered central pain modulation in chronic musculoskeletal pain to date. This is the first systematic review specifically targeting altered central pain modulation as the primary outcome in musculoskeletal pain populations. Early identification of people at risk of developing chronic pain with altered central pain modulation may guide clinicians in appropriate management, diminishing the burden of persistent pain on patients and heath care providers alike. Systematic Review Registration no.: PROSPERO 2015:CRD42015032394.Key words: Predictive factors, pre-morbid and acute stage baselines, altered central pain modulation, chronic musculoskeletal pain, sensory processing, somatization.

Ankle syndesmosis repair and rehabilitation in professional rugby league players: a case series report.

BACKGROUND/AIM: The distal tibiofibular joint is described as a syndesmosis. Traditionally, severe syndesmotic injuries with diastasis have been treated surgically with screw fixation. This case series details an ankle syndesmosis tightrope repair and an accelerated rehabilitation protocol that reduces the amount of time to return to professional rugby league in the UK. The aim of this study was to describe players' journey from injury, through diagnosis to surgery, rehabilitation and return to participation, detailing time scales and methods used at each stage to highlight the change in current practice. METHODS: Players were identified via a single orthopaedic surgeon in the UK who specialises in ankle syndesmosis repair. Between January 2010 and September 2015, adult men playing full-time professional rugby league in the UK Super League with ankle syndesmosis injuries were identified. RESULTS: Eighteen players from six different clubs were included. The most common mechanism of injury was forced dorsiflexion/eversion. The average return to participation was 64 days (SD 17.2, range 38-108). This compares favourably to reports of between 120 and 180 days following screw fixation. CONCLUSION: Ankle syndesmosis tightrope repair and an accelerated rehabilitation protocol is as safe as traditional methods. The accelerated rehabilitation protocol promotes early weight-bearing and has shown to expedite the return to sport for professional Rugby League players. It is possible to return to sport 2 months after a tightrope repair and accelerated rehabilitation, compared with 3-6 months post screw fixation. This is extremely encouraging for the professional sporting population.

Experiences of attendance at a neuromuscular centre: perceptions of adults with neuromuscular disorders.

PURPOSE: The aim of this research is to gain an insight into adults with neuromuscular disorders' experiences of attendance at a specialised, voluntary sector, Neuromuscular Centre and explore its value to these adults who attend for treatment, education or employment. METHOD: This study was qualitative in design. In-depth interviews were conducted with nine self-selected participants, recruited from the population of adults with neuromuscular disorders who attended the Neuromuscular Centre. Interviews were transcribed verbatim and thematically analysed. Thematic networks were utilised to aid interpretation. RESULTS: Participants saw the benefit of specialist input to remain mobile and independent for longer. The Centre created a culture of understanding and empathy which facilitated mutual support and self-acceptance. Opportunities for employment and education offered a sense of purpose. Sharing experiences developed self-knowledge and the ability to self-manage their condition. CONCLUSION: Attendance at this voluntary sector Neuromuscular Centre provided physical, psychosocial and economic benefits. The Neuromuscular Centre through its holistic approach offers a unique model for rehabilitation of adults with neuromuscular disorders. As an enterprise, satellite centres adopting the ethos of the Centre could be created, which could potentially help to redress the inequalities in health care for adults with neuromuscular disorders.

Physiotherapy after arthroscopic partial meniscectomy surgery: an assessment of costs to the National Health Service, patients, and society.

OBJECTIVES: The purpose of this study was to determine and inform clinicians, managers, and budget allocators of the costs incurred to the British National Health Service (NHS), patient, and society when attending clinic-based physiotherapy compared with not attending clinic-based physiotherapy after arthroscopic partial meniscectomy surgery. METHODS: The valuation principle used in this study was the economic concept of opportunity cost. Costs were referred to as direct medical (NHS), direct nonmedical (patient), and indirect (societal) costs. Due to the difficulties of their measurement and valuation, intangible costs, in the form of pain and anxiety related to the effect of receiving or not receiving treatment, have not been considered in this analysis. RESULTS: Providing clinic-based physiotherapy after knee arthroscopic partial meniscectomy surgery is more costly to the NHS and patient, but no more costly to society than when not providing it and does not result in reduced contact with the NHS. CONCLUSIONS: Clinic-based physiotherapy after knee arthroscopic partial meniscectomy surgery is costly and evidence is needed that its effectiveness is high enough to support its use.