ack Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute L Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pa Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain A ack Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain in Acute Thoracic Spinal Pain Acute Thoracic Spinal Pain Acute Thoracic cute Thoracic Spinal Pain Acute Thoracic Spinal Pain Acute Thoracic Spina Pain Acute Thoracic Spinal Pain Acute Thoracic Spinal Pain Acute Thoracic Acute Thoracic Spinal Pain Acute Thoracic Spinal Pain Acute Thoracic Spin in Acute Thoracic Spinal Pain Acute Thoracic Spinal Pain Acute Thoracic Evidence-based Management of Acute Musculoskeletal Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck k Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acu ute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Ne Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute A Guide for Clinicians in Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Sh ute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute S Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Should in Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Sh nterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior Knee Pa or Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain An Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior Knee P Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anter nterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior Knee Pa Australian Acute Musculoskeletal Pain Guidelines Group Evidence-based Management of Acute Musculoskeletal Pain A Guide for Clinicians Australian Acute Musculoskeletal Pain Guidelines Group AUSTRALIAN ACADEMIC PRESS PTY LTD PUBLISHERS FOR THE BEHAVIOURAL SCIENCES Project Overview, Funding and Participants This guide is derived from an evidence review, “Evidence-based Management of Acute Musculoskeletal Pain” (available online at www.nhmrc.gov.au), undertaken by the Australian Acute Musculoskeletal Pain Guidelines Group (2003) The evidence review was submitted to the National Health and Medical Research Council (NHMRC) and was approved by the Council in June 2003 This guide summarises the findings of the evidence review and provides information sheets for consumers The evidence review was coordinated by the University of Queensland, funded by the Commonwealth Department of Health and Ageing, and approved by the following organisations: • • • • • • • • Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine Australian Osteopathic Association Australian Physiotherapy Association Australian Rheumatology Association Chiropractic and Osteopathic College of Australasia Chiropractors’ Association of Australia Consumers’ Health Forum of Australia Royal Australian College of General Practitioners Disclaimer Every attempt has been made to locate the most recent scientific evidence Judgment is necessary when applying evidence in a clinical setting It is important to note that weak or insufficient evidence does not necessarily mean that a practice is inadvisable, but may reflect the insufficiency of evidence or the limitations of scientific investigation This document is intended as a guide to practice The ultimate decision of how to proceed rests with the clinician and the patient and depends on individual circumstances and beliefs (NHMRC 1999) First published in 2004 by Australian Academic Press Pty Ltd 32 Jeays Street Bowen Hills QLD 4006 Australia www.australianacademicpress.com.au All responsibility for editorial matter rests with Australian Acute Musculoskeletal Pain Guidelines Group Any views or opinions expressed are therefore not necessarily those of Australian Academic Press Copyright © 2004 Australian Acute Musculoskeletal Pain Guidelines Group ISBN 875378 52 Text design by Andrea Rinarelli of Australian Academic Press, Brisbane ii Contents List of Tables & Figures About this Group Introduction Background Summary of the Findings of the Evidence Review Scope Evidence Review and Guideline Development Process Key Messages Limitations of the Evidence Review References 1 5 Principles of Acute Pain Management 2.1 2.2 2.3 2.3.1 2.3.2 2.4 2.5 Chapter xi 1.1 1.2 1.3 1.4 1.5 1.5.1 1.6 Chapter vii About this Guide Chapter vi Pain Acute and Chronic Pain Pain Assessment Pain Management Key Messages: Acute Pain Management References 9 10 10 11 11 12 Effective Communication 14 3.1 3.2 Communication Key Messages: Communication References 14 14 15 Key Messages: Interventions ‘Red Flags’ ‘Yellow Flags’ iii Contents iv Key Messages: Management Plan References 16 16 16 17 17 18 18 Acute Low Back Pain 19 Background Definition Scope Alerting Features of Serious Conditions Key Messages: Acute Low Back Pain References 19 19 20 20 21 29 Acute Thoracic Spinal Pain 30 Background Definition Scope Alerting Features of Serious Conditions Key Messages: Acute Thoracic Spinal Pain References 30 30 30 31 31 34 Acute Neck Pain 35 Background Definition Scope Alerting Features of Serious Conditions Key Messages: Acute Neck Pain References 35 35 35 36 37 43 Acute Shoulder Pain 44 8.1 8.2 8.3 8.4 8.5 Chapter Developing a Management Plan Components of a Management Plan 7.1 7.2 7.3 7.4 7.5 Chapter 16 6.1 6.2 6.3 6.4 6.5 Chapter Management Plan for Acute Musculoskeletal Pain 5.1 5.2 5.3 5.4 5.5 Chapter 4.1 4.2 4.2.1 4.2.2 4.2.3 4.3 Chapter Background Definition Scope Alerting Features of Serious Conditions Key Messages: Acute Shoulder Pain References 44 44 45 45 46 50 Assessment Management Review Contents Anterior Knee Pain 51 9.1 9.2 9.3 9.4 9.5 Background Definition Scope Alerting Features of Serious Conditions Key Messages: Anterior Knee Pain References 51 51 52 52 53 57 Appendix A Pain Assessment Tools 59 Appendix B Ancillary Investigations 62 Appendix C Canadian C-Spine Rule 63 Appendix D Knee Rules: Indications for Knee Xray 64 Appendix E Patient Information Sheets 66 Chapter Acute Low Back Pain Acute Thoracic Spinal Pain Acute Neck Pain Acute Shoulder Pain Anterior Knee Pain Glossary of Terms 77 v List of Tables & Figures 1.1 1.2 2.1 3.1 4.1 5.1 5.2 6.1 6.2 7.1 7.2 8.1 8.2 9.1 9.2 A1 A2 A3 A4 A5 B1 C1 D1 D2 D3 vi Tables Levels of Evidence Criteria for Categorising Interventions Acute Pain Management: Key Messages Effective Communication: Key Messages Management Plan: Key Message Alerting Features of Serious Conditions Associated with Acute Low Back Pain Summary of Key Messages: Acute Low Back Pain Alerting Features of Serious Conditions Associated with Acute Thoracic Spinal Pain Summary of Key Messages: Acute Thoracic Spinal Pain Alerting Features of Serious Conditions Associated with Acute Neck Pain Summary of Key Messages: Acute Neck Pain Alerting Features of Serious Conditions Associated with Acute Shoulder Pain Summary of Key Messages: Acute Shoulder Pain Alerting Features of Serious Conditions Associated with Anterior Knee Pain Summary of Key Messages: Anterior Knee Pain Figures Elements of a Pain History Pain Diagram Categorical Pain Rating Scale Visual Analogue Scale of Pain Intensity (VAS) Ten Point Numerical Rating Scale (NRS) Appropriate Investigations for Possible Serious Causes of Acute Musculoskeletal Pain The Canadian C-Spine Rule Ottawa Knee Rule Pittsburgh Knee Rule Bauer Rule 11 14 18 21 22 31 32 37 38 46 47 53 54 59 60 61 61 61 62 63 64 65 65 About this Group Executive Committee Professor Peter Brooks, Chair Associate Professor Lyn March Professor Nikolai Bogduk Professor Nicholas Bellamy Executive Dean, Faculty of Health Sciences, University of Queensland Consultant Rheumatologist and Clinical Epidemiologist; Associate Professor in Medicine and Public Health, University of Sydney; Senior Staff Specialist, Royal North Shore Hospital Director, Newcastle Bone and Joint Institute, Royal Newcastle Hospital Director, Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland Project Management Ms Natalie Spearing Ms Megan Fraser Project Manager, Faculty of Health Sciences, University of Queensland Project Assistant, Faculty of Health Sciences, University of Queensland Review Groups Acute Low Back Pain Associate Professor Lyn March Dr Lyndal Trevena Mr Simon French Ms Trudy Rebbeck Dr Fiona Blyth Consultant Rheumatologist and Clinical Epidemiologist; Associate Professor in Medicine and Public Health, University of Sydney; Senior Staff Specialist, Royal North Shore Hospital General Practice, University of Sydney Department of General Practice Chiropractor, Chiropractic and Osteopathic College of Australasia Musculoskeletal Physiotherapist, Australian Physiotherapy Association Medical Epidemiologist, Pain Management and Research Centre, Royal North Shore Hospital vii About this Group Professor Nicholas Bellamy Ms Rebecca Coghlan Dr Nick Penney Dr Hanish Bagga Acute Thoracic Spinal Pain Dr Michael Yelland Dr Keith Charlton Associate Professor Gwendolen Jull Professor Peter Brooks Professor Nicholas Bellamy Acute Neck Pain Professor Nikolai Bogduk Dr Philip Bolton Associate Professor Gwendolen Jull Professor Nicholas Bellamy Dr Phillip Giles Associate Professor Les Barnsley viii Director, Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland Consumer Representative, Consumers’ Health Forum of Australia Osteopath, Australian Osteopathic Association PhD Fellow, Institute of Bone and Joint Research, University of Sydney General Practice, Musculoskeletal Medicine, Australasian Faculty of Musculoskeletal Medicine Chiropractor, Queensland Physiotherapist, Australian Physiotherapy Association Executive Dean, Faculty of Health Sciences, University of Queensland Director, Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland Professor of Pain Medicine; Director, Newcastle Bone and Joint Institute, Royal Newcastle Hospital Chiropractor, Head of Human Physiology, University of Newcastle Physiotherapist, Australian Physiotherapy Association Director, Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland General Practice, Musculoskeletal Medicine, Australasian Faculty of Musculoskeletal Medicine Rheumatologist, Australian Rheumatology Association About this Group Acute Shoulder Pain Dr Wade King Associate Professor Rachelle Buchbinder Associate Professor Sally Green Dr Scott Masters Dr Henry Pollard Dr Peter Nash Professor Peter Brooks Professor Nicholas Bellamy Dr Simon Bell Anterior Knee Pain Dr David Vivian Associate Professor Lyn March Dr Sallie Cowan Dr Kay Crossley Professor Nicholas Bellamy Pain Medicine Specialist, Newcastle Pain Management and Research Group, Royal Newcastle Hospital Rheumatologist, Australian Rheumatology Association Physiotherapist, Australian Physiotherapy Association General Practice, Musculoskeletal Medicine, Australasian Faculty of Musculoskeletal Medicine Chiropractor, Chiropractic and Osteopathic College of Australasia Rheumatology, Director Rheumatology Research Unit, Nambour Hospital Executive Dean, Faculty of Health Sciences, University of Queensland Director, Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland Orthopaedic Surgeon, Victoria General Practice, Musculoskeletal Medicine, Australasian Faculty of Musculoskeletal Medicine Consultant Rheumatologist and Clinical Epidemiologist; Associate Professor in Medicine and Public Health, University of Sydney; Senior Staff Specialist, Royal North Shore Hospital Centre for Sports Medicine Research, School of Physiotherapy, University of Melbourne Centre for Sports Medicine Research, School of Physiotherapy, University of Melbourne Director, Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland ix • Anterior Knee Pain Table 9.2 continued ANTERIOR KNEE PAIN: KEY MESSAGES EVIDENCE LEVEL Insufficient Evidence (continued) Analgesics (Simple and Opioid) • There are no randomised controlled studies of the effectiveness of paracetamol or opioids versus placebo in the treatment of patellofemoral pain NO LEVEL I OR II EVIDENCE Electrical Stimulation • There are no randomised controlled studies of the effectiveness of electrical stimulation of the quadriceps muscle for patellofemoral pain NO LEVEL I OR II EVIDENCE • LEVEL II There is insufficient evidence that one form of electrical stimulation of the quadriceps muscle is superior to another for treating patellofemoral pain Non-steroidal Anti-inflammatory Drugs (NSAIDs) • There are no randomised controlled studies of the effectiveness of NSAIDs versus placebo in the treatment of patellofemoral pain NO LEVEL I OR II EVIDENCE • Different types of NSAIDs provide similar relief of patellofemoral pain after five days of use LEVEL II • Serious adverse effects of NSAIDs include gastrointestinal complications (e.g bleeding, perforation) LEVEL I Patellar Taping • There is insufficient evidence that patellar taping alone is effective in relieving patellofemoral pain; however it may be a useful adjunct to exercise therapy programs Progressive Resistance Braces • There is insufficient evidence that progressive resistance braces are effective in relieving patellofemoral pain compared to no treatment (this treatment is not routinely available in Australia) Therapeutic Ultrasound • There is insufficient evidence that therapeutic ultrasound is more effective compared to ice massage for the treatment of patellofemoral pain LEVEL I, II LEVEL I LEVEL I Evidence of No Benefit Laser Therapy • There is evidence that low-level laser therapy provides similar effect to sham laser in the management of patellofemoral pain LEVEL I * Indicative only A higher rating of the level of evidence might apply (see 1.6: Limitations of the Evidence Review) ‹ Features of serious conditions are summarised in Table 9.1 56 Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians • Anterior Knee Pain References Almeida SA, Trone DW, Leone DM, Shaffer RA, Patheal SL, Long K (1999a) Gender differences in musculoskeletal injury rates: a function of symptom reporting? Medicine and Science in Sports and Exercise, 31: 1807–1812 Almeida SA, Williams KM, Shaffer RA, Brodine SK (1999b) Epidemiological patterns of musculoskeletal injuries and physical training Medicine and Science in Sports and Exercise, 31: 1176–1182 Australian Acute Musculoskeletal Pain Guidelines Group (AAMPGG) (2003) Evidence-Based Management of Acute Musculoskeletal Pain [Online Available at http://www.nhmrc.gov.au] Australian Academic Press: Brisbane Baquie P, Brukner P (1997) Injuries presenting to an Australian sports medicine centre: a 12-month study Clinical Journal of Sport Medicine, 7: 28–31 Clement DB, Taunton SE, Smart GW, McNicol KL (1981) A survey of overuse running injuries The Physician and Sportsmedicine, 9: 47–58 Crossley K, Bennell K, Green S, McConnell J (2001) A systematic review of physical interventions for patellofemoral pain syndrome Clinical Journal of Sport Medicine, 11: 103–110 DeHaven KE, Lintner DM (1986) Athletic injuries: comparison by age, sport, and gender American Journal of Sports Medicine, 14: 218–24 Derscheid GL, Feiring DC (1987) A statistical analysis to characterize treratment adherence of the 18 most common diagnoses seen at the sports medicine clinic The Journal of Orthopaedic and Sports Physical Therapy, 9: 40–46 Devereaux MD, Lachmann SM (1984) Patello-femoral arthralgia in athletes attending a Sports Injury Clinic British Journal of Sports Medicine, 18: 18–21 Heir T, Glomsaker P (1996) Epidemiology of musculoskeletal injuries among Norwegian conscripts undergoing basic military training Scandinavian Journal of Medicine Science in Sports, 6: 186–191 James SL, Bates BT, Osternig LR (1978) Injuries to runners American Journal of Sports Medicine, 6: 6–14 Jones BH, Cowan DN, Tomlinson JP, Robinson JR, Polly DW, Frykman PN (1993) Epidemiology of injuries associated with physical training among young men in the army Medicine and Science in Sports and Exercise, 25: 197–203 Kowal DM (1980) Nature and causes of injuries in woman resulting from an endurance training program American Journal of Sports Medicine, 8: 265–269 Levine J (1979) Chondromalacia patellae The Physician and Sportsmedicine, 7: 41–49 Matheson GO, Macintyre JG, Taunton JE, Clement DB, Lloyd-Smith R (1989) Musculoskeletal injuries associated with physical activity in older adults Medicine and Science in Sports and Exercise, 21: 379–385 Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians 57 • Anterior Knee Pain Merskey H (1979) Pain terms: a list with definitions and notes on usage recommended by the IASP Subcommittee on Taxonomy Pain, 6: 249–252 Merskey H, Bogduk N (eds) (1994) Classification of Chronic Pain Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms (2nd Edition) IASP Press: Seattle Milgrom C, Finestone A, Eldad A, Shlamkovitch N (1991) Patellofemoral pain caused by overactivity A prospective study of risk factors in infantry recruits Journal of Bone and Joint Surgery, 73A: 1041–1043 Outerbridge RE (1964) Further studies on the etiology of chondromalacia patellae Journal of Bone and Joint Surgery, 46B: 179–190 Pagliano JW, Jackson DW (1987) A clinical study of 3,000 long distance runners Annals of Sports Medicine, 3: 88–91 Schwellnus MP, Jordaan G, Noakes TD (1990) Prevention of common overuse injuries by the use of shock absorbing insoles A prospective study American Journal of Sports Medicine, 18: 636–641 Shwayhat AF, Linenger JM, Hofherr LK, Slymen DJ, Johnson CW (1994) Profiles of exercise history and overuse injuries among United States Navy Sea, Air, and Land (SEAL) recruits American Journal of Sports Medicine, 22: 835–840 Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G (2000) Intrinsic risk factors for the development of anterior knee pain in an athletic population: a two-year prospective study Amercian Journal of Sports Medicine, 28: 480–489 58 Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians ENDIX APP A Pain Assessment Tools The elements of a pain history (Figure A1) provide information that can alert to the presence of a serious underlying condition It is important to note that in the absence of a serious cause of pain, it is not necessary to obtain a specific patho-anatomic diagnosis to manage acute musculoskeletal pain effectively Figure A1: Elements of a Pain History PAIN HISTORY Site Distribution (refer to Figure A2) Quality Duration Temporal factors Intensity (refer to Figures A3, A4, A5) Aggravating factors Relieving factors Impact on activities of daily living Associated symptoms Onset Previous similar symptoms Previous treatment Current treatment Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians 59 A • Pain Assessment Tools Figure A2: Pain Diagram Please describe the pain problem: Please indicate with an ‘x’ on these figures where your main pain is Shade any area where your pain spreads Please number (2,3,4 etc) any other areas where you have pain Note: Based on National Health and Medical Research Council (1999) Acute Pain Management: Scientific Evidence Commonwealth of Australia: Canberra 60 Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians A • Pain Assessment Tools Figure A3: Categorical Pain Rating Scale None Mild Moderate Severe Extreme Note: Based on National Health and Medical Research Council (1999) Acute Pain Management: Scientific Evidence Commonwealth of Australia: Canberra Figure A4: Visual Analogue Scale of Pain Intensity (VAS) Please place a mark on the 10cm line below to indicate your current level of pain: No pain l—————————————————————————l Extreme pain Note: Based on National Health and Medical Research Council (1999) Acute Pain Management: Scientific Evidence Commonwealth of Australia: Canberra Figure A5: Ten Point Numerical Rating Scale (NRS) No pain 10 Extreme pain Note: Based on National Health and Medical Research Council (1999) Acute Pain Management: Scientific Evidence Commonwealth of Australia: Canberra Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians 61 ENDIX APP B Ancillary Investigations Figure B1: Appropriate Investigations for Possible Serious Causes of Acute Musculoskeletal Pain (intended as a general guide only) SUSPECTED CONDITION REGION OF PAIN (and alerting clinical features or risk factors) Lumbar Spine Fracture History of significant trauma History of minor trauma in association with corticosteroid use, age over 50, history of osteoporosis History of previous fracture or metabolic disease Positive for Canadian C-spine rule Positive for Knee Rule All cases Plain radiography Stress of pars interarticularis Bone scan Infection Fever Sweating Risk factors for infection (e.g invasive procedure, trauma to skin or mucous membrane, immunosuppressive disease or treatment) All cases ESR, FBC, CRP Spinal MRI Tumour Palpable mass Past history of malignancy Age > 50 years Failure to improve with treatment Unexplained weight loss Pain not relieved by rest Cervical Spine Shoulder Knee Osteomyelitis MRI Joint Aspiration, Culture and Microscopy Myeloma IEPG, Serum protein electrophoresis Prostate PSA All cases First line: ESR, CRP Second line: MRI Crystal arthritis Joint effusion Aspiration, Microscopy Aneurysm Vertebral, Cardiovascular risk factors Carotid Anticoagulants Transient ischaemic attacks Aortic Bruits Recent history of torsion to neck Absence of musculoskeletal signs Osteonecrosis Immunosuppression Renal dialysis Use of corticosteroids Diabetes, alcoholism Thoracic Spine MRA Ultrasound MRI Note: ESR: erythrocyte sedimentation rate; FBC: full blood count; CRP: C-reactive protein; MRI: magnetic resonance imaging; IEPG: immunoelectrophoretogram; MRA: magnetic resonance angiography 62 Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians ENDIX APP C Canadian C-Spine Rule Figure C1: The Canadian C-Spine Rule Any high-risk factor that mandates radiography? Age > 65 years or Dangerous mechanism of injurya or Paraesthesias in extremities yes no Any low-risk factor that allows safe assessment of range of motion? Simple rear-end motor vehicle collision (MVC)b or Sitting position in emergency department or Ambulatory at any time or Delayed onset of neck pain (i.e not immediate) or Absence of midline cervical spine tenderness no Radiography yes Able to actively rotate neck 45˚ left and right? unable able No Radiography a: Dangerous mechanisms: • fall from > metre or stairs • axial load to head, e.g diving • high speed MVC (> 100kph), rollover, ejection • motorized recreational vehicles • bicycle collision b: Simple rear-end MVC excludes: • pushed into oncoming traffic • hit by bus or large truck • rollover • hit by high-speed vehicle Note: Based on Stiell, I.G., Wells, G.A., Vandemheen, K.L., Clement, C.M., Lesiuk, H., De Maio, V.J., Laupacis, A., Schull, M., McKnight, R.D., Verbeek, R., Brison, R., Cass, D., Dreyer, J., Eisenhauer, M.A., Greenberg, G.H., MacPahil, I., Morrison, L., Readon, M., & Worthington, J.W (2001) The Canadian C-spine rule for radiography in alert and stable trauma patients Journal of the American Medical Association, 286, 1841–1848 Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians 63 ENDIX APP D Knee Rules: Indications for Knee Xray Traumatic Knee Pain The following Rules provide indications for conventional xray in the event of acute traumatic knee injury: • The Ottawa Knee Rule • The Pittsburgh Knee Rule • The Bauer Rule Figure D1: Ottawa Knee Rule The rule states that a conventional xray is required for acute knee injury in the presence of any of the following findings: • Age 55 years or older • Isolated tenderness of patella • Tenderness at head of fibula • Inability to flex to 90° • Inability to bear weight both immediately post-injury or in the emergency department (described as ‘unable to transfer weight twice onto each lower limb regardless of limping’) This rule has been validated and found to be reliable in the absence of head injury, drug or alcohol intoxication, paraplegia and diminished limb sensation It has a sensitivity of 97%, specificity of 27% and likelihood ratio of 1.3% Note: Based on Stiell, I.G., Greenberg, G.H., Wells, G.A., McDowell, I., Cwinn, A.A., Smith, N.A., Cacciotti, T.F., & Sivilotti, M.L (1996) Prospective validation of a decision rule for the use of radiography in acute knee injuries Journal of the American Medical Association, 275, 611-615 64 Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians D • Knee Rules: Indications for Knee Xray Figure D2: Pittsburgh Knee Rule For patients with acute knee pain and a history of a fall or blunt trauma, the following rules apply: • All patients aged 11 or younger and those aged 51 and older are xrayed • Of those remaining, only those who cannot walk four weight-bearing steps in the emergency department are xrayed Weight-bearing ability is the ability to bear weight fully on the toe pads and heels for four full steps The Pittsburgh Knee Rule has the greatest predictive value of the three rules (sensitivity of 99%, specificity of 60% and a likelihood ratio of 2.5) Note: Seaberg, D.C., & Jackson, R (1994) Clinical decision rule for knee radiographs American Journal of Emergency Medicine, 12, 541-543 Figure D3: Bauer Rule In the Bauer Rule, the inability to bear weight combined with the presence of an effusion or an ecchymosis was initially found to be 100% sensitive and specific for the detection of a fracture Note: Bauer, S.J., Hollander, J.E., Fuchs, S.H., & Thode, H.C (1995) A clinical decision rule in the evaluation of acute knee injuries Journal of Emergency Medicine, 13, 611-615 Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians 65 ENDIX APP E Patient Information Sheets This appendix contains five Information Sheets • Information Sheet No 1: Acute Low Back Pain • Information Sheet No 2: Acute Thoracic Spinal Pain • Information Sheet No 3: Acute Neck Pain • Information Sheet No 4: Acute Shoulder Pain • Information Sheet No 5: Anterior Knee Pain It is intended that you will make multiple copies of the following Information Sheets to use with your patients, keeping the originals to make additional copies as required These Information Sheets can be downloaded from www.nhmrc.gov.au/publications/cphome.htm 66 Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians Glossary of Terms This glossary contains definitions obtained from a range of sources Acute Pain ‘Acute’ pain refers to the duration of pain rather than to its severity Bonica (1953) defined acute pain as pain that is likely to resolve spontaneously within a relatively short time Merskey (1979) subsequently specified the timeframe for acute pain as pain of less than three months duration measure of how well an intervention works in a range of contexts Efficacy The efficacy of a therapeutic intervention is its rate of successful outcomes when applied under ideal conditions Efficacy is expressed as number-needed-to-treat (NNT) Chronic Pain Health Practitioner The International Association for the Study of Pain (IASP) defines chronic pain as pain that has persisted for longer than three months (Merskey and Bogduk 1994) In this document the term ‘health practitioner’ refers to health professionals who receive a fee for service independently (i.e general practitioners, physiotherapists, chiropractors, osteopaths, specialist medical consultants) This list is not exhaustive Clinician In this document the term ‘clinician’ refers to health professionals who receive a fee for service independently (i.e general practitioners, physiotherapists, chiropractors, osteopaths, specialist medical consultants) This list is not exhaustive in relation to clinicians who participate in the care of people with musculoskeletal pain Consumer In this document the term ‘consumer’ is used in cases where a person is acting independently of a clinician Where a person is receiving care from a clinician, the term ‘patient’ is used instead Effect Size An effect size is the standardised mean difference between two groups An effect size quantifies the effectiveness of a particular intervention relative to a comparison intervention by measuring the size of the difference between two groups It provides a Intervention An intervention will generally be a therapeutic procedure such as treatment with a pharmaceutical agent, surgery, a dietary supplement, a dietary change or psychotherapy Some other interventions are less obvious, such as early detection (screening), patient educational materials, or legislation The key characteristic is that a person or their environment is manipulated in order to benefit that person Manipulation (Spinal) Manual therapy technique in which loads are applied to the spine using short or long-lever methods The spinal joint to which the technique is applied is moved to its end range of voluntary motion, followed by application of a single high velocity, low amplitude thrust Spinal manipulation is usually accompanied by an audible pop or click Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians 77 Glossary of Terms Manual Therapy The application of physical techniques, which includes but is not limited to, massage, spinal manipulation and mobilisation Massage A mechanical form of therapy in which the soft tissue structures of the low back are pressed and kneaded, using the hand or a mechanical device Many different types of massage are performed, including but not limited to, acupressure, deep-tissue therapy, friction massage, Swedish massage, myofascial release, shiatsu, reflexology, craniosacral therapy, trigger and pressure point therapy Mobilisation Mobilisation is the passive application of repetitive, rhythmical, low velocity movements of varying amplitudes applied within the joint range of motion The technique includes methods of a singular or repetitive movement and/or stretching of the spinal joints Pain Pain is defined as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’ (Merskey and Bogduk 1994) Pain, Recurrent Recurring episodes of pain may be labelled as ‘recurrent pain’ and classified as acute or chronic depending on the duration of the episode Patient In this document the term ‘consumer’ is used in cases where a person is acting independently of a clinician Where a person is receiving care from a clinician, the term ‘patient’ is used instead ‘Red Flags’ The term ‘red flags’ refers to clinical (i.e physical) features that may alert to the presence of serious but relatively uncommon conditions or diseases requiring urgent 78 evaluation Such conditions include tumours, infection, fractures and neurological damage Screening for serious conditions occurs as part of the history and physical examination and should occur at the initial assessment and subsequent visits Alerting features of serious conditions are covered in detail in the specific guideline topics Randomised Controlled Trial An experimental comparison study in which participants are allocated to treatment/intervention or control/placebo groups using a random mechanism to allocate them to either group When there is equal chance of allocation to either the treatment or the control group, allocation bias is eliminated Systematic Review The process of systematically locating, appraising and synthesising evidence from scientific studies in order to obtain a reliable overview Treatment See ‘Intervention’ ‘Yellow Flags’ The term ‘yellow flags’ was introduced to identify psychosocial factors that may increase the risk of chronicity and that should be assessed when progress is slower than expected The presence of psychosocial factors is a prompt for further detailed assessment and early intervention The areas to evaluate include: • Attitudes and beliefs about pain • Behaviours • Compensation issues • Diagnostic and treatment issues • Emotions • Family • Work ‘Red flags’ and ‘yellow flags’ are not mutually exclusive and intervention may be required for both clinical and psychosocial risk factors Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians NOTES Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians 79 NOTES 80 Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians ... Musculoskeletal Pain? ??) is available at www.nhmrc.gov.au • The guide covers the management of five regions of acute musculoskeletal pain (acute low back pain, acute thoracic spinal pain, acute neck pain, acute. .. Brisbane Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians 15 4.1 Management Plan for Acute Musculoskeletal Pain Developing a Management Plan A management plan for acute. .. causes of back pain, the presence of these features in conjunction with Evidence-based Management of Acute Musculoskeletal Pain: A Guide for Clinicians • Acute Low Back Pain acute low back pain