Low back pain enhanced by psychological factors

Psychological and social stressors often enhance the symptoms of low back pain, experts say.

Associate Professors Leigh Atkinson, from Wesley Pain and Spine Centre in Brisbane, and Andrew Zacest from Royal Adelaide Hospital wrote in the Medical Journal of Australia that the high incident of low back pain is best understood in a biopsychosocial framework.

They say the pain from an injury is compounded by other issues such as work dissatisfaction, family stress, depression and at times secondary gain.

Compensation and third party insurance can impact pain and prolong rehabilitation. Furthermore, a study of workers compensation patients receiving surgery found the outcomes were poor.

“The incidence of persistent post-operative pain syndrome was as high as 40% and … there was a 50% success rate, at best, from the first operation, 30% from the second and 15% from the third,” the authors explained.

High expectation of successful surgical outcomes

Low back pain in the most common symptom seen in primary care, however patients often have high expectations from modern medicine.

“Not uncommonly, the patient attends the surgical consultation with an expectation that the problems can be fixed,” the authors wrote.

However despite an escalation in numbers performed, surgeries on low back pain remain controversial.

In the past 11 years, there has been a 267% increase of spinal fusion surgeries in the US and there has also been a disproportionate increase of surgeries in private hospitals compared to public.

There is a large array of techniques for spinal fusion however despite them all having different technical complications, there is little evidence of one providing better outcomes than another.

Multiple Cochrane studies have confirmed insufficient evidence of the effectiveness of spinal fusions, one in 2005 finding “variable clinical outcomes ranging between 16% and 95%.”

The authors believe an increased there needs to be a national audit of patient centred outcomes for spinal fusion.

“While the spinal fusion procedure remains controversial, it would be valuable for spinal surgeons to undertake a national audit of patient-centred outcomes for the procedure, similar to the excellent audit carried out for hip and knee arthroplasties by the Australian orthopaedic surgeons,” they concluded.

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[Seminar] Osteogenesis imperfecta

Osteogenesis imperfecta is a phenotypically and molecularly heterogeneous group of inherited connective tissue disorders that share similar skeletal abnormalities causing bone fragility and deformity. Previously, the disorder was thought to be an autosomal dominant bone dysplasia caused by defects in type I collagen, but in the past 10 years discoveries of novel (mainly recessive) causative genes have lent support to a predominantly collagen-related pathophysiology and have contributed to an improved understanding of normal bone development.

[Correspondence] Medical education and medical professionalism in China

In October, 2015, Youyou Tu, a Chinese medical researcher, won the Nobel Prize in Medicine or Physiology for her discovery of artemisinin as an anti-malarial therapy.1 This announcement has drawn national attention and caused fierce controversy in the scientific community in mainland China.

[Comment] Left-to-right atrial shunting: new hope for heart failure?

So far, no treatments have proven effective for heart failure with preserved ejection fraction—a syndrome with dismal prognosis.1 The syndrome is heterogeneous and associated with many comorbidities. Pathophysiology of the disorder is poorly understood, although a common hallmark is large artery stiffness and heart stiffness, whether related to fibrosis or myocardial titin-based stiffness. As a consequence, the heart’s ability to cope with exercise-induced haemodynamic overload is restricted. Exercise would inevitably produce an abrupt rise in pulmonary and left atrial pressure, the main driver of dyspnoea in patients with heart failure with preserved ejection fraction.

[Perspectives] Sexual science beyond the medical

The US television series Masters of Sex tells the story of how William H Masters and Virginia E Johnson began to work together in the 1960s to study, observe, and measure the physiology of human sexual response. The series depicts the couple as pioneers in applying clinical observation to the study of human sexuality and focuses on the challenges they faced in persuading medical authorities to accept the validity of their work. Masters of Sex presents a later chapter within a longer history of the 150-year struggle to establish sex research as a legitimate discipline.

[Seminar] Hydrocephalus in children

Hydrocephalus is a common disorder of cerebral spinal fluid (CSF) physiology resulting in abnormal expansion of the cerebral ventricles. Infants commonly present with progressive macrocephaly whereas children older than 2 years generally present with signs and symptoms of intracranial hypertension. The classic understanding of hydrocephalus as the result of obstruction to bulk flow of CSF is evolving to models that incorporate dysfunctional cerebral pulsations, brain compliance, and newly characterised water-transport mechanisms.

6 procedures and tests that should be questioned: physiotherapists

The Choosing Wisely campaign will reach the next stage in mid-March with the release of their next wave of recommendations from Australian medical colleges, societies and associations.

The campaign kicked off in 2015, with the Australasian College for Emergency Medicine, the Australasian Society of Clinical Immunology and Allergy, The Royal Australian College of General Practitioners, The Royal Australian and New Zealand College of Radiologists and The Royal College of Pathologists of Australasia all releasing their recommendations of tests and treatments to question.

In the next few weeks, the next wave of colleges will release their recommendations, including a second list from the RACGP.

In anticipation of the announcement, the Australian Physiotherapy Association has developed a list of 6 recommendations that clinicians and consumers should question. It is the only allied health profession among twelve medical colleges and societies taking part in Choosing Wisely.

They say their recommendations are not prescriptive and should merely help start a conversation about what is appropriate and necessary in each individual situation.

Related: Richard King: The right choice

Their list is:

Don’t request imaging for patients with non-specific low back pain and no indicators of a serious cause for low back pain.
Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated decision rule.
Don’t request imaging for acute ankle trauma unless indicated by the Ottawa Ankle Rules, (localized bone tenderness or inability to weight-bear as defined in the Rules).
Don’t routinely use incentive spirometry after upper abdominal and cardiac surgery.
Avoid using electrotherapy modalities in the management of patients with low back pain.
Don’t provide ongoing manual therapy for patients with adhesive capsulitis of the shoulder.

The six recommendations were collated from a member survey with around 2800 responses, which was then examined by an expert panel.

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[Comment] Offline: Paolo Macchiarini—science in conflict

The resignation of Anders Hamsten as Vice-Chancellor of the Karolinska Institute has accelerated a growing sense of emergency within the Swedish biomedical science community. His departure comes during the same week that the Royal Swedish Academy of Sciences issued an unprecedented statement accusing Paolo Macchiarini of “ethically indefensible working methods”. The Academy is the body that awards annual Nobel Prizes in Physics, Chemistry, and Economics (the Nobel Prize in Physiology or Medicine is awarded by the Karolinska Institute, hence the likely acute embarrassment at the tarnished reputation of one of the world’s most respected scientific centres).

A broad perspective on anatomy education: celebrating teaching diversity and innovations

Anatomy education is an ever-evolving field. Innovative anatomy teaching practices are actualised by dedicated, professionally qualified academic staff who often devote their entire careers to the education of future clinicians. While traditional approaches to anatomy education focused on surgical training and knowledge-based competency,1 modern anatomy literacy must be applied to a wide variety of clinical disciplines. Thus current teaching approaches need to reflect this. To this end, modern topographic anatomy is combined with other anatomical sciences (ie, embryology, histology and neuroscience), and taught within integrated medical curricula in the context of clinical medicine, clinical skills, pathology and radiology. As with other pre-clinical and para-clinical fields (including biochemistry, physiology and immunology), there are clear benefits in engaging teaching staff with a variety of qualifications and expertise to maximise the effectiveness of the vertical and horizontal knowledge integration that is essential in modern medical curricula.

The highest quality of medical anatomy education is more likely to emerge from a diverse group of motivated and dedicated academic professional anatomy educators in combination with clinically based staff than from those knowledgeable only in a single discipline as has recently been proposed.1,2 Modern professional anatomy educators may have degrees in anatomy (including clinical anatomy), anthropology and education, medicine or other clinical degrees. Staff with a variety of expertise and experiences make for a richer student learning environment. Effective anatomy learning contexts include an evolutionary focus on the developmental underpinnings of the human form, a clinical focus on anatomical relationships, and even a focus on adult learning theories to improve retention of learned material. Ultimately, each of these educator-infused contexts can foster the critical thinking skills necessary for effective clinical reasoning. Underscoring a need for diverse, multifaceted anatomy educators, the literature suggests that medical education in clinical years often lacks a clear connection to basic sciences (of which anatomy is but one).3 This work suggests that a collaborative approach between scientists and clinicians is essential for improved learning of anatomy. In addition, the role of the modern anatomy educator in the digital age is to facilitate students’ knowledge acquisition and application; this illustrates how important it is that these teachers have expertise that extends beyond anatomical facts and includes pedagogical competency.

As well as infusing anatomy teaching with clinical relevance, anatomists are pioneering innovations in medical education. Some innovations include multimedia software, peer–peer learning of surface anatomy using body painting4 and the world’s first three-dimensional printed series of anatomical dissections.5 As anatomy education continues to evolve, the roles and backgrounds of anatomy educators should and will expand. Collaboration is essential for medical education and its educators to continue to meet the changing needs of both students and the medical profession in general.

News briefs

Harvey named to Friends of Science in Medicine board

Associate Professor Ken Harvey, from Monash University’s School of Public Health and Preventive Medicine, has been appointed to the executive of Friends of Science in Medicine (FSM). He has been an influential member of the Commonwealth Pharmaceutical Health and Rational Use of Medicines Committee and most recently served on the Federal Government’s Natural Therapies Review Committee, which found no evidence for the effectiveness of any of the 18 common taxpayer-supported alternative treatments reviewed. Dr Harvey was a member of the expert group that drafted the World Health Organization’s Ethical Criteria for Medicinal Drug Promotion. FSM was established in 2011 and is supported by almost 1200 leading Australian scientists and clinicians. “No one has done more to protect consumers from the unethical marketing of prescription and ‘alternative’ medicines in our country,” said FSM president, Professor John Dwyer, AO.

Anatomy bestseller from 1613 published online

Columbia University in New York has digitised the 1661 translation of an anatomy “flapbook”, first published in 1613, and which remained a bestseller for 150 years. Catoptrum Microcosmicum, originally in Latin, “explains the human body, using movable flaps to take people down through successive layers”, reports Gizmodo. “The first layer was the person delicately draped in a way that preserved their modesty. The layer of drapery came off first. The book features a female figure and a male figure, both shown from the front and the back. Each figure is drawn with one foot standing on a skull.” Also featured is a pregnant female torso, which Gizmodo described as “the creepiest experience imaginable” and includes a “crotch-demon”. Available online at https://archive.org/details/ldpd_11497246_000.

Chromium in the spotlight

Gizmodo reports that University of New South Wales and University of Sydney researchers have found that popular chromium supplements are partially converted into a carcinogenic form when they enter cells. The National Health and Medical Research Council recommends 25–35 micrograms of chromium daily as the adequate adult intake. A maximum of 200 micrograms per day is considered safe by the US National Academy of Sciences. Over-the-counter supplement tablets, available in Australia and most commonly used for weight management, body building and type 2 diabetes, have been found to contain up to 500 micrograms each. The research, originally published in the chemistry journal Angewandte Chemie, was conducted on animal fat cells, which were x-rayed to allow scientists to observe the behaviour of chromium in the cell. The researchers say more study is needed to conclusively say whether the supplements significantly alter cancer risk.

Zika joins list of mosquito-borne nasties

A rare mosquito-borne virus called Zika is spreading from its African home through Asia and the Americas, with the United States Centers for Disease Control issuing its first travel advisory for the disease, for travellers through Puerto Rico, Wired reports. “In Brazil, the number of infants born with shrunken, malformed brains has gone up by a factor of 10 since Zika entered the country, and scientists there are trying to establish a causal link to the virus.” Closely related to dengue fever and yellow fever, Zika is hard to detect because “the classic test for Zika — checking a person’s blood for antibodies that bind to the Zika virus — spikes a false positive when it sees antibodies for those other two diseases”. Complicating the issue is that Zika also appears to be spread through sexual contact.