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Articles

The Blamed Bladder

Teaser: 

Lauren Campbell, PT, MScPT, MCPA,1 Jessica Nargi, PT, MScPT, MCPA,2

1Registered Physiotherapist, Pelvic Health Physiotherapy on Bay, Toronto, ON.
2 Registered Physiotherapist, Pelvic Health LifeMark Physiotherapy, Toronto, ON.

CLINICAL TOOLS

Abstract: Bladder pain syndrome/interstitial cystitis (BPS/IC) is associated with symptoms of urgency, frequency, and pain in the bladder or pelvis, in the absence of infection or disease. While manual therapy skills performed by a specialized pelvic floor physiotherapist can improve pain and symptoms by as much as 75-80%,23 treatment strategies need to look beyond, because the persistent nature of this condition suggests there is also dysfunction occurring within the peripheral and central nervous systems. Other symptom-improving treatments include bladder retraining, neurophysiology-based pain education, mindfulness meditation, and a variety of other strategies to help quiet their hypersensitive nervous systems.
Key Words: bladder pain syndrome, interstitial cystitis, pelvic floor physiotherapy, biopsychosocial framework, neurophysiology-based pain education, central sensitization.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

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Identify research and treatment for BPS/IC need to be beyond the bladder.
Understand a pelvic physiotherapist's assessment and treatment framework for BPS/IC.
Understand the importance of tissue dysfunction and central sensitization in BPS/IC.
Use a biopsychosocial framework when approaching BPS/IC
The bladder is likely not "at fault" and given the persistent nature of symptoms, one must consider the whole body.
Pelvic floor physiotherapy is MORE than manual treatment and exercise prescription
Physiotherapists have an excellent knowledge base, dynamic skill set, and also have the time required to educate and help implement behavioural modifications.
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Many older patients of mine have metal implants in their limbs following some form of reconstructive surgery. It is the age of the bionic person.

With so many "snowbirds" and with security metal detectors almost everywhere, there is often an expressed concern about whether having a metal implant in the hip or knee might delay you or lead to problems when you pass through airport or cruise security metal detectors.

I recently had a comparable experience when flying, which I do quite often. I had acquired a MedicAlert bracelet, which also is a common accoutrement of many older patients. As I passed through the security arch having already removed all my usual triggers (phone, wallet, belt, watch), the alarm went off—I realized that the Medic-Alert bracelet, whose clasp is such that it is very difficult to open, clearly for safety reasons, was the culprit. I mentioned it to the agent—who took his wand and clearly identified the source of the alarm, and when he finished the rest of the scan, he let me through without any problems.

I was curious and perused the medical literature on the subject, given the high prevalence of seniors with metal in their bodies—part of the contemporary miracle of modern medicine. I recall a time when severe knee and hip arthritis left seniors either completely immobilized or chronically racked by significant, often life-altering pain.
It is not that the surgery is "easy," and it's not always successful, but for many, it can have a dramatic and long-lasting beneficial effect. No less important than the surgery itself is that there seems to be a very flexible ceiling on age—with some very elderly individuals found suitable for surgery—depending on what other medical conditions exist.
Many of the articles that discuss the issue remark on a practice in the past, when patients with metal hardware in their bodies often provided the security agents with letters or cards attesting to their condition. However, it is now felt that these are not needed nor heeded, as there is no way of verifying the veracity of the author—and the backup metal detector or full body scan will do the trick more effectively and assuredly.

What most of the articles on the subject suggest is that the traveller should alert the security agent right up front about the issue rather than waiting for the detector to go off. I thought of having the clasp on my MedicAlert bracelet changed to one that could be more readily opened and closed but decided that the security of a bracelet that could not readily inadvertently fall off was more important than the minor inconvenience of a manual security scan.

Some things, we often say, just "come with the territory." Travel has become more complicated because of issues of security. There is no doubt that the recent tragic bombing of a passenger plane in the Middle East will result in either more intense scrutiny of travellers or some new directives on screening—just when things seemed to be easing up in North American airports.

Medicine has become more complicated because of novel treatments that, although life enhancing or life saving (such an internal heart pacemaker which also has metal wires), may cause some modicum of inconvenience at the security gate when people travel.

This seems to be a small price to pay to achieve both desirable ends—being able to walk unattended through a security gate after restorative surgery, and making sure that fellow travellers are safe in their travels.

Still, during those years when I was studying medicine all this would have been in the realm of wild imagination.

This article was originally published online at http://www.cjnews.com/living-jewish/travel/do-metal-implants-hinder-your-ability-to-travel

 

Cervical Radiculopathy: Diagnosis and Management

Teaser: 

Heidi Godbout, MD,1 Sean Christie, MD, FRCSC,2

1Dalhousie University, Dept. Surgery (Neurosurgery), Dept. Medical Neurosciences.
2Associate Professor, Dalhousie University, Dept. Surgery (Neurosurgery).

CLINICAL TOOLS

Abstract: Neck and arm pain are common reasons to seek medical attention, especially in the working population. However, there are several diagnostic pitfalls that must be avoided. Appropriate, conservative management will lead to improvement in a significant number of patients. Knowing when to refer a patient as well as what imaging modalities are indicated is crucial to managing cervical radiculopathy in the primary care setting. The purpose of this review is to help primary care physicians diagnose, investigate and treat cervical radiculopathy and to know when a surgical referral is appropriate.
Key Words: Cervical radiculopathy, neurological exam, imaging, conservative treatment, surgery.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

1. Cervical pain is a common clinical problem; pure cervical radiculopathy is much less frequent.
2. The natural history of cervical radiculopathy is favorable; most patients improve within 3 months.
3. Imaging is only required if there are indications of sinister, non-mechanical pathology or when surgery is being contemplated.
4. Surgery produces beneficial results in 85-90% of cases.
1. A well-constructed musculoskeletal and neurological history and physical examination can distinguish between mechanical neck pain, cervical radiculopathy, cervical myelopathy or shoulder pathology.
2. C5-6 and C6-7 are the most common levels affected.
3. C6 radiculopathy leads to numbness in the thumb and weakness in wrist extension.
4. C7 radiculopathy leads to numbness in the middle finger and triceps weakness.
5. Spurling's manoeuver can be used to reproduce radicular symptoms. It should not be used when myelopathy is suspected.
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The Role of Nutraceuticals in Atopic Dermatitis

The Role of Nutraceuticals in Atopic Dermatitis

Teaser: 

Jacky Lo, MD,1 Joseph M. Lam, MD, FRCSC,2

1 is a resident in the Family Medicine Residency at the University of British Columbia. He was previously a registered dietitian at the College of Dietitians in BC.
2is a pediatric dermatologist and a clinical assistant professor in the Departments of Pediatrics and Dermatology at the University of British Columbia.

CLINICAL TOOLS

Abstract: Atopic dermatitis (AD) is a chronic relapsing and remitting dermatosis with no definitive cure. Because treatment often remains challenging, the use of nutraceuticals has been gaining popularity as an alternative therapy.
Key Words: Nutraceuticals, atopic dermatitis, prevention, treatment.
The use of prebiotics in formula fed infants may reduce the incidence of AD up until two years of life.
The use of prenatal and/or postnatal probiotics, especially with Lactobacillus rhamnosus and Bifidobacterium, has been shown to reduce the incidence of AD. However, the evidence for its long-term effects appears to be inconsistent.
There is conflicting evidence regarding the use of vitamin D alone and zinc in the treatment of AD.
Routine supplementation of vitamin E alone and selenium does not appear to be beneficial in the treatment of AD.
While the use of fish oil has not been shown to have any statistically significant benefit in the treatment of AD, its use has been associated with improved quality of life, reduction in area affected in a pooled analysis of two studies and pruritus in one study.
Education plays an important in the management of AD and emphasis should be made to explore patients' reasons for turning to alternative therapies.
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Navigating the Gender Spectrum: A General Overview of Transgender Health Care

Navigating the Gender Spectrum: A General Overview of Transgender Health Care

Teaser: 

Dr. Adam C. Millar, MD, MScCH, FRCPC,

Mount Sinai Hospital, Assistant Professor, Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract:Transgenderism is common, with quoted prevalence rates of between 0.5-1% of the population.1,2,3 The term "transgender" reflects a broad spectrum of identities, including agender, pangender, genderqueer and genderfluid. Although there is increased public recognition of transgender issues, many physicians remain uncomfortable managing matters of transgender health. There is a paucity of high quality, long term randomized controlled trials on many transgender health topics, requiring physicians to rely largely on consensus guidelines. Integration of transgender-related subject matter into medical school curricula is one of the first steps towards enabling future physicians to increase their comfort in transgender health care.
Key Words: Transgender, trans, testosterone, estrogen, androgen blockade.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

1. Transgenderism is not limited to the binary gender constructs of male and female. The term "transgender" includes a broad spectrum of identities, including agender, pangender, genderfluid and genderqueer.
2. Lack of physician comfort with medical management of the transgender patient has been linked to increased rates of refusal of medical care, as well as verbal harassment and in extreme cases physical assault.
3. Due in part to a lack of large randomized controlled trials, many transgender guideline recommendations are based on expert opinion and relatively low quality evidence.
Rather than assume one's gender identity, it is advisable to ask the patient how they identify, and what pronouns are preferred.
There are no specific hormonal targets during transition therapy. Instead, treatment targets are defined by the patient's goals and overall sense of well-being.
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Benign Prostatic Hyperplasia—Medical and Surgical Treatment Options

Benign Prostatic Hyperplasia—Medical and Surgical Treatment Options

Teaser: 

Dean S. Elterman, MD, MSc, FRCSC,1 Udi Blankstein, MD,2

1Attending Urologic Surgeon, Toronto Western Hospital, University Health Network, Assistant Professor, Division of Urology, Department of Surgery, University of Toronto, Toronto, ON.
2Department of Urology, McMaster University, Hamilton, ON.

CLINICAL TOOLS

Abstract: Benign prostatic hyperplasia (BPH) affects the aging male. Treatment options vary widely. Some men will elect to conservatively monitor their symptoms and make alterations to their lifestyle choices. Pharmacotherapy options exist as well, and include alpha-blockers, 5-alpha reductase inhibitors and phosphodiesterase-5 inhibitors. Lastly, surgical options are also a viable treatment option, with many types at the disposal of the caregiver. Technological advancements have changed, and will continue to change the field in the near future. This review outlines the important aspects of this common affliction.
Key Words:Benign prostatic hyperplasia, management, treatment, referral.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

There is a spectrum of bother ranging from mild nuisance to significant decrease in quality of life – this is largely associated with how the patient perceives the problem.
Physical exam and medical history are imperative in the initial assessment of BPH.
Conservative measures and lifestyle changes should be the first line treatment choice.
Surgical intervention should be attempted after failure of medical therapy to alleviate symptoms and prevent kidney injury or infection.
Ensure that there are no other causes that may cause LUTS such as various medications, and other comorbidities.
When considering more invasive intervention, ensure that the surgical team knows the patient's anticoagulation status.
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Cutaneous Features of Neurofibromatosis

Cutaneous Features of Neurofibromatosis

Teaser: 

Sang-Eun Kim , BSc, MSc,1 Joseph M. Lam, MD, FRCPC,2

1Faulty of Medicine, University of British Columbia, BC.
2Assistant Clinical Professor, Department of Paediatrics, Associate Member, Department of Dermatology, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: Neurofibromatosis type 1 (NF1) is a multisystem genetic disorder that is characterized by café-au-lait spots, axillary or inguinal freckles, cutaneous neurofibromas, and skeletal dysplasias. Currently, there are no curative therapies for NF1 but medical therapies, including systemic sirolimus, have opened the door for significant medical advances in the treatment of NF1. Management of NF1 has been focused on routine examinations looking out for potential complications of NF1. However, many patients with NF1 are missed and may not be diagnosed early. The following review article will provide an overview of select common and uncommon cutaneous features of NF1 to help the practitioner recognize, diagnose and treat patients with NF1.
Key Words: Neurofibromatosis type 1, café-au-lait spots, axillary freckles, inguinal freckles, cutaneous neurofibromas.
Clinical diagnosis of NF1 requires the presence of at least 2 out of the 7 criteria.
Not all patients with café-au-lait spots will have NF1.
Axillary and inguinal freckling are the most specific criteria for NF1.
Three different types of cutaneous neurofibromas are dermal, subcutaneous, and plexiform neurofibromas (PNs). PNs can become malignant.
Juvenile xanthogranuloma and nevus anemicus are uncommon associated cutaneous features of NF1.
NF1 is a genetic disorder and there is no cure.
Patients should be routinely monitored for rare complications and annual exam should include BP measurement, skin and bone abnormality assessment, visual acuity checks, and ophthalmological evaluations.
Not all Cafe-au-lait spots require specialist referral however early recognition and prompt referral is essential.
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CORE BACK TOOL 2016: New and Improved!

Members of the College of Family Physicians of Canada may claim one non-certified credit per hour for this non-certified educational program.

Mainpro+® Overview
Teaser: 

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,1 Yoga Raja Rampersaud, MD, FRCSC,2 Jess Rogers3Dr. Hamilton Hall, MD, FRCSC,4

1 is a Family Physician practising Sport and Exercise Medicine at the Toronto Rehabilitation Institute, University Health Network. She is appointed at the University of Toronto, Department of Family and Community Medicine as an Associate Clinical Professor.
2Associate Professor Department of Surgery, University of Toronto, Divisions of Orthopaedic and Neurosurgery, University Health Network Medical Director, Back and Neck Specialty Program, Altum Health, Past President Canadian Spine Society, Toronto, ON.
3 is the Director at the Centre for Effective Practice (CEP). Jess' role includes developing evidence-based clinical guidance for providers. Jess was the Project Lead in executing the primary care provider education component of Ontario's Low Back Pain initiative including the CORE Back Tool. CEP is pleased to have funded the update of the CORE Back Tool 2016 to continue supporting primary care providers.
4 is a Professor in the Department of Surgery at the University of Toronto. He is the Medical Director, CBI Health Group and Executive Director of the Canadian Spine Society in Toronto, Ontario.

CLINICAL TOOLS

Abstract: Through the redesign of the already successful Clinically Organized Relevant Exam (CORE) Back Tool, primary care clinicians now have a more comprehensive, user-friendly approach to clinical decision making for patients presenting with low back pain. The key components of the tool include a high yield history connected to mechanical low back pain patterns, embedded key patient messages, clear listing of appropriate radiological indications, criteria for consultant referrals as well as a management matrix geared to office practice. A clinical case will be used to demonstrate the application of the tool to practice and instruct the reader on the key features.
Key Words: Low Back Pain, Tool, Primary Care Providers, Management.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

1. Mechanical Patterns are a logical way to conceptualize, assess and manage low back pain.
2. If pain does not fit a mechanical pattern, the patient may have non-spine referred pain from organs or a chronic pain disorder.
3. Radicular (nerve) pain will have a positive straight leg raise (SLR) with reproduction of the typical leg dominant pain and possible abnormal neurological signs.
Initial patient management should include goals of reducing pain and increasing activity.
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Osteoporotic Vertebral Compression Fractures: Diagnosis and Management

Osteoporotic Vertebral Compression Fractures: Diagnosis and Management

Teaser: 

Michael M.H. Yang, MD, M.Biotech,1 W. Bradley Jacobs, MD, FRCSC,2

1Division of Neurosurgery, Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada.
2Division of Neurosurgery, Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada.

CLINICAL TOOLS

Abstract: Osteoporotic vertebral compression fractures (VCFs) are the most common fragility fracture and have significant impact on numerous indices of health quality. High risks patients should be identified and appropriate preventative therapy initiated. The majority of VCFs can be managed in a non-operative fashion, with analgesia as required to support progressive mobilization. Patients who fail non-operative measures may be considered for percutaneous vertebral augmentation. However, the efficacy of these procedures in altering the natural history of recovery is controversial. Surgery has a limited role in the initial management of VCFs and is typically restricted to the rare circumstance of VCF associated with acute neurological dysfunction.
Key Words: osteoporosis, vertebral compression fracture, vertebroplasty, kyphoplasty.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

1. Osteoporosis is under diagnosed in Canada. Early diagnosis, fragility fracture risk stratification and initiation of preventative treatment is important, as osteoporotic vertebral compression fractures (VCFs) have a significant associated personal and societal health utility cost.
2. Patients suspected of having a VCF should have an AP and lateral X-ray of the suspected region. If VCF is confirmed, an upright X-ray should be performed to assess for stability. CT and/or MR imaging has limited utility in the absence of red flag signs or symptoms.
3. VCFs should be managed with initiation of an appropriate pain management regiment, early bed rest as required for pain control and gradual mobilization. Patients with refractory pain 4–6 weeks after onset can be considered for percutaneous vertebral cement augmentation (e.g. vertebroplasty), although the clinical efficacy of such procedures remains unclear.
A few screening measurements can be performed in the office setting to help significantly improve the likelihood of detecting a VCF on radiological studies. They include prospective height loss of greater than 2cm or a height loss, or a height loss based on history of more than 6cm, a rib-to-pelvis distance of less than 2 fingerbreadths, or an occipital-to-wall distance greater than 5cm.
Most patients with osteoporotic VCFs do not need a referral to a spine surgeon. Acute pain from a new VCF usually improves over a period of 6 weeks. Non-operative management should follow the WHO analgesic ladder starting with acetaminophen/NSAIDs followed by opioids, as necessary. The goal of treatment is to provide pain relief and facilitate early functional rehabilitation.
Patients with high or medium 10-year fracture risk should be considered for pharmacotherapy to prevent the progression of low bone mineral density and osteoporotic fractures.
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