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Spine and Sport: Are Athlete's Back Injuries Different?

Spine and Sport: Are Athlete's Back Injuries Different?

Teaser: 

Dr. Julia Alleyne, BHSc(PT), MD, CCFP, Dip. Sport Med MScCH,

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.

CLINICAL TOOLS

Abstract: Athletes participating in training and competition for an average of 8 hours a week have a one year prevalence for spine injuries as high as 68%; an average increase of 18-31% compared to non-athletes. Except for young growing athletes at risk for structural deformity, most spine injuries are soft tissue and self-limiting. Risk factors include a sudden increase in training hours, transition in strength and coordination related to growth, sustained back flexion, reduced dynamic core stability and repetitive trunk rotation and hyper extension. Decreased training levels following back injury lead to deconditioning and muscle imbalance increasing the risk of recurrence and prolonging recovery. Core stability testing can identify patients for targeted exercise.
Key Words: Sport-related, spine, hypermobility, core stability, overuse.

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

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Pre-test CME Quiz Post-test CME Quiz
Frequent repetition and sustained postures in rotation, hyperextension and full flexion require advanced levels of strength and flexibility for the athlete to remain injury-free.
The two most common risk factors for low back pain in training athletes is overuse strain and excessive spinal movements.
Treatment consists of both reducing the demands on the paraspinal muscles and increasing the amount of core stability.
It is important to screen for generalized joint hypermobility syndrome (JHS) affecting all joints using the Beighton Score, as this condition may require investigation and can be an indication of other medical syndromes.
The most specific test with high inter-rater reliability to determine core stability is the single leg standing balance stork test. The patient stands on one leg and raises the other knee to 90 degrees then maintains balance for a minimum of 25 seconds.
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Related Terms: Back Health, Sports Medicine, Sport-related, hypermobility, core stability, overuse, spine

TINNITUS is an "Aura Symptom" in Need of a Multidisciplinary Approach to Facilitate Diagnosis and Treatment

TINNITUS is an "Aura Symptom" in Need of a Multidisciplinary Approach to Facilitate Diagnosis and Treatment

Teaser: 

Dr. Pradeep Shenoy, MD, FRCS, FACS, DLO,1 Dr. Eric Deschenes, Au. D.2

1Otolaryngolost , Campbellton, NB, Canada.
2Audiologist, Campbellton, NB. Canada.

CLINICAL TOOLS

Abstract: Tinnitus is a perception of sound in the absence of sound stimulation (Figure 1). Various reasons are blamed for the causes of the tinnitus. Very rarely, tinnitus is seen in normal-hearing children where no obvious cause is detected. In these instances, tinnitus does not persist for long. In some people it may occur spontaneously as in old age, and in some individuals it is induced by noise exposure, ototoxic drug use, stress, smoking, or excessive coffee consumption (Figure 2). In some, tinnitus may be associated with other symptoms like vertigo and deafness. Such symptoms can be correlated with congenital sensorineural hearing loss, wax accumulation, serous otitis media, Meniere's disease, vestibular neuronitis, acoustic neuroma, vascular causes like a/v malformation or fistulae, and also in some patients, temperomandibular dysfunction. Tinnitus can cause anxiety, depression and sleep disorders, and in some individuals, extreme anxiety can lead to suicidal tendencies. Conventional medical treatment uses medication, sound therapy and relaxation. Management using electromagnetic stimulation and low intensity laser is also reported in the literature.
Key Words: Tinnitus counselling, sound therapy, hyperacusis, ototoxic drugs, presbyacusis, noise induced deafness (acoustic trauma), electromagnetic therapy, relaxation exercises.
Tinnitus is the perception of sound without external acoustic stimuli and is often described as ringing, whistling, buzzing, gushing of water, or a pulsatile noise.
Most researchers theorize that tinnitus is caused by initial damage to the outer hair cells in the cochlea, followed by impairment of the inner hair cells.
Tinnitus can cause anxiety, depression, sleep disorders, and in some cases, extreme anxiety that can lead to suicidal tendencies.
There is no method to eliminate tinnitus entirely; the goal with patients suffering from tinnitus is to provide the tools necessary to effectively manage their reaction to tinnitus symptoms.
Tinnitus can be attributed to a wide variety of causes, and it is difficult to study and treat tinnitus because of the lack of objective diagnostic tools.
To help manage tinnitus symptoms, sound therapy (tinnitus masking and tinnitus retraining) can be used in conjunction with alternative therapies like relaxation exercises, breathing exercises, hypnosis, vitamins and herbs, low level laser treatment, and electromagnetic treatment.
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Related Terms: Otolaryngology, Tinnitus counselling, sound therapy, hyperacusis, ototoxic drugs, presbyacusis, noise induced deafness (acoustic trauma), electromagnetic therapy, relaxation exercises

A Scaly Periorbital Rash in a Preschool-aged Boy

A Scaly Periorbital Rash in a Preschool-aged Boy

Teaser: 

Jennifer Smitten, MD, FRCPC,1 Joseph M Lam, MD, FRCPC,2

1BC Children's Hospital, University of British Columbia, BC.
2Assistant Clinical Professor, Department of Paediatrics, Associate Member, Department of Dermatology, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: A healthy 4-year-old boy presented with an 8-month history of a pruritic scaly eruption around his right eye associated with several small pearly papules on the face. A clinical diagnosis of an eczematous id reaction to molluscum contagiosum was made. While up to 40% of cases of molluscum contagiosum may have an associated eczematous dermatitis, these are often under-recognized or misdiagnosed.
Key Words: Pediatrics, Dermatology, Dermatitis, Molluscum, Eczema, Id reaction, Viral exanthem, Hypersensitivity.
Eczematous id reactions to molluscum contagiosum (MC) in children are common, occurring in up to 40% of cases of MC.
Id reactions to MC can be challenging to diagnose, as they may occur at sites distant from the MC lesions.
Id reactions can be caused by a variety of infectious and noninfectious dermatoses.
Asymptomatic id reactions do not require pharmacologic treatment and a watchful waiting approach is reasonable.
1. Id reactions can be caused by a variety of infectious and noninfectious dermatoses, including allergic contact dermatitis to nickel, scabies infestation, tinea infection and molluscum infection.
2. In a unilateral eczematous dermatitis, consider molluscum dermatitis, especially in a child with no personal or family history of atopy.
3. Treatment of symptomatic id reactions may help to reduce spread of MC via autoinoculation from scratching.
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Related Terms: Dermatology, pediatric, dermatology, dermatitis, Molluscum, Eczema, Id reaction, Viral exanthem, Hypersensitivity

Bipolar Electrofulgration with Endoscopic Approach in Allergic Turbinates

Bipolar Electrofulgration with Endoscopic Approach in Allergic Turbinates

Teaser: 

Dr. Sohail Abdul Malik, DLO, FCPS (ENT), Dr. Pooja Chodankar, MBBS, DLO, Dr. Pradeep Shenoy, MD, DLO, FRCS, FACS,

Former Head of ENT Department Armed Forces Hospital, Kuwait,
Currently the ENT service chief, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada.

CLINICAL TOOLS

Abstract: Rhinological practice in Kuwait has always included a barrage of cases of allergic rhinitis. Arrays of treatment modalities like monopolar electrocautery to the inferior turbinates and laser vaporization have been experimented with and have yielded a diversity of results. Here is a synopsis of the use of endoscopic bipolar cauterization of middle and inferior turbinates in cases of allergic rhinitis, a treatment which achieves superior results in comparison with other therapeutic options.
Key Words: bipolar cauterization, bipolar electrofulguration, inferior turbinates, nasoendoscope.

Allergic rhinitis is a common problem in the Middle East region; several treatment modalities have been experimented with to improve patient symptoms.
Cautery with a specially designed bipolar probe can be used to cauterize different parts of the turbinates.
Endoscopic bipolar diathermy was deemed to be less useful in patients with moderate to severe deviation of the septum who were therefore excluded from the study.
Endoscopic bipolar diathermy demonstrated better long term results than other treatment options such as: submucosal diathermy, partial inferior turbinectomy and linear cautery.
Endoscopic bipolar diathermy as a treatment option increased nasal airflow with minimal damage to the mucocillary function and maximal destruction of submucosal tissue to the engorged portion of the inferior turbinates.
There is evidence of subjective improvement in the nasal symptoms of 89.1% of cases, and objective improvement of symptoms in 65.5% of cases which combined rhinomanometric study and nasoendoscopy.
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Related Terms: Otolaryngology, bipolar cauterization, bipolar electrofulguration, inferior turbinates, nasoendoscope

Vertebral Metastatic Disease: A Practice Guideline for the General Practitioner

Vertebral Metastatic Disease: A Practice Guideline for the General Practitioner

Teaser: 

Michael S. Taccone,1 Markian Pahuta,2 Darren M.Roffey,3,4Eugene K. Wai,2,3,4

1Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
2Division of Orthopedic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
3Ottawa Combined Adult Spinal Surgery Program, The Ottawa Hospital, Ottawa, ON, Canada.
4Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.

CLINICAL TOOLS

Abstract: Vertebral metastatic disease afflicts a significant proportion of cancer patients, most commonly those with breast and lung disease. Symptoms can include tumor-related pain, neurological deficit from spinal cord or nerve compression and pathological fracture with mechanical instability. Appropriate workup includes identifying the primary disease, defining the extent of spinal and extra-spinal pathology and classifying spinal stability based on the pattern of osseous involvement. Specific therapy for the vertebral metastatic disease can include pharmacologic therapy to deliver analgesia, steroids, bisphosphonate, anti-neoplastic therapy, radiation therapy as either primary or adjuvant therapy and surgical intervention for mechanical or neurologic instability.
Key Words: Vertebral metastatic disease, metastatic epidural spinal cord compression, spinal instability, spine surgery, spinal radiation therapy, pathologic fracture.

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.

Pre-test CME Quiz Post-test CME Quiz
Red flags are non-specific and unreliable means of determining spinal malignancy in patients with back pain. Clinical suspicion combined with history and physical exam are best for increasing pre-test probability of imaging studies.
Initial evaluation and referral to definitive management should be made within 24 hours of detection of significant neurological deficit, significant metastatic epidural spinal cord compression or instability.
MRI is the imaging modality of choice for initial evaluation and assessment of overall spinal tumor burden.
Vertebral metastatic disease is very common in patients with cancer.
SINS, ESCCS, Tomita score, Tokuhashi score and the Modified Bauer scores are all important tools for determining the most appropriate referral.
In eligible candidates, surgery with adjuvant radiotherapy yields faster and more sustainable neurologic stability and recovery.
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Related Terms: Back Health, Vertebral metastatic disease, metastatic epidural spinal cord compression, spinal instability, spine surgery, spinal radiation therapy, pathologic fracture

Error in Radiology: Negligence or Human Nature

D'Arcy Little, MD CCFP FRCPC, Chief of Diagnostic Imaging, Orillia Soldiers' Memorial Hospital,
Adjunct Clinical Lecturer, Department of Medical Imaging, University of Toronto, Toronto, ON,
Forensic Radiologist, Forensic Sciences and Coroners' Complex, Toronto, ON,
2015 Resident in Scientific Communications, Banff Centre, Banff, AB.

Related Terms: Radiology, radiology, errors

A Reticulate Hyperpigmented Abdominal Patch Associated with Chronic Abdominal Pain

A Reticulate Hyperpigmented Abdominal Patch Associated with Chronic Abdominal Pain

Teaser: 

Julie Man, MD,1 Joseph M. Lam, MD, FRCPC,2

1Department of Family Medicine, University of Alberta, Edmonton, AB.
2Assistant Clinical Professor, Department of Paediatrics, Associate Member, Department of Dermatology, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: A 13-year-old girl presented with a 3-month history of a reticulate hyperpigmented patch over the lower abdomen. Her past medical history was significant for recurrent abdominal pain, Ehlers-Danlos syndrome, a mild learning disability, and multiple allergies. On physical examination, she had a reticulate, hyperpigmented patch distributed diffusely over the lower abdomen (Figure 1). The remainder of her exam was unremarkable. Upon questioning, it was revealed that the patient had been applying a hot water bottle to the lower abdomen for the last 4 months to help relieve the discomfort associated with the abdominal pain. This history led to the diagnosis.
Key Words: Erythema ab igne, hyperpigmentation, reticulate, thermal injury.
Erythema ab igne may present as a transient erythematous eruption, or as a reticulate hyperpigmentation.
Erythema ab igne is a clinical diagnosis which rarely requires biopsy confirmation.
Direct questioning about heat sources, such as prolonged laptop computer use, aids the diagnosis.
Treatment consists of patient education and removal of the heat source.
1. Erythema ab igne is a recognizable condition associated with chronic exposure to heat sources such as heating pads, hot water bottles, electric blankets, space heaters and laptop computers.
2. The differential diagnosis for erythema ab igne includes livedo reticularis, livedoid vasculitis, cutis marmorata telangiectatica congenita, a reticulate port-wine stain and poikiloderma.
3. The most important treatment for erythema ab igne is recognition and removal of the source of infrared radiation.
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Related Terms: Dermatology, erythema ab igne, hyperpigmentation, reticulate, thermal injury

Anticipatory Conversations: Is there a connection to Ice Cream?

Anticipatory Conversations: Is there a connection to Ice Cream?

Teaser: 

Michael Gordon, MD, MSc, FRCPC,

Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System, Professor of Medicine, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract: Advance care planning has become a much touted and potentially very important addition to the new operative structure of meeting the many challenges of an ever increasingly older population. From what used to be discussions about CPR and DNR the process has evolved into what many expect might become the basis of end-of-life decision-making that may assist family members and health care providers to meet the needs, wishes and priorities of the elderly population, particularly when they are nearing that last trajectory of life.
Key Words: Artificial nutrition and hydration, advance care planning, living wills, end-of-life planning.
1. Planning before there is a medical crises can help avoid medical decisions that may not be in keeping with your wishes and values.
2. Artificial nutrition and hydration may not be what you really want, even though in its simplest form it may seem desirable as a way of avoiding death.
Communication with those who will be responsible for decision-making when you are no longer able to do so is key to having your end-of-life wishes fulfilled and should not be left to crises situations.
If you have favorite foods, make sure your substitute decision-makers know about them so that when the time comes you will not be deprived of your most enjoyed foods, because some health care provider deems them to be "unhealthy" or not in keeping with an "optimal diet".
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Related Terms: Dementia, artificial nutrition and hydration, advanced care planning, living wills, end-of-life planning

Diagnostic Radiology in Low Back Pain

Diagnostic Radiology in Low Back Pain

Teaser: 

Dr. Ted Findlay, D.O., CCFP,1 Amar Suchak, MD, FRCP(C),2

1Clinical Assistant Professor, Department of Medicine, University of Calgary, Private Family Medicine practice, Medical Staff, Alberta Health Services, Calgary Zone, Calgary, Alberta.
2Clinical Assistant Professor Department of Radiology, Department of Nuclear Medicine, University of Calgary, Calgary, Alberta.

CLINICAL TOOLS

Abstract: Many clinicians believe that imaging is necessary to accurately diagnose and manage low back pain. However, there is good evidence that in the absence of "Red Flags", there is an overuse of both routine X-rays and advanced diagnostic imaging such as MRI. When imaging is used without appropriate clinical indications, it is rare for the results to lead to a change in a treatment plan. Management is based on adequate history and confirmatory physical examination. This article uses three actual cases as the basis for exploring the place of diagnostic imaging in treating low back pain.
Key Words: low back pain, diagnosis, radiology, indications, appropriate.

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.

Pre-test CME Quiz Post-test CME Quiz
1. While imaging may be required in the management of specific cases of low back pain particularly when "Red Flags" are present, it is rare that unexpected findings will result in a change of the treatment plan.
2. Be very cautious about the terminology used to describe the results of imaging studies and whenever possible normalize the results for the patient. Many abnormal findings may be "normal" for patients in older age groups. Many may be present in patients who are pain free.
3. Ensure that the patient understands that the results of the images are not necessarily a barrier to recovery.
4. Except to establish the boney contours of the spine, when advanced imaging is required an MRI examination is often the preferred option.
5. Be very cautious about attributing the cause of a patient's pain to the results found on imaging. Careful correlation with the clinical presentation is required before deciding on any change in treatment.
In the absence of clinical "Red Flags", there is no indication to image the spine before initiating treatment.
It is never appropriate to delay treatment for mechanical low back pain to wait for an imaging procedure.
Prepare the patient, before advanced imaging is performed, that there is a very high likelihood that the investigation will find "abnormalities" but that these changes are usually the result of natural aging and no cause for concern.
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Related Terms: Back Health, low back pain, diagnosis, radiology, indications, appropriate

Sacral Neuromodulation for Overactive Bladder

Teaser: 

Dr. Dean S. Elterman, MD, MSc, FRCSC,1 Harkiran K. Sagoo, BSc(Hons),2

1Attending Urologic Surgeon, Toronto Western Hospital, University Health Network, Assistant Professor, Division of Urology, Department of Surgery, University of Toronto, Toronto, ON.
24th Year Medical Student at GKT School of Medicine, King's College London, U.K.

CLINICAL TOOLS

Abstract: Sacral Neuromodulation (SNM) is a FDA-approved minimally invasive surgical therapy offered as a third-line treatment for refractory overactive bladder (OAB). Studies report improvements in continence, mean number of voids/day, quality of life, depression and sexual function in patients receiving SNM compared to medical therapy, with treatment success sustained long-term and with few adverse events. SNM is recommended by CUA and AUA guidelines in the treatment of OAB in carefully selected patients.
Key Words:Neuromodulation, Neurostimulation, Overactive, Bladder, Incontinence.

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.

Pre-test CME Quiz Post-test CME Quiz
Sacral neuromodulation should be offered as third-line treatment for patients with overactive bladder symptoms refractory to conservative/behavioural and/or pharmacological treatment.
Sacral neuromodulation is a minimally invasive procedure that may be offered to carefully selected patients with severe refractory overactive bladder that are willing to undergo a surgical procedure.
Sacral neuromodulation activates inhibitory sympathetic neurons using low-amplitude electrical stimulation of S3 afferent nerve roots to prevent detrusor contraction.
A prospective, randomized multi-center trial (level 1 evidence) reported improvements in incontinence, mean number of voids/day, quality of life, depression and sexual function in patients receiving sacral neuromodulation compared to standard medical treatment.
Adverse events/complications associated with SNM use include: pain at the implantation site, lead migration, wound-related complications, bowel dysfunction, infection, and generator problems.
Sacral neuromodulation is a FDA-approved minimally-invasive surgical therapy used as third-line treatment of overactive bladder symptoms/refractory overactive bladder. It is carried out in two stages, the first (evaluation) stage involves insertion of a temporary generator to assess clinical efficacy, and the second stage involves insertion of a permanent neuromodulator implant in patients that have demonstrated >50% improvement in symptoms during the evaluation stage.
Evidence from randomized, controlled trials, prospective multicenter, prospective single-center and retrospective studies demonstrates clinical efficacy of SNM in reducing symptoms of overactive bladder in these patients and therefore SNM is recommended by CUA and AUA guidelines in the treatment of overactive bladder in carefully-selected patients, as the risks of the procedure outweigh the burdens of the overactive bladder syndrome.
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Related Terms: Gender & Health, Men’s Health, Women’s Health, Neuromodulation, Neurostimulation, Overactive, Bladder, incontinence