Advertisement

Advertisement

Articles

Start Exercising Already! A Physician's Step-by-step Guide to Prescribing Exercise for All Patients

Teaser: 

Dr. Aly Abdulla, MD, CCFP, FCFP, DipSportMed CASEM, CTH, CCPE, McPL,1
Neelam Charania, BSc, MSc (OT),2

1 is a family doctor with specialties in sports medicine, palliative care, and cosmetic medicine. He can be found on Twitter, LinkedIn and https://ihopeyoufindthishumerusblog.wordpress.com/
2 has a Masters in Occupational Therapy from Boston University.

CLINICAL TOOLS

Abstract: Sedentarianism raises multiple health concerns. In an effort to provide safe options this article will include a short primer on types of exercises along with a step-by-step approach to exercise prescription in the adult population.
Key Words: exercise, sedentarianism, exercise prescription.
1. Exercise has been shown to improve both physical and mental well-being through the following mechanisms: improved body physique, reduced disability associated with arthritis, mproved balance and a reduction in falls, and improved psychological health.
2. Most physicians are aware of the two most common types of exercise training; aerobic/cardiovascular endurance training and muscular strength/resistance training. Other types of exercise are performed to improve flexibility, balance and coordination.
3. The exercise programme's duration should begin at about 10 minutes and progress to 20-30 minutes (it is possible to divide this into tenminute aliquots).
4. The latest research confirms that only one set per exercise or strength training is required to have the same benefit as multiple sets
5. The most important caveat is not to progress if pain, discomfort, or interposing illness is encountered. Sometimes a holding pattern or regression is required
1. The Canadian Society for Exercise Physiology (CSEP)* through Health Canada has developed the Physical Activity Readiness Questionnaire (PAR-Q) which can easily identify adults for whom physical activity might be inappropriate or those who should have a more thorough medical work-up prior to starting an exercise programme.
2. Every attempt should be commended, and any indiscretion should not be belaboured. The patient should be veered back to his goals without guilt.
3. I ask each patient to record their heart rate upon waking and their post-exercise heart rate. This is the beginning of their exercise log, which will include the type of exercise, duration, intensity, and frequency. Patients should be be encouraged to bring it to each appointment. This serves two purposes— ONE, it helps familiarize the patient with his or her level of exertion and progress, and TWO, it helps, within the actual exercise regimen, to target appropriate intensity levels.
4. The simplified calculation for determining MHR is MHR = (220-age). Intially target 40-60% MHR over 1-2 months, then improve to 70-75% MHR over 6months, then maintain.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Sports Medicine, exercise, sedentarianism, exercise prescription
Disclaimer: 
Disclaimer at the end of each page

The Impact of Depressive Symptoms: Considerations for Clinicians Treating Patients with Low Back Pain

Teaser: 

Jessica Wong, DC, MPH,1
Linda Carroll, PhD, 2
Pierre Côté, DC, PhD, 3

1 Research Associate, UOIT-CMCC Centre for Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC).
2Professor Emeritus, School of Public Health, University of Alberta.
3 Professor and Canada Research Chair in Disability Prevention and Rehabilitation, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT); Director, UOIT-CMCC Centre for Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC).

CLINICAL TOOLS

Abstract: A considerable proportion of patients with low back pain (LBP) experience depressive symptoms. A clinical case is used to highlight potential steps that clinicians can take to help manage depressive symptoms in these patients: 1) Assess for depressive symptoms using a valid and reliable questionnaire; 2) Provide education, reassurance, and self-management strategies to initiate the program of care; 3) Adjust care plans if patients also present with depressive symptoms (e.g., ongoing support and education); and 4) Provide ongoing assessment of depressive symptoms, and consider referrals to a specialist or other health care providers (e.g., counselors, clinical psychologists, or psychiatrists) for further evaluation if symptoms are worsening.
Key Words: Low back pain, depressive symptoms, depression, depressive disorder.

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
A considerable proportion of patients with low back pain present with depressive symptoms
Depressive symptomatology includes depression that has not been formally diagnosed and symptoms that do not meet the criteria for depression
The presence of depression may indicate poorer recovery from low back pain
Patients experiencing low back pain and concomitant depressive symptoms may benefit from ongoing assessments, education, reassurance, and self-management strategies
Assess for depressive symptoms in patients with LBP using a valid and reliable questionnaire (e.g., Patient Health Questionnaire-9)
Provide education, reassurance, and self-management strategies to all patients with LBP to initiate the program of care
Adjust the care plan accordingly if patients also present with depressive symptoms, including additional support and education (e.g., addressing misconceptions, encouraging activity) on an ongoing basis
Provide ongoing assessment of depressive symptoms, and consider referrals for further evaluation if symptoms are worsening
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Back Health, low back pain, depressive symptoms, depression, depressive disorders
Disclaimer: 
Disclaimer at the end of each page

Importance of Screening Children with Adenotonsillar Hypertrophy for Obstructive Sleep Apnea

Teaser: 

Madison O.L. Rays, Sharon Chung, PhD, Maya Capua, MD, Colin M. Shapiro, MBBCh, PhD, FRCPC,

Youthdale Child and Adolescent Sleep Centre and Youthdale Treatment Centres, Toronto, ON.

CLINICAL TOOLS

Abstract: Obstructive sleep apnea (OSA) is a disorder in which patients stop breathing repeatedly during sleep, and it is linked to a number of serious medical consequences. However, most patients with OSA remain undiagnosed. The consequences of OSA are particularly severe in children. Adenotonsillar hypertrophy (AT) is a major factor in the etiology of Obstructive Sleep Apnea (OSA) in children. Physicians should consider snoring, pauses in breathing while asleep, restless sleep, bizarre sleeping positions, paradoxical chest movements, cyanosis, bedwetting, hyperactivity, and disruptive behaviour in school as possible indications of untreated OSA in children. The presentation of OSA in children differs substantially from that in adults. For example, hyperactivity is often a primary symptom in children but is not a symptom typically found in adults.
Key Words: obstructive sleep apnea (OSA), children, adenotonsillar hypertrophy (AT), medical consequences.
The presentation of OSA in children is significantly different than that in adults; hyperactivity can be a primary symptom in children but is not typically found in adults.
Adenotonsillar hypertrophy is an indicator of undiagnosed OSA in children and merits a sleep study.
Untreated OSA in children can lead to medical and psychiatric issues.
Adenotonsillectomy, a common treatment for OSA in children with large tonsils, not only reduces or eliminates the OSA, but in most cases improves the associated behavioral problems.
Evidence-based medicine supports the need for children with adenotonsillar hypertrophy to be referred to a sleep specialist to be screened for OSA regardless of the degree of tonsillar enlargement.
The I'm Sleepy questionnaire allows doctors to quickly and easily identify children with a high risk of having OSA.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Men’s Health, Women’s Health, obstructive sleep apnea, children, adenotonsillar hypertrophy, medical consequences
Disclaimer: 
Disclaimer at the end of each page

Osteoarthritis—“Twinges in all your hinges”

Teaser: 

Dr. Aly Abdulla, MD, CCFP, FCFP, DipSportMed CASEM, CTH, CCPE, McPL,1
Neelam Charania, BSc, MSc (OT),2

1 is a family doctor with specialties in sports medicine, palliative care, and cosmetic medicine. He can be found on Twitter, LinkedIn and https://ihopeyoufindthishumerusblog.wordpress.com/
2 has a Masters in Occupational Therapy from Boston University and involved in managing and rehabilitating patients with chronic osteoarthritis and disability.

CLINICAL TOOLS

Abstract: Osteoarthritis is most common form of arthritis. It is also very disabling. Fortunately, there is a long list of medical therapies including education, OTC meds, strengthening, braces, prescribed medications, standard and non-standard intra-articular therapies and some new experimental therapies. This article focuses on well known and well proven therapies like cortisone and hyaluronic acid injections into large joints like knees and hips. Large meta-analysis shows improvement in pain, physical function and stiffness in a simple well tolerated procedure with minimal side effects.
Key Words: osteoarthritis, arthritis, knee, hip, joint injections, steroid, hyaluronic acid.
OA symptoms include joint pain, morning stiffness <30min, reduced ROM, and possibly swelling.
The most common joints are knees, hips, fingers, thumbs, big toes and lumbar spine.
The key pathophysiology in OA is destruction of cartilage and bone formation, which reduces function and causes pain.
Simple x-rays are diagnostic. There is no need for advanced imaging like CT or MRI for OA.
A combination of therapy is key to successfully managing this condition.
If morning stiffness >30 minutes, stiffness and pain increases with rest, joint warmth or erythema, or three or more joints, you should think of inflammatory, septic, or crystal arthritis RATHER than osteoarthritis.
Don't forget about weight loss, bracing, topical agents, or non conventional medications like duloxetine or tramadol in osteoarthritis.
There is no maximum amount of cortisone injections in a joint but it is mainly used for stiffness, swelling and pain.
Hyaluronic acid intra articular injections manage symptoms of pain, stiffness, range of motion, and physical function. The best formulations are high MW and cross-linked because they last longer.
New experimental therapies like PRP, MSC, and ACI have limited evidence and are costly.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Sports Medicine, osteoarthritis, arthritis, knee, hip, joint injections, steroid, hyaluronic acid
Disclaimer: 
Disclaimer at the end of each page

Exercise Prescription for Back Pain

Teaser: 

Eugene K. Wai, MD, MSc, CIP, FRCSC1
R. Michael Galbraith, DO, CCFP (SEM), Dip Sport Med2
Denise C. Lawrence Wai BScPT3
Susan Yungblut, PT, MBA4
Ted Findlay, DO, CCFP, FCFP5

1 is an orthopedic surgeon who specializes in the care of adult spinal disorders. He is also an Associate Professor in the Department of Surgery at the University of Ottawa. In addition he is the Research Chair for the Canadian Spine Society.
2Private practice Elite Sports Medicine in Lethbridge, AB.. Head Team Physician, Lethbridge Hurricanes (WHL). Clinical Lecturer, Dept of Family Medicine, University of Calgary School of Medicine.
3 is a Physical Therapist in Ottawa and a Research Assistant at The Ottawa Hospital.
4 Physiotherapist, Liquidgym, Ottawa; Nordic Walking Instructor and Urban Poling Master Trainer, OttawaNordicWalks; Past Director, Exercise is Medicine Canada
5 is a Clinical Assistant Professor in the Department of Medicine at the University of Calgary. He is also in a Private Family Medicine practice. In addition he is on Medical Staff at Alberta Health Services, Calgary Zone in Calgary, Alberta.

CLINICAL TOOLS

Abstract: Exercise is one of the most effective and simplest evidence-based recommendations to manage acute and chronic back pain. This paper discusses the physiology and evidence to support exercise as effective treatment. We will provide guidance on how to assess and prescribe exercise and offer methods to educate and encourage physical activity for patients with back pain.
Key Words: Back Pain, Physical Activity, Exercise Prescription, Motivational Interviewing.

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. Exercise is one of the most effective and simplest evidence-based recommendations to manage acute and chronic back pain.
2. For chronic back pain the most important exercise is the one the patient will actually do.
3. For acute back pain the exercise prescriptions should take into account the patient's directional preference of exercise (Pattern of Pain) and the patient's unique situation.
4. Exercise Prescriptions should include the F.I.T.T. principle (Frequency, Intensity, Time and Type).
Simply asking the patient about exercise has been shown to be effective in improving health outcomes. Consistent messaging about the positive role of physical activity is important.
Most forms of physical activity are usually beneficial. The exercise prescription should take in to account what the patient is actually prepared to do.
Patients often require reassurance that pain associated with exercising does not lead to physical harm.
Motivational interviewing is a structured, empathetic method to engage resistant patients.
Walking is free.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Back Health, back pain, physical activity, Exercise Prescription, Motivational Interviewing
Disclaimer: 
Disclaimer at the end of each page

Keep Your Head when Dealing with Concussion

Teaser: 

Dr. Aly Abdulla1
Adil Abdulla2
Neelam Charania3

1 is a family doctor with specialties in sports medicine, palliative care, and cosmetic medicine. He can be found on Twitter, LinkedIn and https://ihopeyoufindthishumerusblog.wordpress.com/
2 is a law student at the University of Toronto that has suffered 13 concussions.
3 is a Masters in Occupational Therapy from Boston University and involved in managing and rehabilitating patients with chronic concussion syndrome.

CLINICAL TOOLS

Abstract: Concussion or minimal traumatic brain injury is a confusing medical condition that is more common than previously appreciated. At the Berlin congress in 2016, 3 key tools and 11 key processes have been developed to clarify this condition and ensure good outcomes. This article summarizes those recommendations in an easy to use format.
Key Words: Concussion, minimal traumatic brain injury (mTBI), symptoms, protocol.
Do the SCAT5 or cSCAT5 on everyone with a mTBI.
When thinking of concussion also consider cervical spine or neck injury and vestibular injury. Learn to differentiate them. Treat accordingly.
The patient should rest for 24–48 hours after the injury, then can be encouraged to become gradually and progressively more active while staying below their cognitive and physical symptom-ex-acerbation thresholds
Any patients having persistent concussive symptoms (> 14 days for an adult or > 30 days in a child) should be referred to a specialist in mTBI and prescribed active rehabilitation.
Have a high rate of suspicion for mTBI
Most mTBI are managed well with Remove from play, Re-evaluate in office using SCAT5, and Rest
Repeat clinical testing is de rigeur for Return to Play
Learn to manage symptoms like poor sleep, mood changes, and deconditioning while patients recover.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Sports Medicine, concussion, minimal traumatic brain injury (mTBI), symptoms, protocol
Disclaimer: 
Disclaimer at the end of each page

What is Pediatric Alopecia Areata?

Teaser: 

Kailie Luan,1 Joseph M. Lam, MD, FRCPC,2

1Faculty of Medicine, University of Alberta, Edmonton, AB.
2Clinical Assistant Professor, Department of Pediatrics and Dermatology, University of British Columbia, BC.

CLINICAL TOOLS

Abstract: Alopecia areata is a chronic immune-mediated disorder that causes nonscarring hair loss. Although most commonly causing discrete hair loss on the scalp, the condition can affect any hair bearing area of the body and cause significant emotional and psychosocial distress. While intralesional glucocorticoids are often used as initial treatment for adults with the condition, therapeutic options for children are more limited with concerns of treatment tolerability and potential side effects. This article aims to provide an overview of alopecia areata with particular focus on managing this chronic condition in children.
Key Words: Alopecia areata, clinical presentation, diagnosis, management, pediatrics.
Alopecia areata is a chronic relapsing disorder characterized by non scarring hair loss that can affect any hair-bearing area of the body
While intralesional glucocorticoids are often used as initial treatment for adults, potent topical corticosteroids are effective as first line therapy in children due to better treatment tolerability
The diagnosis is generally made on clinical grounds with the majority of patients presenting with limited patchy disease affecting the scalp
In cases of inadequate response, topical minoxidil or immunotherapy are additional options, with systemic corticosteroids and immunosuppressive agents reserved for refractory cases, and IL-2 and JAK inhibitors as new emerging therapies for AA
Not all patients with alopecia areata require treatment as up to 50 percent of patients with limited alopecia areata will experience spontaneous regrowth of hair.4
Due to the benign nature of alopecia areata, and spontaneous remission is common, watchful waiting is considered a reasonable option in cases of limited disease.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Dermatology, Alopecia areata, clinical presentation, diagnosis, management, pediatrics
Disclaimer: 
Disclaimer at the end of each page

Upper Extremity Pain: Where's the pathology—Neck or Shoulder?

Teaser: 

Andrew Trenholm, MD, MSc, FRCSC,1
Fred Xavier, MD, PhD,2
Sean Christie, MD, FRCSC,3

1 Associate Professor Orthopaedics (Upper Extremity and Trauma) Dalhousie University, Halifax, NS.
2Fellow, Combined Spine Program, Department of Surgery, Dalhousie University, Halifax, NS.
3 Associate Professor, Dalhousie University, Department of Surgery (Neurosurgery), Halifax, NS.

CLINICAL TOOLS

Abstract: Neck and shoulder disorders are among the leading causes of pain and disability. History and physical examination are key components to clinical diagnosis and to determining whether the source of the arm pain is the neck or the shoulder. When consistent with the history, it is recommended to perform targeted provocative tests or manoeuvers. Several studies have shown that using a test item cluster improves diagnostic accuracy more than any single test item alone. Imaging, electrophysiological and laboratory studies are usually unnecessary unless there are clear clinical indications.
Key Words: Cervical radiculopathy, Neck pain, Shoulder pain, Clinical diagnosis, Provocative tests.

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. Sinister pathology is rarely produces completely intermittent pain.
2. Neck pain is frequently associated with psychosocial stress and heightened emotional response.
3. The first step in taking the history is to establish the site of the dominant pain.
4. A neurological examination should include tests for spinal cord involvement causing cervical myelopathy.
5. Neck dominant pain can include pain felt in the face, upper back, top of the shoulder, anterior chest and headache.
The best way to differentiate between the neck and the shoulder as the source of upper limb pain is to assess the effect of movement in each area on the patient's typical pain.
The provocative tests should be chosen to confirm a suspected diagnosis. By themselves they are not a reliable guide to the specific pathology.
Neck and shoulder problems may coexist particularly in older patients and the examination of one should always include a screen of the other.
Radicular arm pain is more often caused by boney foraminal nerve root entrapment than by a new "soft" disc herniation.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Back Health, cervical radiculopathy, neck pain, Shoulder pain, clinical diagnosis, Provocative tests
Disclaimer: 
Disclaimer at the end of each page

Insufficiency Fractures of the Femur and Sacrum

Teaser: 

Dr. M.S. Alam, MD, MBBS, CCFP, FCFP

Clinical Lecturer, Cumming School of Medicine, Calgary, University of Calgary, Family Medicine Department, Calgary, AB.

CLINICAL TOOLS

Abstract: Insufficiency Fractures (I.F) are non-traumatic fractures that occur in abnormal bone (low density bone). Usually occurs in elderly post-menopausal women and is non-traumatic. X-rays are unremarkable and MRI showed extensive bone marrow oedema and subchondral fracture.
Ms. Shirley Cooke, a 61 year old with a background of low bone mass, breast cancer, Diabetes Melitis type 2, HTN, splenic artery thrombosis came in with a dull pain on her left knee and occasionally some sharp element, with unremarkable examination on knees.
Recently, she was diagnosed with left ankle avulsion fracture of lateral maleolus and is wearing an ankle boot for healing.
It is important to make the correct diagnosis in order to avoid complications."
Key Words: Insufficiency Fracture (I.F), low bone mass, management.
1. With regard to I.F of femoral Condyle—Although the knee symptoms will always be unilateral, on the side of the meniscal tear, and are more frequent in older woman, the pain of an insufficiency fracture can easily be confused with that of other joint pathologies and therefore be easily missed.2
2. With regard to I.F of Femoral Neck—This fracture is seen in the elderly osteoporotic patient, often following a trivial event such as a slip without a fall. The resultant boney defect may be a compression fracture, which is inherently stable, or a transverse fracture, more common in older patients and is potentially much more serious.
3. With regard to I.F of Sacrum—The possibility of an insufficiency fracture should be considered in elderly osteoporotic patients, particularly women, following evenly seeming innocuous trauma to the posterior pelvis who exhibit constant buttock pain which may radiate to the thigh or groin and is unaffected by spinal movement.
MRI is the gold standard for Dx. I.F.
Symptoms and conventional tests may not be helpful, High Index of suspicious is needed.
To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.
Related Terms: Women’s Health, Insufficiency Fracture, low bone mass, management
Disclaimer: 
Disclaimer at the end of each page