iii
BY THE NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL
EVIDENCE-BASED
MANAGEMENT OF
PAIN
ACUTE MUSCULOSKELETAL
AUSTRALIAN ACADEMIC PRESS PTY LTD
Brisbane
PARTICIPATION
The work is a joint initiative of the University of Queensland and the Commonwealth Depar
of Health and Ageing. The evidence review was undertaken by a multi-disciplinary group.
The following organisations participated in the review and have approved the contents:
•Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine
•Australian Osteopathic Association
•Australian Rheumatology Association
•Australian Physiotherapy 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 necessar
applying evidence in a clinical setting. It is important to note that weak evidence does not necessarily
mean that a practice is unadvisable, 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 rthe clinician and the patient and depends on individual circumstances and beliefs (NHMR
First published in December 2003 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 GroupAny views or opinions expressed are therefore not necessarily those of Australian Academic Press.
Copyright © 2003 Australian Acute Musculoskeletal Pain Guidelines Group
National Library of Australia Cataloguing-in-Publication data:
Evidence-based management of acute musculoskeletal pain.
Bibliography.
For medical professionals.
ISBN 1 875378 49 9.
1. Musculoskeletal system — Diseases — Treatment.
2. Evidence-based medicine. 3. Pain — Treatment. I.
Australian Acute Musculoskeletal Pain Guidelines Group.
616.7
Cover and text design by Andrea Rinarelli of Australian Academic Press, Brisbane.
Typeset in Adobe Garamond by Australian Academic Press, Brisbane.
Contents
Chapter
Chapter
Chapter
Chapter
List of Tables..........................................................................................................................................................................................................x
List of Figures
...................................................................................................................................................................................................
xii
About the Group:
Australian Acute Musculoskeletal Pain Guidelines Group
...............................xiii
1 Executive Summary.....................................................................................................................................................................................1
Rationale ............................................................................................................................................................................................................1
Scope ......................................................................................................................................................................................................................1
Summary of Findings .....................................................................................................................................................................2
Limitations of Findings
................................................................................................................................................................2
Summary of Key Messages
.................................................................................................................................................2
>References
...............................................................................................................................................................................................................16
2 Acute Pain Management........................................................................................................................................................17
Pain .........................................................................................................................................................................................................................17
Acute Pain
...................................................................................................................................................................................................17
Pain Assessment
..............................................................................................................................................................................17
Pain Management
..........................................................................................................................................................................20
Pain Management Plan
.........................................................................................................................................................20
Interventions for Acute Musculoskeletal Pain
..............................................................................21
>References
...............................................................................................................................................................................................................22
3 Effective Communication........................................................................................................................................................23
Communication ...................................................................................................................................................................................23
Medical Terminology
.................................................................................................................................................................23
Learning Methods
..........................................................................................................................................................................23
Factors Affecting Communication
.......................................................................................................................23
Evidence Review
..............................................................................................................................................................................23
Research Priorities
.......................................................................................................................................................................24
>References
...............................................................................................................................................................................................................24
4 Acute Low Back Pain......................................................................................................................................................................25
Definition of Acute Low Back Pain ....................................................................................................................25
Scope
...................................................................................................................................................................................................................25
Guideline Development Process
...........................................................................................................................26
Research Agenda for Acute Low Back Pain
.....................................................................................27
Summary of Key Messages
.............................................................................................................................................28
DIAGNOSIS
..................................................................................................................................................................................................................32
>Aetiology and Prevalence
..............................................................................................................................................................32
Conditions Associated with Acute Low Back Pain:
Radiological Findings
................................................................................................................................................................32
>History
..............................................................................................................................................................................................................................33
Pain History
...............................................................................................................................................................................................33
Clinical Features of Specific Conditions
...................................................................................................35
❿☎Alerting Features of Serious Conditions (see Table 4.6)
......................................36
>Physical Examination
..............................................................................................................................................................................36
Physical Assessment
................................................................................................................................................................36
Psychosocial Assessment
...............................................................................................................................................37
Neurological Assessment
.................................................................................................................................................38
Chapter
>Ancillary Investigations ......................................................................................................................................................................38
Imaging
.............................................................................................................................................................................................................38
Other Investigations
....................................................................................................................................................................
39
>Terminology
.............................................................................................................................................................................................................39
Diagnostic Terms
.............................................................................................................................................................................39
PROGNOSIS
................................................................................................................................................................................................................39
Natural History
.....................................................................................................................................................................................39
Prognostic Risk Factors
........................................................................................................................................................40
INTERVENTIONS
................................................................................................................................................................................................
42
Evidence of Benefit
......................................................................................................................................................................42
Conflicting Evidence
...................................................................................................................................................................43
Insufficient Evidence
.................................................................................................................................................................46
>Economic Implications
.........................................................................................................................................................................
54
>References
...............................................................................................................................................................................................................54
5 Acute Thoracic Spinal Pain.....................................................................................................................................................63
Definition of Acute Thoracic Spinal Pain ................................................................................................63
Scope
...................................................................................................................................................................................................................63
Guideline Development Process
...........................................................................................................................63
Research Agenda for Acute Thoracic Spinal Pain
.................................................................64
Summary of Key Messages
.............................................................................................................................................65
DIAGNOSIS
..................................................................................................................................................................................................................67
>Aetiology and Prevalence
..............................................................................................................................................................67
Serious Conditions
........................................................................................................................................................................67
Mechanical Conditions
..........................................................................................................................................................69
Conditions Referring Pain to the Thoracic Spine
.......................................................................70
Conditions Referring Pain from the Thoracic Spine
..............................................................71
Prevalence of Conditions Causing Acute Thoracic Spinal Pain
.......................71
>History
..............................................................................................................................................................................................................................71
Pain History
...............................................................................................................................................................................................
71
>Physical Examination
..............................................................................................................................................................................72
Inspection
.....................................................................................................................................................................................................72
Palpation
........................................................................................................................................................................................................73
Movement
....................................................................................................................................................................................................74
❿☎Alerting Features of Serious Conditions (see Table 5.7)
......................................74
>Ancillary Investigations
......................................................................................................................................................................74
Plain Radiography
..........................................................................................................................................................................74
Computed Tomography (CT) Scanning
........................................................................................................76
Magnetic Resonance Imaging (MRI)
.............................................................................................................76
Other Investigations
....................................................................................................................................................................77
Cost Effectiveness of Investigations
...............................................................................................................77
>Terminology
.............................................................................................................................................................................................................77
Recommended Terms
...............................................................................................................................................................77
PROGNOSIS
................................................................................................................................................................................................................78
Natural History
.....................................................................................................................................................................................78
Influence of Risk Factors and Diagnostic
and Therapeutic Interventions
..................................................................................................................................78
INTERVENTIONS
................................................................................................................................................................................................78
Evidence of Benefit
......................................................................................................................................................................78
Other Treatment
.................................................................................................................................................................................78
>References
...............................................................................................................................................................................................................78
Chapter
Chapter
6 Acute Neck Pain............................................................................................................................................................................................83
Definition of Acute Neck Pain ....................................................................................................................................83
Scope
...................................................................................................................................................................................................................83
Guideline Development Process
...........................................................................................................................83
Summary of Key Messages
.............................................................................................................................................
85
Research Agenda for Acute Neck Pain
....................................................................................................90
DIAGNOSIS
..................................................................................................................................................................................................................90
>Aetiology and Prevalence
..............................................................................................................................................................
90
Rare Causes of Acute Neck Pain
.........................................................................................................................90
Uncommon Causes of Acute Neck Pain
...................................................................................................91
Common Causes of Acute Neck Pain
............................................................................................................
91
Other Issues
.............................................................................................................................................................................................92
Aetiological Risk Factors (Idiopathic neck pain)
........................................................................
92
Aetiological Risk Factors (Whiplash-Associated Neck Pain)
.............................94
>History
..............................................................................................................................................................................................................................94
Pain History
...............................................................................................................................................................................................94
❿☎Alerting Features of Serious Conditions (see Table 6.5)
....................................95
>Physical Examination
..............................................................................................................................................................................
96
General Examination
..................................................................................................................................................................96
Neurological Examination
.................................................................................................................................................96
Musculoskeletal Examination
....................................................................................................................................97
>Ancillary Investigations
......................................................................................................................................................................97
Plain Radiography
..........................................................................................................................................................................97
Canadian C-Spine Rule
............................................................................................................................................................98
Computed Tomography Scanning
....................................................................................................................100
Magnetic Resonance Imaging
..............................................................................................................................100
Single Photon Emission Computed Tomography
....................................................................101
Other Ancillary Investigations
................................................................................................................................101
>Terminology
.........................................................................................................................................................................................................101
Specific and Serious Causes of Acute Neck Pain
...............................................................101
Terms to Describe Acute Neck Pain
...........................................................................................................101
PROGNOSIS
............................................................................................................................................................................................................101
Natural History
.................................................................................................................................................................................101
Prognostic Risk Factors
....................................................................................................................................................102
INTERVENTIONS
............................................................................................................................................................................................103
Evidence of Benefit
..................................................................................................................................................................103
Insufficient Evidence of Benefit
..........................................................................................................................106
Evidence of No Benefit
......................................................................................................................................................110
>References
...........................................................................................................................................................................................................110
7 Acute Shoulder Pain..........................................................................................................................................................................119
Definition of Acute Shoulder Pain ...................................................................................................................119
Scope
...............................................................................................................................................................................................................119
Guideline Development Process
........................................................................................................................119
Research Agenda for Acute Shoulder Pain
....................................................................................121
Summary of Key Messages
..........................................................................................................................................121
DIAGNOSIS
..............................................................................................................................................................................................................124
>Aetiology and Prevalence
...........................................................................................................................................................124
Painful Conditions of the Shoulder
.................................................................................................................124
Conditions Referring Pain to the Shoulder
........................................................................................127
Prevalence of Conditions Causing Acute Shoulder Pain
..........................................127
Aetiological Risk Factors
................................................................................................................................................128
Chapter
>History ..........................................................................................................................................................................................................................129
Pain History
............................................................................................................................................................................................129
General History
................................................................................................................................................................................
130
Psychosocial History
.............................................................................................................................................................130
Evidence of Reliability
..........................................................................................................................................................130
Evidence of Validity
..................................................................................................................................................................130
>Physical Examination
..........................................................................................................................................................................130
Inspection
.................................................................................................................................................................................................130
Palpation
.....................................................................................................................................................................................................130
Movement Testing
......................................................................................................................................................................131
Evidence of Reliability
..........................................................................................................................................................132
Evidence of Validity
..................................................................................................................................................................133
❿Alerting Features of Serious Conditions (see Table 7.11)
..............................
134
>Ancillary Investigations
..................................................................................................................................................................134
Medical Imaging
...........................................................................................................................................................................134
Indications for Medical Imaging
........................................................................................................................
134
Plain Radiography
.......................................................................................................................................................................134
Ultrasonography
............................................................................................................................................................................135
Magnetic Resonance Imaging
..............................................................................................................................137
MR Arthrography
.........................................................................................................................................................................139
Radionuclide Bone Scanning (Scintigraphy)
................................................................................139
Other Ancillary Investigations
................................................................................................................................140
Conclusion
...............................................................................................................................................................................................140
>Terminology
.........................................................................................................................................................................................................140
PROGNOSIS
............................................................................................................................................................................................................141
Natural History
.................................................................................................................................................................................141
Prognostic Risk Factors
....................................................................................................................................................142
INTERVENTIONS
............................................................................................................................................................................................142
Evidence of Benefit
..................................................................................................................................................................142
Conflicting Evidence
...............................................................................................................................................................145
Insufficient Evidence
.............................................................................................................................................................145
>References
...........................................................................................................................................................................................................146
8 Anterior Knee Pain................................................................................................................................................................................155
Definition of Patellofemoral Pain .......................................................................................................................155
Scope
...............................................................................................................................................................................................................155
Guideline Development Process
........................................................................................................................155
Summary of Key Messages
..........................................................................................................................................157
Research Agenda for Anterior Knee Pain
..........................................................................................160
DIAGNOSIS
..............................................................................................................................................................................................................160
>Aetiology and Prevalence
...........................................................................................................................................................160
Aetiology of Patellofemoral Pain
.......................................................................................................................160
Serious Conditions Causing Anterior Knee Pain
.....................................................................161
Other Specific Conditions Causing Anterior Knee Pain
..............................................161
Conditions Referring Pain to the Anterior Knee
.......................................................................163
Prevalence of Causes of Anterior Knee Pain
...............................................................................163
Aetiological Risk Factors for Patellofemoral Pain
............................................................... 163
>History
......................................................................................................................................................................................................................... 164
Pain History
........................................................................................................................................................................................... 164
❿Alerting Features of Serious Conditions (see Table 8.3)
................................. 165
>Physical Examination
......................................................................................................................................................................... 165
Inspection
................................................................................................................................................................................................ 165
Palpation
.................................................................................................................................................................................................... 165
Chapter
Appendix
Appendix
Appendix
Appendix
Appendix
Assessment of Movement ........................................................................................................................................... 166
Reliability and Validity of Physical Tests
.............................................................................................. 167
Summary of Clinical Features of Patellofemoral Pain
...................................................
167
>Ancillary Investigations
................................................................................................................................................................. 167
Medical Imaging
.......................................................................................................................................................................... 167
Plain Radiography
...................................................................................................................................................................... 167
Computed Tomography (CT)
...................................................................................................................................... 169
Radionucleotide Scan
......................................................................................................................................................... 169
Magnetic Resonance Imaging (MRI)
........................................................................................................ 169
Ultrasound
.............................................................................................................................................................................................. 169
Arthrography
...................................................................................................................................................................................... 170
Other Ancillary Investigations
............................................................................................................................... 170
>Terminology
........................................................................................................................................................................................................
170
Patellofemoral Pain
................................................................................................................................................................. 170
PROGNOSIS
........................................................................................................................................................................................................... 170
Natural History
................................................................................................................................................................................ 170
INTERVENTIONS
........................................................................................................................................................................................... 170
Evidence of Benefit
................................................................................................................................................................. 171
Conflicting Evidence
............................................................................................................................................................. 172
Insufficient Evidence
............................................................................................................................................................ 172
Evidence of No Benefit
..................................................................................................................................................... 173
>Economic Implications
.................................................................................................................................................................... 173
>References
.......................................................................................................................................................................................................... 174
9 Process Report.............................................................................................................................................................................................183
>Overview ..................................................................................................................................................................................................................183
Multi-Disciplinary Involvement
........................................................................................................................... 183
Target Audiences
........................................................................................................................................................................ 183
>Evidence Review Process
......................................................................................................................................................... 183
Evaluation of Existing Guidelines
..................................................................................................................... 183
Search for New Evidence
............................................................................................................................................ 184
Critical Appraisal Process
........................................................................................................................................... 185
Data Analysis and Key Messages
.................................................................................................................. 185
Development of a Management Plan
for Acute Musculoskeletal Pain
....................................................................................................................... 185
>Economic Implications
.................................................................................................................................................................... 187
>Consultation Process
......................................................................................................................................................................... 187
>Health Consumers
................................................................................................................................................................................... 187
>Dissemination and Implementation
........................................................................................................................... 187
Dissemination Strategies
.............................................................................................................................................. 187
Implementation Strategies
.......................................................................................................................................... 187
Revision Strategy
........................................................................................................................................................................ 187
>Legal Implications
................................................................................................................................................................................... 188
>References
.......................................................................................................................................................................................................... 188
A Glossary of Terms....................................................................................................................................................................................189
B Table of Unit Costs (November 2002)
............................................................................................................... 191
C Ancillary Investigations
...............................................................................................................................................................195
D Consultation
........................................................................................................................................................................................................197
E Tables of Included and Excluded Studies
...............................................................................................199
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