Max Kamien

A Rational Management of Tennis Elbow

SummaryTennis elbow is due to a torque injury or sudden overstretching of tendons which insert into the epicondyles of the humerus. The predominant lesion is an enthesopathy — a pathological lesion at the insertion of tendon into bone. The most common site is at the lateral epicondyle and this is 3 times as frequent as at the medial epicondyle. Approximately 50% of tennis players can expect to get a tennis elbow at some time during their playing lifetime. In one-third of the players this will be severe enough to interfere with their tasks of daily living. The major unresolved question about the aetiology of tennis elbow is why it has its peak incidence between the ages of 40 and 50 years and why 90% of players then have no further recurrence.Making sense of the literature on the treatment of tennis elbow is difficult because there are few tudies that have used the acceptable epidemiological techniques of the prospective randomised controlled trial or case-controlled study. Most papers are based on a collection of highly selected cases which represent the more intractable end of the tennis elbow spectrum and their reported results have been inconsistent. Tennis elbow is largely a self-limiting condition. The prime aim of treatment should be based on Hippocrates’ first tenet of medicine — first do no harm. Therapy should start with the simple and conservative before progressing to the more complex and invasive therapies. It should be acceptable to the patient, cost-effective and where invasive therapy is recommended, the potential benefits should clearly outweigh the risks. The principles of therapy for tennis elbow are to relieve pain, microbleeding and inflammation, promote healing, rehabilitate the injured arm and try to prevent recurrence. The most effective modalities of treatment are found to be cryotherapy in the acute stage then nonsteroidal anti-inflammatory drugs and heat in its various modalities including ultrasound. This is combined with rest which is best defined as the absence of painful activity. Injection of a depot preparation of cortisone is effective although patient reports are not as flattering as those of doctors. There is no advantage and in fact considerable disadvantage in using more than 2 such injections. Therapies such as acupuncture and chiropractic have not been evaluated. Nevertheless they cause no harm, may result in good and should be tried before resorting to more invasive therapy.Rehabilitation should run parallel to treatment. This requires attention to strengthening of the muscles around the elbow joint and gradual return to full play. It also includes attention to the biomechanics of stroke production and to the type, weight and balance of racquet, tension of strings and size of grip. Invasive therapy such as Mill’s manipulation and surgery should only be used as a last resort taking care to exclude patients whose elbow pain is part of a psychiatric pain syndrome or who have been unable to follow adequate conservative therapy. The time at which the various modalities of treatment should be used depends on the occupational and to a lesser extent the leisure needs of the patient. Treatment of a patient with severe or prolonged elbow pain often requires an holistic approach involving the patient’s biological, psychological, social and occupational circumstances.

Management of Type 2 diabetes in Western Australian metropolitan general practice

The purpose of this study was: (1) to record GP opinions, practices and outcomes for the care of Type 2 Diabetes Mellitus (DM2), (2) compare practice facilities and process of care with a criterion of recommended competent care and (3) determine if there were any differences between vocationally registered and non-vocationally registered GPs. A random sample of 204 metropolitan doctors from 124 practices was selected and an audit performed on 467 of their patient records. GPs pursued good blood sugar control and advocated lifestyle changes before hypoglycaemic drugs. Over 80% regard uncomplicated DM2 as a condition for general practice management. However, only 15% conducted an annual diabetes check, 9% had a diabetic register, 6% a diabetic recall system and 8% used a diabetic health care checklist for monitoring their patients. The most commonly recorded processes of medical audit in the previous 12 months were: blood pressure (94%), duration of diabetes (72%), blood glucose (70%), diet (66%), body weight (56%), HBA1c (52%) and ophthalmoscopy (50%). The least commonly recorded processes of care were body mass index (5%), inspection of the feet (18%), enquiries about vaginitis or impotence (23%). The amount of exercise, alcohol and tobacco was recorded in only 34% of records. Hypoglycaemic drugs were used appropriately but the most commonly used drugs for treating hypertension in DM2 patients were thiazide diuretics and beta-blockers. Vocationally registered (VR) doctors had better records, higher process of care scores and more were willing to participate in the study than non-vocationally registered (NVR) doctors. However, there was no difference in metabolic control between patients from either group. The use of a Diabetic Health Care Checklist would improve diabetes care especially in the search for early complications and in the recording of HBA1c and other metabolic parameters. The drugs commonly used to control hypertension can have adverse effects on glucose and lipid metabolism and should be replaced with glucose and lipid neutral drugs.

Change in Aboriginal childhood morbidity and mortality in Bourke 1971–84

Abstract In the early 1970s, the Aboriginal community of Bourke attempted to improve its socioeconomic and health status through a number of community development activities. As a result, markers of nutrition in early childhood, housing conditions and access to health care all improved, in spite of a deterioration in employment opportunities and adult health. Coincidentally, most markers of the health of Aboriginal children in Bourke improved over the period 1971–84. In particular, Aboriginal child admissions due to gastroenteritis, eye and ear infections and accidents, and the community prevalence of trachoma, middle ear disease and pneumonia among Aboriginal children, decreased. Skin infections were an exception to this general picture, becoming more prevalent over the period.

Health care needs of the children of single mothers in a Perth suburb

This paper reports a prevalence study of illness in children in a lower socioeconomic suburb of Perth. The study shows that single mothers reported higher rates of both emotional and physical disorder in their children compared with mothers from nuclear families. The children from single families were also reported as having a poorer immunization status. It is argued that children from single families constitute a vulnerable group and deserve special attention from those in the health system who care for children.

An analysis of white and aboriginal children under five years of age admitted to the Bourke District Hospital from September 1971 to August 1972.

This study includes all white and Aboriginal children under the age of 5 years admitted to the Bourke District Hospital over a 12 month period. 15% of all white children and 72% of all Aboriginal children in the Bourke shire were admitted to hospital on at least one occasion; Aboriginal children had proportionately 10 times the number of hospital admissions on a population basis.

Distance learning in a local setting: a structured learning course for the introduction of general practice to undergraduate students

This paper describes the development and evaluation of a structured introductory course in general practice. Following some of the principles developed in distance education, the Department provides everything the student needs for the formal learning requirement as well as detailed assistance in how best to tackle the selected topics. The course was reported to be demanding, relevant and enjoyable. The major areas requiring attention were in reducing the amount of reading required, more help in learning to work in small student-run groups and more one-to-one supervision of physical examination skills. With further refinement the course should be applicable to other medical schools in developed countries.

The secret bread tests: Selective primary health care or experimentation on human-beings?

This is a case history which describes an attempt to fortify the bread of Australian Aborigines in an isolated area of New South Wales. The medically successful intervention was accomplished by the publication of scientific enquiry and by attention to the culture of Aborigines. Paradoxically the long-term failure of the project was also due to the power of the written word and the neglect of the culture of the more densely populated and politically dominant white community. The need for doctors to be aware of the different approaches of primary health care and selective primary health care is stressed so that a general practitioner who provides health care for minority groups of the Fourth World can better define his role and relevance.

Differences in teaching about the acute sore throat within one medical faculty

To examine the consistency of teaching about the acute sore throat in four departments in one medical faculty, and to determine whether there is agreement between what is taught and the evidence‐based literature.