Sue Greenhalgh

Anterior knee pain and cold knees: a possible association in women.

Abnormal reactions to environmental cold have been observed in some patients with Anterior Knee Pain (AKP). The aims of this study were to investigate whether palpation of the knee could classify patients into those with and those without cold knees; whether this classification could be objectively validated using thermal imaging; whether the cold and not cold knee groups varied in response to a cold stress test and in patient-reported measures. Fifty eight patients were recruited; palpation classified them into cold and not cold groups. Twenty-one (36%) patients were classified as having a cold knee by palpation: fourteen (36%) females and seven males (37%). Preliminary analysis suggested gender might be an effect modifier and the number of men was small, therefore the analysis focussed on females. Women with cold knees had a significantly smaller patellar skin fold, lower levels of activity and worse scores on the MFIQ, there also appeared to be an association with a traumatic onset. Women with cold knees were more likely to report cold weather affected their knees and they preferred a hot water bottle compared to an ice-pack on their knee; there was also a trend towards having to wear extra tights/long johns in the winter. This study has helped to define a clinical profile for a group of females with AKP and cold knees. This group appears to demonstrate a mild form of Reflex Sympathetic Dystrophy.

A qualitative investigation of Red Flags for serious spinal pathology

Red Flags are prognostic variables for serious patholgy, i.e. benign or malignant tumour, infection, fracture or auda equina syndrome. Only 1% of cases of low back ain are caused by serious spinal pathology [1]. For some ears, the major international guidelines on managing low ack pain have been consistent in recommending screenng for Red Flags [1–8]. Historically, Red Flags have been eveloped using clinical observation and retrospective analsis. Unfortunately, with a few exceptions, the prognostic trength of individual Red Flags or combinations of Red lags is not known. In order to be considered prognostic, variable does not necessarily need to be caused by a particlar pathological process, but it must be strongly associated ith the development of a specific outcome in order to preict its occurrence. Demographic variables such as age and ender are often considered prognostic. Risk factors are conidered to be distinct from prognostic factors and are often elated to lifestyle. For example, smoking is an important isk factor in developing lung cancer, but tumour stage is the ost important prognostic factor in individuals who have the isease [9]. Due to the way in which Red Flag lists have evolved and eveloped, there is an almost overwhelming profusion of Red lags. The recently published clinical guidelines for the physotherapy management of persistent low back pain [8] state hat 119 items in the subjective history and 44 items in the bjective history have been identified as Red Flags. In addiion, these guidelines state that there is wide variation in the efinition of a Red Flag. As part of the process, members of the development group ere surveyed for levels of agreement on individual Red lag items [8]; no Red Flag item achieved 100% agreement.

Malignant myeloma of the spine

Summary A patient diagnosed with simple mechanical back pain appeared to respond to physiotherapy. His pain later increased and subsequent investigation revealed a malignant spinal tumour. This was surgically removed and he resumed many activities of daily living. Retrospectively, this patient displayed from the outset several symptoms diagnostic of serious pathology.

Margaret: a tragic case of spinal Red Flags and Red Herrings

Abstract Objective This case illustrates how easily patient misattribution can influence the clinical reasoning process and it alerts physiotherapists to safeguard from the influences of Red Herrings . Design It is the second in a series of case studies considering patients with serious spinal pathology. Setting This paper considers the case of a 49year old lady who was referred to a Spinal Assessment Clinic in a district general hospital. The clinic was established specifically to deal with more complex spinal patients, identifying those at risk of chronicity, surgical cases or those with more complex pathology. Unfortunately this case was subsequently diagnostically triaged as serious spinal pathology. Conclusion As misattribution of symptoms by the patient is common, it is essential that the clinician considers a thorough subjective and objective assessment. When drawing inferences from the findings it is vital to stand back and consider if the attributed cause and effect is an inherent likelihood and consider whether there may be important information missing.

An investigation into the patient experience of Cauda Equina Syndrome: A qualitative study

PURPOSE: The aim of this study was to identify how Cauda Equina Syndrome (CES) symptoms may be more effectively identified by patients along with their experiences with clinicians. Patient’s symptoms and understandings of their condition were explored, including issues associated with bladder, bowel and sexual function. METHOD: An interpretive research paradigm using a narrative approach was adopted utilising qualitative one-to-one semistructured interviews. Narrative research is a useful way to explore patients’ perceptions of and the meanings attached to CES symptoms. The clinical setting was within an NHS Foundation Trust in an industrial town in the Northwest of England. Participants were recruited from the population of patients who, in the preceding 18 months had attended the Orthopaedic service for care related to CES. New cases presenting during the data collection period were also eligible for inclusion. Ten patients consented, 7 females and 3 males, average age 58.5 years (range 33–72). All interview data was transcribed and subjected to narrative analysis. The narrative analysis explored perceptions of and the meanings associated with the personal and emotional aspects of the participant’s pain and symptoms, along with how these aspects of the participants experiences were relayed to the clinician or affected their interaction with clinicians. RESULTS: Narrative analysis identified two key issues to be essential in facilitating timely diagnosis of CES a) clinician’s knowledge of signs and symptoms and an awareness of these by patients b) communication about these signs and symptoms using a language understandable to both patients and clinicians.

Why do patients with Simple Mechanical Back Pain seek Urgent Care

OBJECTIVE To explore why patients with simple mechanical back pain seek urgent care. DESIGN Qualitative Exploratory Inquiry based on the principles of Grounded Theory. SETTING Urgent Care. METHODS Data collection by semi-structured interview. PARTICIPANTS Eleven patients presenting to urgent care (Accident and emergency, Walk-in Centre and Out of hours service) with back pain. RESULTS The study identified eight key motivators of patients with mechanical back pain seeking urgent care: (1) GP access, (2) Pain, (3) Function, (4) Something being different, (5) Something being wrong, (6) Desire for investigation, (7) Third Party Influence and (8) Repeat visits. CONCLUSION This study provides some evidence to support the notion that patients are willing to use primary care services for the treatment of Simple Mechanical Back Pain but that access is frequently limited and untimely. The study concludes that inappropriate attendances at urgent care facilities are frequently a human response to perception of pain severity which is reinforced by functional loss, uncertainty, the need to provide care for others and the encouragement of others. While it is asserted that there is a clear need for mass education in this area, it is also speculated that attendance at urgent care may occur to overtly escalate the need for assistance and illustrate to sceptical significant others the severity of the condition.

Cauda Equina Syndrome and the challenge of diagnosis for physiotherapists: A review

Cauda Equina Syndrome (CES) is a well known condition where early detection is paramount. The new onset of bladder and bowel dysfunction, sexual dysfunction and saddle anaesthesia are commonly used as clinical indicators of possible CES. Although the presence of these symptoms alongside LBP should always be taken seriously, the causes of these individual problems are multifactorial. Many of the ‘other’ factors are frequently seen within the general and LBP population and commonly complicate the clinical picture. This review provides a comprehensive overview of the different factors that may lead to the development of bladder and bowel dysfunction, sexual dysfunction and/or saddle anaesthesia. It is hoped that improved knowledge of these reasons may ensure comprehensive subjective questioning of LBP patients.

Assessment and management of cauda equina syndrome

INTRODUCTION Cauda equina syndrome (CES) is a rare condition that affects the nerves in the spine supplying the bladder, bowel and sexual function. Identification and subsequent urgent action is required to avoid permanent damage to these essential organs. Delays in diagnosis can have devastating and life changing consequences for patients and result in high cost negligence claims. PURPOSE The purpose of this masterclass is to examine the current evidence and provide an evidence-based, clinically reasoned approach in the safe management of patients presenting with CES. It will include a focus on the importance of communication, documentation and a practical approach to safety netting those at risk. IMPLICATIONS FOR PRACTICE CES has significant implications for patients and clinicians alike. Timely, effective diagnosis and management of patients with CES results in a better outcome.

Development of a toolkit for early identification of Cauda Equina Syndrome.

Aim To develop a simple cauda equina syndrome (CES) toolkit to facilitate the subjective examination of low back pain patients potentially at risk of CES. To undertake preliminary validation of the content of the toolkit. BACKGROUND CES is a rare condition which can be very challenging to identify in a generalist medical setting. METHOD A three phase iterative design with two stake holder groups; extended scope practitioners experienced in managing CES patients and CES sufferers. Toolkit development Synthesis of existing CES literature with CES patient data generated from in depth interviews. Toolkit validation Content validation of the draft toolkit with CES patients. Toolkit validation Content validation of the draft toolkit with extended scope physiotherapists. Findings A three arm toolkit has been developed for use with patients considered by the clinician as at risk of developing CES (eg, worsening low back pain with symptoms/signs of progressive sensory-motor deficit in the lower limbs); patient expertise, clinical expertise, research and pathways. Uniquely, the toolkit drew upon the lived experiences of patients suffering from CES to inform the content.

The answer is in the questioning: Subjective history taking and serious spinal pathology

This case presents a 43 yr old woman with an eight-week history of progressing leg weakness set against a long history of chronic back pain. She was referred to the Orthopaedic department following referral from her General Practitioner. The weakness became so distressing to the patient that it resulted in a prior attendance at an Accident & Emergency department. The case illustrates the complexities of clinical reasoning within the area of serious pathology of the spine. It demonstrates the importance of detailed subjective history questioning in the quest for early diagnosis, which is particularly important for clinicians who work in an autonomous or extended role.