Table Of Content

cute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute te Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Ac Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pa Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pa Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pa Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Lo Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Anterior Knee Pain Anterior Knee Pain AnteriEor KVneeI PDain AEnteNriorC KneEe P-ainB AAnteriSor KEneeD Pain Anterior Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain v Anterior Knee Pain Ant Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior MANAGEMENT OF ACUTE MUSCULOSKELETAL PAIN Australian Acute Musculoskeletal Pain Guidelines Group APPROVED 5 JUNE 2003 BY THE NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL EVIDENCE-BASED MANAGEMENT OF ACUTE MUSCULOSKELETAL PAIN Australian Acute Musculoskeletal Pain Guidelines Group iii AUSTRALIAN ACADEMIC PRESS PTY LTD Brisbane PARTICIPATION The work is a joint initiative of the University of Queensland and the Commonwealth Department ofHealth 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 necessary when 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 rests with the clinician and the patient and depends on individual circumstances and beliefs (NHMRC 1999). 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 Group. Any 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. iv Contents List of Tables x .......................................................................................................................................................................................................... List of Figures xii ................................................................................................................................................................................................... About the Group: Australian Acute Musculoskeletal Pain Guidelines Group xiii ............................... Chapter 1 (cid:1) Executive Summary 1 ..................................................................................................................................................................................... Rationale 1 ............................................................................................................................................................................................................ Scope 1 ...................................................................................................................................................................................................................... Summary of Findings 2 ..................................................................................................................................................................... Limitations of Findings 2 ................................................................................................................................................................ Summary of Key Messages 2 ................................................................................................................................................. >References 16 ............................................................................................................................................................................................................... Chapter 2 (cid:1) 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 ............................................................................................................................................................................................................... (cid:1) Chapter 3 Effective Communication 23 ........................................................................................................................................................ Communication 23 ................................................................................................................................................................................... Medical Terminology 23 ................................................................................................................................................................. Learning Methods 23 .......................................................................................................................................................................... Factors Affecting Communication 23 ....................................................................................................................... Evidence Review 23 .............................................................................................................................................................................. Research Priorities 24 ....................................................................................................................................................................... >References 24 ............................................................................................................................................................................................................... Chapter 4 (cid:1) 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 ................................................................................................... (cid:2)(cid:1)Alerting Features of Serious Conditions (see Table 4.6) 36 ...................................... >Physical Examination 36 .............................................................................................................................................................................. Physical Assessment 36 ................................................................................................................................................................ Psychosocial Assessment 37 ............................................................................................................................................... Neurological Assessment 38 ................................................................................................................................................. v (cid:1)Contents >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 ............................................................................................................................................................................................................... (cid:1) Chapter 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 .................................................................................................................................................................................................... (cid:2)(cid:1)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 ............................................................................................................................................................................................................... vi (cid:1)Contents Chapter 6 (cid:1) 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 ............................................................................................................................................................................................... (cid:2)(cid:1)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 ........................................................................................................................................................................................................... Chapter 7 (cid:1) 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 ................................................................................................................................................ vii (cid:1)Contents >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 .................................................................................................................................................................. (cid:2)Alerting 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 ........................................................................................................................................................................................................... Chapter 8 (cid:1) 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 ........................................................................................................................................................................................... (cid:2)Alerting Features of Serious Conditions (see Table 8.3) 165 ................................. >Physical Examination 165 ......................................................................................................................................................................... Inspection 165 ................................................................................................................................................................................................ Palpation 165 .................................................................................................................................................................................................... viii (cid:1)Contents 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 .......................................................................................................................................................................................................... Chapter 9 (cid:1) 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 .......................................................................................................................................................................................................... (cid:1) Appendix A Glossary of Terms 189 .................................................................................................................................................................................... (cid:1) Appendix B Table of Unit Costs (November 2002) 191 ............................................................................................................... Appendix C (cid:1) Ancillary Investigations 195 ............................................................................................................................................................... Appendix D (cid:1) Consultation........................................................................................................................................................................................................197 Appendix E (cid:1) Tables of Included and Excluded Studies 199 ............................................................................................... ix (cid:1)List of Tables List of Tables 4.1 Conditions Associated with the Presence of Acute Low Back Pain 33 4.2 Radiological Findings in Patients with Low Back Pain in Primary Care 33 4.3 Prevalence of Spondylosis in Asymptomatic Individuals and Patients with Lumbar Spinal Pain 34 4.4 Prevalence of Disc Degeneration in Asymptomatic Individuals and Patients with Lumbar Spinal Pain 34 4.5 Comparison of Somatic Referred and Radicular Pain 35 4.6 Alerting Features (‘Red Flags’) of Serious Conditions Associated with Acute Low Back Pain 36 4.7 Prevalence of Abnormalities on CT Scan in a Population of Asymptomatic Individuals Aged Between 21 and 80 Years 39 4.8 Prevalence of Abnormalities on MRI Scans of 67 Asymptomatic People 39 5.1 A Systematic Classification of Causes of Acute Thoracic Pain 67 5.2 Aspects of Clinical Presentation for a Series of 442 Patients with Pyogenic Infection of the Spine 68 5.3 Odds Ratios for Incident Fractures of the Thoracolumbar Spine for Back Pain and Disability in Women Over 50 69 5.4 Relative Prevalence of Local Causes of Thoracic Pain 72 5.5 Distribution of Agreement Amongst Four Examiners Concerning the Presence or Absence of Dysfunction in 10 Unmarked Thoracic Spinal Segments in 15 Subjects 73 5.6 Abnormal Palpatory Findings in Examination of Segments T1–8 in 25 Asymptomatic Subjects 74 5.7 Alerting Features of Serious Conditions Associated with Acute Thoracic Spinal Pain 75 5.8 Comparison of the Location of Pain in Patients with Scheuermann’s Kyphosis with Age and Sex Matched Controls 76 5.9 Prevalence of Thoracolumbar Fractures in Patients by Age in 99 Patients with Blunt Trauma Prompting Radiological Investigation 76 5.10 Prevalence of Thoracic Spinal Fractures in Retrospective Studies of Blunt Trauma Victims in Trauma Centres on Whom Thoracolumbar Radiographs Were Performed 76 5.11 Risk Factors for Thoracolumbar Fracture in Patients with Blunt Trauma injuries Admitted to a Trauma Centre 77 6.1 Acute Neck Pain as the Principal Presenting Feature: Possible Causes 90 6.2 Medical, Social and Occupational Risk Factors Shown Not To Be Aetiological Risk Factors for Neck Pain 93 6.3 Medical, Social and Occupational Risk Factors Weakly Associated with Neck Pain 93 6.4 Psychosocial Risk Factors Shown Not To Be Related to Neck Pain 93 6.5 Alerting Features of Potentially Serious Conditions Associated with Acute Neck Pain 96 6.6 Factors Associated with Chronic Neck Pain After Whiplash: Insurance Data 102 x (cid:1)List of Tables 6.7 Demographic and Clinical Factors Associated with Chronic Neck Pain After Whiplash 103 7.1 A Guide to Described Causes of Acute Shoulder Pain 125 7.2 Prevalence Rates of Some Conditions Causing Acute Shoulder Pain 128 7.3 Reliability of Symptoms Elicited by Two Experienced Clinicians 131 7.4 Validity of Histories of Rotator Cuff Lesions 131 7.5 Inter-Rater Reliability of Shoulder Range Inclinometry by Physiotherapists and Rheumatologists 132 7.6 Reliability of Physical Signs Elicited by Challenging Restraints 132 7.7 Validity of Physical Signs Elicited by Tests that Challenge Restraints to Shoulder Movement 133 7.8 Validity of Physical Signs of Impingement 133 7.9 Validity of Physical Signs of Rotator Cuff Lesions 133 7.10 Validity of Physical Signs of Biceps Tendon Lesions 134 7.11 Alerting Features of Serious Conditions Associated with Acute Shoulder Pain 134 7.12 Validity of Ultrasonography Versus Arthrography in the Diagnosis of Rotator Cuff Tears as Reported by Several Authors 136 7.13 Validity of Ultrasonography Versus Surgical FIndings in the Diagnosis of Rotator Cuff Tears as Reported by Several Authors 136 7.14 Ultrasonographic Findings of Rotator Cuff Tears in People without Symptoms As Found in Two Studies 136 7.15 Inter-Observer Reliability of MRI in Diagnosis of Rotator Cuff Tears: Kappa Score Ranges Between Five Experienced Radiologists 137 7.16 Validity of MRI Versus Surgical Findings in the Diagnosis of Labral injuries as Reported by Several Authors 137 7.17 Validity of MRI Versus Surgical Findings in the Diagnosis of Rotator Cuff Tears as Reported by Several Authors 138 7.18 MRI Findings of Rotator Cuff Tears in 96 People Without Symptoms 138 7.19 MRI Findings of Rotator Cuff Tears in 100 People Without Symptoms 138 7.20 Prevalence of MRI ‘Abnormalities’ in People With and Without Symptoms 139 7.21 Reliability of Clinical Diagnosis of Shoulder Pain as Shown by Five Studies 140 7.22 Short Term Recovery of Acute Shoulder Pain 141 7.23 Longer Term Recovery of Acute Shoulder Pain 141 7.24 Recovery of Disability Associated with Acute Shoulder Pain 142 7.25 Biological Risk Factors for Shoulder Pain as Shown in Various Reports 143 7.26 Psychosocial Risk Factors for Shoulder Pain as Shown in Various Reports 143 8.1 Potential Causes of Anterior Knee Pain 160 8.2 Prevalence of Conditions Presenting as Anterior Knee Pain 163 8.3 Alerting Features of Serious Conditions Associated with Anterior Knee Pain 165 8.4 Natural History of Patellofemoral Pain: Summary of Study Results 170 9.1 Ideal Study Types for Clinical Questions 184 9.2 Levels of Evidence 184 9.3 Criteria for Categorising Interventions 186 xi Evidence-based Management of Acute Musculoskeletal Pain

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All responsibility for editorial matter rests with Australian Acute Musculoskeletal Pain Guidelines Group. Any views or opinions Musculoskeletal Physiotherapist, Australian Physiotherapy Association. Dr Fiona Blyth. Medical Normality and reliability in the clinical assess- ment of backache.
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cute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute Neck Pain Acute te Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Acute Shoulder Pain Ac Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pa Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pa Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pa Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Pain Acute Thoratic Spinal Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Lo Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Low Back Pain Acute Anterior Knee Pain Anterior Knee Pain AnteriEor KVneeI PDain AEnteNriorC KneEe P-ainB AAnteriSor KEneeD Pain Anterior Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain v Anterior Knee Pain Ant Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior Knee Pain Anterior MANAGEMENT OF ACUTE MUSCULOSKELETAL PAIN Australian Acute Musculoskeletal Pain Guidelines Group APPROVED 5 JUNE 2003 BY THE NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL EVIDENCE-BASED MANAGEMENT OF ACUTE MUSCULOSKELETAL PAIN Australian Acute Musculoskeletal Pain Guidelines Group iii AUSTRALIAN ACADEMIC PRESS PTY LTD Brisbane PARTICIPATION The work is a joint initiative of the University of Queensland and the Commonwealth Department ofHealth 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 necessary when 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 rests with the clinician and the patient and depends on individual circumstances and beliefs (NHMRC 1999). 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 Group. Any 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. iv Contents List of Tables x .......................................................................................................................................................................................................... List of Figures xii ................................................................................................................................................................................................... About the Group: Australian Acute Musculoskeletal Pain Guidelines Group xiii ............................... Chapter 1 (cid:1) Executive Summary 1 ..................................................................................................................................................................................... Rationale 1 ............................................................................................................................................................................................................ Scope 1 ...................................................................................................................................................................................................................... Summary of Findings 2 ..................................................................................................................................................................... Limitations of Findings 2 ................................................................................................................................................................ Summary of Key Messages 2 ................................................................................................................................................. >References 16 ............................................................................................................................................................................................................... Chapter 2 (cid:1) 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 ............................................................................................................................................................................................................... (cid:1) Chapter 3 Effective Communication 23 ........................................................................................................................................................ Communication 23 ................................................................................................................................................................................... Medical Terminology 23 ................................................................................................................................................................. Learning Methods 23 .......................................................................................................................................................................... Factors Affecting Communication 23 ....................................................................................................................... Evidence Review 23 .............................................................................................................................................................................. Research Priorities 24 ....................................................................................................................................................................... >References 24 ............................................................................................................................................................................................................... Chapter 4 (cid:1) 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 ................................................................................................... (cid:2)(cid:1)Alerting Features of Serious Conditions (see Table 4.6) 36 ...................................... >Physical Examination 36 .............................................................................................................................................................................. Physical Assessment 36 ................................................................................................................................................................ Psychosocial Assessment 37 ............................................................................................................................................... Neurological Assessment 38 ................................................................................................................................................. v (cid:1)Contents >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 ............................................................................................................................................................................................................... (cid:1) Chapter 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 .................................................................................................................................................................................................... (cid:2)(cid:1)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 ............................................................................................................................................................................................................... vi (cid:1)Contents Chapter 6 (cid:1) 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 ............................................................................................................................................................................................... (cid:2)(cid:1)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 ........................................................................................................................................................................................................... Chapter 7 (cid:1) 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 ................................................................................................................................................ vii (cid:1)Contents >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 .................................................................................................................................................................. (cid:2)Alerting 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 ........................................................................................................................................................................................................... Chapter 8 (cid:1) 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 ........................................................................................................................................................................................... (cid:2)Alerting Features of Serious Conditions (see Table 8.3) 165 ................................. >Physical Examination 165 ......................................................................................................................................................................... Inspection 165 ................................................................................................................................................................................................ Palpation 165 .................................................................................................................................................................................................... viii (cid:1)Contents 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 .......................................................................................................................................................................................................... Chapter 9 (cid:1) 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 .......................................................................................................................................................................................................... (cid:1) Appendix A Glossary of Terms 189 .................................................................................................................................................................................... (cid:1) Appendix B Table of Unit Costs (November 2002) 191 ............................................................................................................... Appendix C (cid:1) Ancillary Investigations 195 ............................................................................................................................................................... Appendix D (cid:1) Consultation........................................................................................................................................................................................................197 Appendix E (cid:1) Tables of Included and Excluded Studies 199 ............................................................................................... ix (cid:1)List of Tables List of Tables 4.1 Conditions Associated with the Presence of Acute Low Back Pain 33 4.2 Radiological Findings in Patients with Low Back Pain in Primary Care 33 4.3 Prevalence of Spondylosis in Asymptomatic Individuals and Patients with Lumbar Spinal Pain 34 4.4 Prevalence of Disc Degeneration in Asymptomatic Individuals and Patients with Lumbar Spinal Pain 34 4.5 Comparison of Somatic Referred and Radicular Pain 35 4.6 Alerting Features (‘Red Flags’) of Serious Conditions Associated with Acute Low Back Pain 36 4.7 Prevalence of Abnormalities on CT Scan in a Population of Asymptomatic Individuals Aged Between 21 and 80 Years 39 4.8 Prevalence of Abnormalities on MRI Scans of 67 Asymptomatic People 39 5.1 A Systematic Classification of Causes of Acute Thoracic Pain 67 5.2 Aspects of Clinical Presentation for a Series of 442 Patients with Pyogenic Infection of the Spine 68 5.3 Odds Ratios for Incident Fractures of the Thoracolumbar Spine for Back Pain and Disability in Women Over 50 69 5.4 Relative Prevalence of Local Causes of Thoracic Pain 72 5.5 Distribution of Agreement Amongst Four Examiners Concerning the Presence or Absence of Dysfunction in 10 Unmarked Thoracic Spinal Segments in 15 Subjects 73 5.6 Abnormal Palpatory Findings in Examination of Segments T1–8 in 25 Asymptomatic Subjects 74 5.7 Alerting Features of Serious Conditions Associated with Acute Thoracic Spinal Pain 75 5.8 Comparison of the Location of Pain in Patients with Scheuermann’s Kyphosis with Age and Sex Matched Controls 76 5.9 Prevalence of Thoracolumbar Fractures in Patients by Age in 99 Patients with Blunt Trauma Prompting Radiological Investigation 76 5.10 Prevalence of Thoracic Spinal Fractures in Retrospective Studies of Blunt Trauma Victims in Trauma Centres on Whom Thoracolumbar Radiographs Were Performed 76 5.11 Risk Factors for Thoracolumbar Fracture in Patients with Blunt Trauma injuries Admitted to a Trauma Centre 77 6.1 Acute Neck Pain as the Principal Presenting Feature: Possible Causes 90 6.2 Medical, Social and Occupational Risk Factors Shown Not To Be Aetiological Risk Factors for Neck Pain 93 6.3 Medical, Social and Occupational Risk Factors Weakly Associated with Neck Pain 93 6.4 Psychosocial Risk Factors Shown Not To Be Related to Neck Pain 93 6.5 Alerting Features of Potentially Serious Conditions Associated with Acute Neck Pain 96 6.6 Factors Associated with Chronic Neck Pain After Whiplash: Insurance Data 102 x (cid:1)List of Tables 6.7 Demographic and Clinical Factors Associated with Chronic Neck Pain After Whiplash 103 7.1 A Guide to Described Causes of Acute Shoulder Pain 125 7.2 Prevalence Rates of Some Conditions Causing Acute Shoulder Pain 128 7.3 Reliability of Symptoms Elicited by Two Experienced Clinicians 131 7.4 Validity of Histories of Rotator Cuff Lesions 131 7.5 Inter-Rater Reliability of Shoulder Range Inclinometry by Physiotherapists and Rheumatologists 132 7.6 Reliability of Physical Signs Elicited by Challenging Restraints 132 7.7 Validity of Physical Signs Elicited by Tests that Challenge Restraints to Shoulder Movement 133 7.8 Validity of Physical Signs of Impingement 133 7.9 Validity of Physical Signs of Rotator Cuff Lesions 133 7.10 Validity of Physical Signs of Biceps Tendon Lesions 134 7.11 Alerting Features of Serious Conditions Associated with Acute Shoulder Pain 134 7.12 Validity of Ultrasonography Versus Arthrography in the Diagnosis of Rotator Cuff Tears as Reported by Several Authors 136 7.13 Validity of Ultrasonography Versus Surgical FIndings in the Diagnosis of Rotator Cuff Tears as Reported by Several Authors 136 7.14 Ultrasonographic Findings of Rotator Cuff Tears in People without Symptoms As Found in Two Studies 136 7.15 Inter-Observer Reliability of MRI in Diagnosis of Rotator Cuff Tears: Kappa Score Ranges Between Five Experienced Radiologists 137 7.16 Validity of MRI Versus Surgical Findings in the Diagnosis of Labral injuries as Reported by Several Authors 137 7.17 Validity of MRI Versus Surgical Findings in the Diagnosis of Rotator Cuff Tears as Reported by Several Authors 138 7.18 MRI Findings of Rotator Cuff Tears in 96 People Without Symptoms 138 7.19 MRI Findings of Rotator Cuff Tears in 100 People Without Symptoms 138 7.20 Prevalence of MRI ‘Abnormalities’ in People With and Without Symptoms 139 7.21 Reliability of Clinical Diagnosis of Shoulder Pain as Shown by Five Studies 140 7.22 Short Term Recovery of Acute Shoulder Pain 141 7.23 Longer Term Recovery of Acute Shoulder Pain 141 7.24 Recovery of Disability Associated with Acute Shoulder Pain 142 7.25 Biological Risk Factors for Shoulder Pain as Shown in Various Reports 143 7.26 Psychosocial Risk Factors for Shoulder Pain as Shown in Various Reports 143 8.1 Potential Causes of Anterior Knee Pain 160 8.2 Prevalence of Conditions Presenting as Anterior Knee Pain 163 8.3 Alerting Features of Serious Conditions Associated with Anterior Knee Pain 165 8.4 Natural History of Patellofemoral Pain: Summary of Study Results 170 9.1 Ideal Study Types for Clinical Questions 184 9.2 Levels of Evidence 184 9.3 Criteria for Categorising Interventions 186 xi Evidence-based Management of Acute Musculoskeletal Pain

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All responsibility for editorial matter rests with Australian Acute Musculoskeletal Pain Guidelines Group. Any views or opinions Musculoskeletal Physiotherapist, Australian Physiotherapy Association. Dr Fiona Blyth. Medical Normality and reliability in the clinical assess- ment of backache.
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