Proceedings of Singapore Healthcare

Volume 19 Number 3 2010
Musculoskeletal (Orthopaedic) and Sports Medicine Issue

EDITORIAL
Of Growth Factors and Snake Oils
Lie D, Shyamla N, Tan TY, Wong WP

ORIGINAL ARTICLE
Low Back Pain in Changi General Hospital: An Observational Study
Goh MR, Po IYY, TH, Olafsdottir K

Abstract
Aims: The aim is to study the profile of local low back pain (LBP) patients and their physiotherapy management in an outpatient physiotherapy clinic.

Methods: A retrospective study was done with records of LBP patients attending the Musculoskeletal
Physiotherapy Clinic at Changi General Hospital from January to June 2009. Age, LBP onset, occupation, time off work, investigation results, and functional outcomes were obtained.

Results: Ninety-four records were screened. Majority of patients (59.6%) were aged between 30-50 years old. Sixty-six percent were engaged in occupations that involved sustained postures. Majority of patients (91.5%) had minor/no trauma in association to the onset of their symptoms. Although majority of patients (64.9%) did not take any time off work to manage their LBP, a total of 640 days were lost off work due to LBP. Majority of patients (93.6%) underwent radiological investigations. There was no significant correlation between radiating symptoms and presence of nerve root compression on MRI (p = 0.144). In addition, pathology did not significantly impact on rehabilitative outcome in our sample (p = 0.397, p = 0.602). A review of clinical practice with regards to ordering radiological investigations may be required to minimise radiation exposure and increase cost effectiveness. Patients improved from a mean of 4.00 to 9.10 on the Patient Specific Functional Scale (PSFS) within an average of 3.65 sessions. There was a significant relationship between earlier onset of therapy and better functional improvement on the PSFS (r= -0.299, p = 0.026). Starting a physiotherapy service in our accident and emergency department may be a good consideration to implement in our hospital.

Conclusions: Sustained postures may contribute to LBP in local patients. Disability and time lost off work as result of LBP appears to be a significant problem locally. Radiology has no correlation with symptoms, nor rehabilitative outcomes. Pathology may have only limited value in determining treatment or prognosis in nontraumatic LBP. A tailored physiotherapy approach towards education, manual therapy and exercises may be effective in improving functional capabilities in local LBP patients. Earlier onset of physiotherapy is associated with better functional recovery in LBP patients.

Keywords: lumbopelvic pain, epidemiology, radiological correlation ends

The Role of Resistance Training in Distance Running
Tan P

Abstract
Isolated The main determinants of distance running performance include V · O2max, lactate threshold (LT), and running economy (RE). The conventional way to achieve improvements in these areas is through endurance training due to the principle of training specificity. Some physiologists believe that the addition of resistance training is beneficial to distance running in the form of injury prevention and preparing runners for pace surge and sprintfinishes. To date, it is consistent among findings that resistance training does not improve nor compromise V ·O2max in trained distance runners while LT improvements are only found in untrained individuals. RE has been shown to improve significantly post resistance training possibly due to neuromuscular changes including a shortening of the stretch-shortening cycle and an increase in muscle stiffness. The primary purpose of this review is to understand the impact of resistance training on the various factors known to affect distance running performance and to recommend resistance training guidelines for the distance runner to adhere to.

Keywords: endurance running, plyometrics, running economy, strength/power training

Spinal Cord Stimulation for the Treatment of Intractable Pain from Failed Back Surgery Syndrome
Pasutharnchat K, Ho KY

Abstract
Introduction: Failed back surgery syndrome (FBSS) is a debilitating chronic neuropathic pain condition, affecting approximately 10-40% of patients after lumbosacral spine surgery. Treatment of FBSS is challenging as conservative therapies and repeat surgery often fail in providing adequate pain relief. Spinal cord stimulation (SCS) has been proven to be a successful therapeutic option in FBSS patients.

Case Report: A 23 year-old male presented with persistent low back pain and bilateral radicular pain after spinal surgery. He was also wheelchair-bound because of his severe pain. Conservative treatment with oral analgesics and interventional pain procedures were unsuccessful in improving his pain. Subsequently, we performed a permanent implantation of epidural leads for SCS after a successful trial of SCS. He reported good coverage of pain without complications after the procedure. Three months after surgery, and after intensive physiotherapy and rehabilitation, he could walk and return to work.

Conclusion: We describe our first successful case of treating intractable pain from FBSS in a patient after implantation of SCS leads in our institution.

Keywords:failed back surgery syndrome, intractable, low back pain, spinal cord stimulation

Cross-sectional and Longitudinal Validity of the Hughston Clinic Knee Questionnaire in Arthroscopic Meniscal Repair
Pua YH, Lim CK

Abstract
Aim: To examine the cross-sectional and longitudinal convergent and discriminant validity and the sensitivity to change of the Hughston Clinic Knee Questionnaire (HCQ) in young adults with meniscal repair.

Method: Seventeen young adults completed the HCQ and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) at 1 week and at 6 weeks after an arthroscopic meniscal repair. Convergent validity was assessed by evaluating the correlation between the HCQ and the SF-36 physical function subscale. Discriminant validity from pain measure was assessed by examining the HCQ with the physical function and bodily pain subscales of the SF-36. Sensitivity to change was assessed using standardised response means. Spearman correlation coefficients were also calculated.

Results: The HCQ showed moderate to strong cross-sectional and longitudinal convergent validity with the SF-36 physical function subscale; however, discriminant validity was not evident for the HCQ. The HCQ showed a larger standardised response mean than did the SF-36 physical function subscale.

Conclusion: Cross-sectional and longitudinal convergent — but not discriminant — validity was established for the HCQ. Although the HCQ was more adept in detecting change scores than did the SF-36 physical function subscale, the reason for this finding was unclear.

Keywords: construct validity, Hughston Clinic Knee Questionnaire, knee, measurement, outcome

Full text of article

Inguinal Hernias: A Current Review of an Old Problem
Chiow AKH, Chong CK, Tan SM

Abstract
The repair of groin hernias are amongst the most commonly performed procedures by the general surgeon today, with almost as many types of repairs as there are hernias.
Inguinal hernias account for 75% of all abdominal wall hernias with a lifetime risk of 27% in men and 3% in women1. Repair techniques have evolved from open suture methods to mesh repairs done either open or laparoscopically, translating to improved patient care and decreasing complications associated with hernia repair.
This article is intended to provide an overview of the presentation and latest evidence based guidelines for the management of inguinal hernias.

Keywords: repair, groin hernia, technique

Full text of article

REVIEW
Community-associated Methicilin-resistant Staphylococcus aureus Skin and Soft Tissue Infections
Wijaya L, Li YH

Abstract
The prevalence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections is increasing globally and in Singapore. Skin and soft tissue infections (SSTIs) are the most common manifestations, ranging from common furuncles to the rare but life-threatening necrotizing fasciitis. Surgical drainage and debridement where feasible are the mainstay of therapy, whereas MRSA-active antibiotics are essential when surgery is not possible or as adjunctive therapy for severe and/or complicated SSTIs. In itself, the continued inexorable rise in CA-MRSA rates poses difficult challenges for primary healthcare and hospital infection control.
Innovative approaches are required to mitigate its impact in both the community and hospital settings.

Keywords: Hygiene, cutaneous abscess, necrotizing fasciitis, antimicrobial susceptibility, linezolid

Pseudosarcomatous Soft Tissue Lesions
Ng V WL

Abstract
Pseudosarcomatous soft tissue lesions are potential pitfalls to both clinicians and pathologists due to their clinical presentation, resemblances to malignant lesions and their rarity. They also have a wide range of differential diagnosis histologically due to their relatively non-specific morphology and natural history of evolving features. The difficulty can be exacerbated by samples obtained from curettings or small biopsies as the architecture of the lesion is very helpful in pointing to the correct diagnosis. Familiarity with these entities is needed to avoid misdiagnosis and unnecessarily radical surgery. Despite recent advances in immunohistochemistry and genetic studies, their diagnosis still rest primarily on a combination of clinical history, radiological findings and histologic morphology.

Keywords: pitfall, pseudosarcomas, reactive

Full text of article

Autologous Growth Factors: A Biological Treatment in Sports Medicine
Leong DKC,Tan BCL,Chew KTL

Abstract
Autologous growth factors have been used in maxillofacial and plastic surgery since the 1990s. The use of preparations rich in growth factors has seen an increase in sports medicine is due to its potential to enhance muscle, tendon, ligament and cartilage healing, and thereby accelerating an athlete’s functional return to play. The efficacy of these autologous preparations rich in growth factors has seen varying healing effects for ligament, tendon, muscle, and cartilage injuries. Current clinical evidence is in its infancy with mainly animal and retrospective human studies, but the use of preparations rich in growth factors has increased, given its favourable safety profile and efficient preparation and delivery systems. It is important for physicians to keep abreast with the latest available preparation devices and current clinical evidence looking into the effects of autologous growth factors on tendon, ligament, muscle and cartilage healing.

Keywords: blood injection therapy, conditioned plasma, ligament, muscle and cartilage healing, platelet-rich plasma, tendon

Dietary Supplements Used in Osteoarthritis
Tan AB, Liew A

Abstract
Osteoarthritis (OA) is the most common form of arthritis and is associated with a high economic burden. Conventional pharmacologic agents are limited by their inability to alter disease progression and are associated with an adverse safety profile. A number of dietary supplements are marketed for treatment of OA. Glucosamine is one of the most commonly used supplements for OA and most research suggests that glucosamine sulfate can improve symptoms of pain related to OA, as well as slow disease progression in patients with OA of the knee. Chondroitin sulphate (CS) also appears to reduce OA symptoms and there is some evidence that CS may have a role as a structure-modifying agent in the management of patients with knee OA. Several other supplements are promoted for treating OA, such as methylsulfonylmethane, Perna canaliculus (green-lipped mussel), Zingiber officinale (ginger), Harpagophytum procumbens (devil’s claw), Curcuma longa (turmeric), and Boswellia serrata (frankincense), but more evidence regarding long-term efficacy or safety are required.

Keywords: arthritis, nutritional, herbal

CASE REPORT
The Hazards of Total Knee Arthroplasty: A Case Report in Illustration
Puah KL,Chin PL, Lo NN

Abstract
Infections and periprosthetic fractures are uncommon but dreaded complications of total knee arthroplasty which carry attendant morbidity and prolonged hospitalization and necessitate repeat surgery. We present a patient with a total knee arthroplasty who had both intra-operative and post-operative periprosthetic fractures who subsequently developed infection of the prosthesis necessitating revision surgery. This was complicated too by positive intra-operative tissue cultures. The clinical course, presentation and management are discussed.
Total knee arthroplasty is a frequently performed and successful operation and its complications are challenging to address and require early recognition by the surgeon with appropriate referral to a dedicated arthroplasty surgeon as needed.

Keywords: infection, periprosthetic fractures, revision surgery, total knee arthroplasty

Histological Specimens from Intravenous Drug Abusers (IVDA)
Poh WT

Abstract
Drug addicts using the injection mode for drug delivery often suffer from complications relating to non-sterile needle pricks besides unintentional effects of the drugs such as anaphylaxis and other organ damage. Non-sterile injections lead to infections of all kinds, most common being viral such as Hepatitis B & C and HIV infections; besides the usual bacterial and fungal infections. The evidence for this habit however, resides in the inert fillers they inject into their bodies together with the drug. Particles phagocytosed by macrophages in the body constitute permanent evidence of their past demeanor. The present write-up serves to illustrate the presence of injected crystalline material in various organs/tissues of 3 living subjects as seen at routine diagnostic histology in a regional acute hospital. The findings at autopsies of those who die from illicit drug abuse are well documented in the forensic literature1.

Keywords: IVDA, heroin, ketamine, subutex, birefringent particles, transbronchial lung, groin nodes, muscle necrosis

Effectiveness of Symptom Guided Therapeutic Approach in Treating Discogenic Pain with Radiculopathy Using a Combination of Directional Preference Exercises, Mobilization and Neural Mobility Exercises
Augustine J

Abstract
Researchers have reported various therapeutic approaches to treat patients with low back pain. The mechanical diagnosis and therapy as proposed by McKenzie, has been shown to be effective in diagnostic, therapeutic and prognostic inference. Most often, the treatment options considered in these studies was directional preference exercises and manual procedures utilising movement and positions. But the effectiveness of symptom guided therapeutic approach in treating discogenic low back pain with radiculopathy using directional preference exercises, mobilization and neural mobility exercises is unknown. A case of a forty three-year-old male presenting with discogenic low back pain along with radiculopathy was assessed with McKenzie approach. Appropriate treatment strategy was selected and prescribed based on the initial assessment. The patient was re-evaluated each session, and treatment modification was made according to his symptom presentation during each visit. He proved to be symptom free after seven visits. This could have been due to disc regression and enhanced neural mobility obtained due to treatment. This case report demonstrates the effectiveness of symptom guided therapeutic management to treat patients with discogenic low back pain along with radiculopathy using appropriate treatment strategies. Finally, the report summarizes the treatment offered and discusses the possible explanation of the specific treatment strategies implemented.

Keywords: Disc herniation; Treatment approach; Discogenic back pain; Radiating pain; Exercises

IMAGING
Association of Patent Ductus Arteriosus with Tetralogy of Fallot
Koh AS, Tan JL

Abstract
In adults, patent ductus arteriosus (PDA) is usually an isolated lesion. We describe a case of an adult male patient with a residual PDA after repair of Tetralogy of Fallot (TOF) in childhood.

Keywords: congenital heart disease, Tetralogy of Fallot, patent ductus arteriosus

LABORATORY INSIGHTS
Bone Turnover Markers
Yap CYF, Aw TC

Abstract
Bone turnover markers (BTM) provide useful data to titrate the optimal dosing regimes for patients within 3–6 months as compared to 1–2 years using bone mineral density (BMD). Serum obtained under standardised conditions (fasting, early morning) should be tested using a precise automated immunoassay for a panel of bone markers that includes a resorption marker — C-terminal cross-linked telopeptide of bone collagen (CTX) — and formation markers — Procollagen Type 1 N-terminal Propeptide (P1NP) and Osteocalcin (OC).

Keywords: Bone Turnover Markers (BTM), Bone Mineral Density (BMD), C-terminal cross-linked telopeptide of bone collagen (CTX), Osteocalcin (OC), Procollagen Type 1 N-terminal Propeptide (P1NP)

STATISTICS
The Correct Interpretation of Confidence Intervals
Tan SH, Tan SB