Shoulder pain in the community: an examination of associative factors using a longitudinal cohort study.

OBJECTIVE: To determine factors that are predictive of incident, recurrent, or resolved shoulder pain in a community-based sample from the general population. METHODS: This study used data from the North West Adelaide Health Study, a cohort study located in the northwestern suburbs of Adelaide, South Australia. Data were obtained between 2004 and 2006 and between 2008 and 2010, with time between measurements ranging from 2-6 years (median 4 years), using a computer-assisted telephone interview, a clinical assessment, and a self-completed questionnaire. Multivariate logistic regression was used to examine the factors associated with shoulder pain. RESULTS: Overall, 14.6% (95% confidence interval [95% CI] 12.7-16.7) of 2,337 eligible participants reported that they had developed (or had incident) shoulder pain between 2 time points of the cohort study, 8.8% (95% CI 7.5-10.3) reported recurrent shoulder pain, and 8.7% (95% CI 7.0-10.6) had resolved shoulder pain. Incident shoulder pain was significantly associated with physically heavier occupational activities and pain in other joints after adjustment for age, sex, and body mass index. Recurrent shoulder pain was also associated with pain in other joints, but also with depressive symptoms, smoking, and decreased shoulder range of movement. Resolved shoulder pain was associated with being female, other areas of pain, and decreased shoulder range of movement, but higher grip strength. CONCLUSION: Different factors were associated with incident, recurrent, or resolved shoulder pain in a longitudinal cohort study. Consideration of all of these factors may assist in the prevention and management of shoulder pain and the possible identification of those at risk of long-term shoulder problems.

Impact of the new national health standard for rail safety workers on ischaemic heart disease risk factors in train drivers.

BACKGROUND: In 2004, a compulsory National Standard for the Australian rail industry was introduced outlining health standards that drivers must meet to be deemed fit to drive. AIM: To examine the trend in ischaemic heart disease (IHD) risk factors in train drivers between 2004 and 2009, following the introduction of a National Standard. METHODS: A retrospective analysis of IHD risk factors of drivers (n = 386) of an Australian train company, who underwent health assessments between February 2004 and November 2009, was performed. The Framingham Score for 10-year risk of coronary artery disease, body mass index (BMI), cigarette smoking, diabetes, systolic and diastolic blood pressure, high-density lipoprotein (HDL), low-density lipoprotein and total cholesterol were compared with that of controls at these two time periods. RESULTS: There were significant reductions in the rates of 10-year coronary heart disease risk/year (OR = 0.47; 95% CI 0.19, 0.75) in the train drivers compared with the control population. This was driven by a reduction in the rate of cigarette smoking (OR = 0.87; 95% CI 0.79, 0.96) and total cholesterol (OR = -0.05; 95% CI -0.09, 0.003) and an increase in HDL cholesterol levels (OR = 0.02; 95% CI 0.006, 0.03) between groups over time. This was despite an increase in BMI (OR = 0.10; 95% CI 0.01, 0.19). CONCLUSION: Following the introduction of a National Standard for drivers in Australia, there has been a significant improvement in the health of drivers. Such a programme may have a significant impact in this group of safety critical workers.

Prevalence and correlates of shoulder pain and stiffness in a population-based study: the North West Adelaide Health Study.

AIM: To determine the prevalence, correlates and impact of shoulder pain in a population-based sample. METHODS: The North West Adelaide Health Study is a representative longitudinal cohort study of people aged 18 years and over. The original sample was randomly selected and recruited by telephone interview. Overall, 3206 participants returned to the clinic during the second stage (2004-2006) and were asked to report whether they had pain, aching or stiffness on most days in either of their shoulders. Data was also collected on body mass index; shoulder range of motion, lifestyle and socioeconomic factors; the Shoulder Pain and Disability Index and the Medical Outcomes Study Short Form 36 (SF36) was used. RESULTS: Overall, 22.3% of participants indicated that they had pain, aching or stiffness in either of their shoulders. Women, those aged 50 years and over, current smokers and those classified as obese were all significantly more likely to report shoulder pain. Respondents with shoulder pain scored lower on all domains of the SF36. In those with shoulder symptoms, women had more severe pain and worse shoulder function than men, and older people had worse shoulder function than younger people. CONCLUSION: Shoulder pain affects almost a quarter of people in the Australian community, with a significant detrimental impact on health-related quality of life and physical functioning.

Engaging medical students in occupational and environmental medicine--a new approach.

BACKGROUND: For a number of reasons, engaging the interest of medical students in the discipline of occupational and environmental medicine (OEM) can be challenging. AIMS: To renew a curriculum in OEM within a graduate medical programme with an emphasis on student involvement to maximize their interest in the topic. METHODS: A second year student cohort of a 4 year graduate medical programme was surveyed as to their preferences for the content of a short course of OEM embedded in their medical course. The course was extensively rewritten as a result of the student survey, with a number of topics deleted from the old course and new topics added. In order to validate the content of the new course, local occupational physicians (OPs) were also surveyed as to their opinion of an appropriate curriculum in OEM for medical students. The new course was taught to the subsequent cohort of second year medical students. The students' ratings of the course pre- and post-revision were compared. RESULTS: The student satisfaction rates of the course significantly improved as a result of the changes. The content of the student-led curriculum was strikingly similar to the course proposed by the local OP with a few key exceptions. CONCLUSIONS: Student involvement in curriculum design in OEM is entirely feasible. It can result in a curriculum similar to that designed by expert opinion but has the advantage of strongly engaging student interest.

Does leisure time physical activity protect against shoulder pain at work?

BACKGROUND: Shoulder pain is a common problem that can impact on work. Leisure time physical activity (LTPA) has the potential to reduce the impact of shoulder pain through its physiological, psychological and social benefits. AIMS: To determine whether LTPA reduces the prevalence of shoulder pain in a working population. METHODS: Participants were selected from a longitudinal population-based cohort study, the North West Adelaide Health Study. Information was gathered by questionnaire on LTPA, smoking, depression and socio-economic factors. Body mass index was measured in a clinic setting. Occupational physical activity (OPA) estimated by job title and shoulder pain was measured using the Shoulder Pain and Disability Index. Workers with and without shoulder pain were compared using logistic regression analysis. RESULTS: Of the 1502 working participants, 16% reported having current shoulder pain. Shoulder pain was associated with older age (OR 1.98, 95% CI: 1.31-2.99) (age >50 years), smoking (OR 1.44, CI: 1.02-2.04), secondary-level educational attainment (OR 1.68, 95% CI: 1.07-2.65), high body mass index (BMI) (OR 1.54, 95% CI: 1.14-2.08) and depression (OR 2.42, 95% CI: 1.60-3.64). There was no effect of LTPA on shoulder pain. CONCLUSIONS: In this community-based cohort, there was no statistically significant association seen between LTPA, OPA and shoulder pain. There was, however, an association between smoking, BMI, secondary-level education, depression and shoulder pain. These modifiable factors may be better targets for preventive efforts than LTPA to reduce the risk of shoulder pain.

Influence of rheumatoid arthritis on work participation in Australia.

BACKGROUND: The aim of the study was to determine the prevalence of work disability in a cohort of Australians with rheumatoid arthritis. METHODS: A cross-sectional study of a sample of 497 individuals aged 18-65 years with rheumatoid arthritis in Adelaide, South Australia, was carried out. RESULTS: Of those employed, 130 (51%) were in full-time employment (> or= 35 h per week) work and 124 (49%) were in part-time employment (average 20 h per week). Overall, the observed/expected numbers working were 254/316 (relative risk 0.8 (0.69-0.91)). Using a comparator adjusted by removing those on the disability support pension, the relative risk of the working was 0.74. The observed/expected numbers working part time in the study group were 124/89 (relative risk 1.4 (1.25-1.65)). Those who continued to work had lower Health Assessment Questionnaire scores, less morning stiffness, superior scores for patient assessed level of function, lower pain scores, lower joint counts, a lower C-reactive protein, better measures of 'patient global assessment' and higher levels of education compared with the group who had ceased work. Overall, of those working at the time of diagnosis, 20% had ceased work within 5 years and approximately 40% had ceased work by 20 years. Of those who ceased work, the mean duration from time of diagnosis to work cessation was 7 years with half the subjects who ceased work doing so within 4 years of diagnosis. CONCLUSION: Work disability associated with rheumatoid arthritis in Australia is very significant and costly. Work disability occurs relatively early in the disease and is associated with several identifiable variables, many of which may be amenable to intervention strategies.

The effect of rheumatoid arthritis on personal income in Australia.

BACKGROUND: The aim of this study was to estimate the effect of rheumatoid arthritis (RA) on the personal income of a cohort of individuals with RA in Australia. METHODS: A cross-sectional study of a sample of 497 working age people with RA in Adelaide, South Australia was carried out. RESULTS: The average personal income of an individual with RA in our cohort in 2003-2004 was $A22 400 compared with the Australian mean annual income of $A38 000. When standardized, the income of our cohort was 66% that of the average income of the Australian population. Overall one-third of the RA cohort relied principally on the social security system for their income and more than 75% of the cohort estimated they had lost greater than $A10 000 per annum in personal income as a result of their disease. Individuals with RA who were not working had annual incomes on average of more than $A20 000 less than those who continued to work. CONCLUSION: The personal income loss associated with RA in Australia is of enormous significance. It reduces a large population of individuals to relative financial poverty and potentially limits their access to a range of services including private health services.

Medical aspects of fitness to drive. What do public hospital doctors know and think?

BACKGROUND: In Australia medical practitioners are often required to assume the responsibility for assessing fitness to drive. However the clinical practice, knowledge and attitudes of doctors with regards to this responsibility are unknown. The aim of this study was to determine the clinical practice, knowledge and attitudes of public hospital doctors in the area of fitness-to-drive decision-making. METHODS: A survey of public hospital doctors in Adelaide, South Australia was undertaken in 2003, shortly after the promulgation nationwide of guidelines to assist in the assessment of patients' fitness to drive. The survey sought details on medical practitioners' clinical practice in this regard, as well as their knowledge of the guidelines. In addition, it sought their attitudes to undertake this responsibility. RESULTS: Eighty-four per cent of respondents had at some time in their working career at least discussed the issue of fitness to drive with their patients. Seventy per cent acknowledged that they had received the recently published guidelines on fitness to drive. Despite this, knowledge of the contents of the guidelines was poor. Attitudes to the responsibility were equivocal with several significant reservations expressed. CONCLUSION: Public hospital doctors in Australia have poor knowledge of the content of published guidelines in the area of fitness to drive. If this situation is to be improved, alternative approaches to the education of this group with respect to this significant public health problem should be considered. Many doctors are uncomfortable with their responsibilities in this area and alternative models of decision-making should be considered.

Suprascapular nerve block in chronic shoulder pain: are the radiologists better?

BACKGROUND: Suprascapular nerve block is a safe and effective treatment for chronic shoulder pain in arthritis, which can be performed either by direct imaging (CT guided) or in the clinic using anatomical landmarks to determine needle placement. OBJECTIVE: To compare a CT guided versus an anatomical landmark approach in a randomised, single blind trial examining the efficacy of suprascapular nerve block for shoulder pain in patients with degenerative joint/rotator cuff disease. METHODS: 67 patients with chronic shoulder pain from degenerative disease participated in the trial. 77 shoulders were randomised. The group randomised to receive the block through the anatomical landmark approach received a single suprascapular nerve block. Those in the CT guided group received an injection of methylprednisolone acetate and a smaller volume of bupivacaine around the suprascapular nerve. The patients were followed up for 12 weeks by a "blinded" observer and reviewed at weeks 1, 4, and 12 after the injection. RESULTS: Significant improvements were seen in all pain scores and disability in the shoulders receiving both types of nerve block, with no significant differences in the improvement in pain and disability between the two approaches at any time. Improvements in pain and disability scores were clinically and statistically significant. No significant adverse effects occurred in either group. Patient satisfaction scores for pain relief using either approach were high. CONCLUSION: The CT guided control and landmark approaches to performing suprascapular nerve blocks result in similar significant and prolonged pain and disability reductions; both approaches are safe.

Suprascapular nerve block (using bupivacaine and methylprednisolone acetate) in chronic shoulder pain.

BACKGROUND: Shoulder pain from inflammatory arthritis and/or degenerative disease is a common cause of morbidity in the community. It is difficult to treat and there are limited data on the efficacy of most interventions. Suprascapular nerve block has shown promise in limited trials in reducing shoulder pain. There have been no large randomised placebo controlled trials examining the efficacy of suprascapular nerve block for shoulder pain in arthritis and/or degenerative disease using pain and disability end points. OBJECTIVE: To perform a randomised, double blind, placebo controlled trial of the efficacy of suprascapular nerve block for shoulder pain in rheumatoid arthritis (RA) and/or degenerative disease of the shoulder. METHODS: 83 people with chronic shoulder pain from degenerative disease or RA took part in the trial. If a person had two painful shoulders, these were randomised separately. A total of 108 shoulders were randomised. Patients in the group receiving active treatment had a single suprascapular nerve block following the protocol described by Dangoisse et al, while those in the other group received a placebo injection of normal saline administered subcutaneously. The patients were followed up for 12 weeks by an observer who was unaware of the randomisation and reviewed at weeks 1, 4, and 12 after the injection. Pain, disability, and range of movement data were gathered. RESULTS: Clinically and statistically significant improvements in all pain scores, all disability scores, and some range of movement scores in the shoulders receiving suprascapular nerve block compared with those receiving placebo were seen at weeks 1, 4, and 12. There were no significant adverse effects in either group. CONCLUSION: Suprascapular nerve block is a safe and efficacious treatment for the treatment of shoulder pain in degenerative disease and/or arthritis. It improves pain, disability, and range of movement at the shoulder compared with placebo. It is a useful adjunct treatment for the practising clinician to assist in the management of a difficult and common clinical problem.

The effect of treatment on radiological progression in rheumatoid arthritis: a systematic review of randomized placebo-controlled trials.

OBJECTIVE: To undertake a systematic review of randomized placebo-controlled trials to assess and rank the efficacy of pharmacological interventions in preventing radiological progression of rheumatoid arthritis. METHODS: The two outcome measures were the weighted standardized mean difference and the odds of progression of X-ray scores pooled as close to 12 months as possible to minimize heterogeneity. RESULTS: A total of 38 trials were identified. Of these, 13 were excluded, leaving data on 3907 subjects. Infliximab, cyclosporin, sulphasalazine, leflunomide, methotrexate, parenteral gold, corticosteroids, auranofin and interleukin 1 receptor antagonist were statistically better than placebo in terms of change in erosion scores. All agents were equivalent statistically, with the exception of infliximab (which was superior to the last five agents). There were similar findings for the odds of progression, with the exception of auranofin (P=0.06) and the infliximab-methotrexate comparison (P=0.07). Other agents did not reach statistical significance in either outcome measure. With the exception of the antimalarials, the magnitude of the effect was consistent with the effect seen in short-term disease activity trials. CONCLUSION: There is published evidence which supports the efficacy of nine agents in decreasing radiological progression in rheumatoid arthritis.

Teaching clinical skills in musculoskeletal medicine: the use of structured clinical instruction modules.

OBJECTIVE: To assess student evaluation, satisfaction, and examination outcomes for a new method of teaching musculoskeletal (MSK) medicine clinical skills, structured clinical instruction modules (SCIM), and to compare with the outcomes of a traditional method of teaching clinical skills (small group bedside tutorials). METHODS: Year 2 students in a 4 year graduate medical school were taught using the method of bedside senior registrar teaching, supplemented by outpatient attendances in 1997 and by SCIM in 2000. All students in 1997 and 2000 were debriefed at the end of each unit of clinical skills teaching for student feedback on their teaching experience using a standardized questionnaire. At the end of the academic year, all students underwent an objective structured clinical examination (OSCE) in clinical skills that included rheumatology (hand examination) and orthopedic surgery (knee examination) stations. The effect of the method of teaching on the students' performance in the rheumatology (hand) and orthopedic surgery (knee) stations was analyzed. RESULTS: Sixty-seven students were taught clinical skills and completed the OSCE in 1997 and 78 students were taught clinical skills by SCIM and completed the OSCE in 2000. The teaching of orthopedics using traditional methods was poor, but there was no difference in satisfaction between traditional methods of teaching and SCIM for orthopedic surgery and rheumatology. There was no statistically significant difference in the performance of students in the hand OSCE stations in 2000 compared to the same station in 1997. There was a small but statistically significant difference in the performance of students in 1997 and 2000 in the knee station, the 1997 students performing better in this station. CONCLUSION: The SCIM is an effective method of teaching clinical skills in MSK medicine, comparable with patient partners and traditional registrar based bedside teaching methods, but it is less resource intensive.

The teaching of occupational and environmental medicine to medical students in Australia and New Zealand.

All the medical schools in Australia and New Zealand were surveyed in order to determine the amount of teaching devoted to occupational and environmental medicine in the medical courses in 1998. A 100% response rate was achieved. The results showed that the number of hours devoted to these topics varied widely, but averaged 12.8 h and 10.5 topics. The most significant factor accounting for the variability was the presence on the universities' teaching staff of individuals trained in the practice of occupational medicine. While our findings show a greater time devoted to these topics than those of similar studies in the United States and Britain, the absolute time remains small when compared with the prevalence of occupational medicine problems in the community. There is little congruence in terms of both content and assessment processes between schools.

Evaluation of patient partners in the teaching of the musculoskeletal examination.

OBJECTIVE: To evaluate student preferences and examination outcomes of 2 different methods of teaching musculoskeletal (MSK) medicine examination techniques. METHODS: Year 2 students in a 4 year graduate medical school were randomized to 3 teaching groups: students in Group 1 were taught by rheumatology fellows, Group 2 by patient partners, while group 3 were randomly allocated to either patient partner (3A) or rheumatology trainee (3B) teaching. All students were debriefed at the end of each teaching block of 4 weeks for feedback on their teaching experience using a standardized questionnaire. In addition, at the end of the academic year, all students sat an objective structured clinical examination (OSCE) in clinical skills that contained a rheumatology station. The effect of method of teaching on students' performance in the rheumatology station was analyzed. RESULTS: Eighty medical students participated in the study. Overall, there was no difference in student ratings of either mode of teaching, although the students reported that patient partner teaching gave more opportunity to practice MSK examination skills and also provided greater feedback to the student. Students reported a preference for rheumatology trainee teaching because they believed the teaching would be more relevant to the content of the examination. There was no statistically significant difference in the performance of the students in the OSCE rheumatology station in regard to the mode of teaching they had received prior to the examination. CONCLUSION: Patient partner teaching is as effective a method of teaching clinical skills in MSK medicine as a traditional resident based form of teaching, with student benefits from patient feedback and greater "hands-on" opportunities. The assessment process should incorporate patient partners to assess the unique aspects of patient educator based teaching of MSK examination techniques.

Radiology of intervertebral cages in spinal surgery.

This pictorial essay reviews the normal appearances and the post-operative complications of intervertebral cages. These are implants which are being more widely used in spinal surgery. The text outlines the background leading to their development, the clinical indications and surgical techniques for insertion of the cages. The normal post-operative appearance of fusion and the complications that can occur are emphasized.

High level transcription of the complement regulatory protein CD59 requires an enhancer located in intron 1.

CD59 is a complement regulatory protein and may also act as a signal-transducing molecule. CD59 transgenic mice have been generated using a CD59 minigene (CD59 minigene-1). Although this minigene contained a 4.6-kilobase pair 5'-flanking region from the human CD59 gene as a promoter, the expression levels of the CD59 mRNA were substantially lower than those observed in humans, suggesting that CD59 gene expression might also require other transcriptional regulatory elements such as an enhancer. To investigate the transcriptional regulation of the CD59 gene, we used three cell lines that express CD59 at different levels. We have identified DNase I-hypersensitive sites in intron 1 in HeLa cells, which express CD59 at high levels, but not in Jurkat (intermediate level) or Raji cells (low level). Furthermore, cell line-specific enhancer activity was detected in a fragment containing these DNase I-hypersensitive sites. The CD59 enhancer was mapped to between -1155 and -888 upstream of the 5'-end of exon 2. To investigate the enhancer activity in vivo, a new CD59 minigene was constructed by the addition of the enhancer fragment into CD59 minigene-1. High expressor CD59 transgenic mice were generated using the new minigene.