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This chapter reviews ways in which chronic pain has been measured in epidemiological studies. It summarizes a simple approach which emphasizes the need for core standard definitions to describe pain presence and persistence, i.e., a discussion of the principles underlying work on a core definition of back pain and how they might be rolled out to epidemiological definitions of chronic pain generally.

Social marketing (also known as public health interventions/campaigns, public education campaigns, and mass media campaigns) involves the systematic application of marketing along with other concepts and techniques to achieve specific behavioural goals for the social good. This is increasingly used to prevent and manage various health conditions, based on the premise that targeting the health or well-being of the population as a whole has the advantage of potentially modifying the knowledge or attitudes of a large proportion of the community simultaneously, thereby providing social support for behavioural change. This chapter describes a social marketing campaign — a mass media intervention that took place in the Victorian state of Australia from 1997 to 1999. This 3-year campaign entitled Back Pain: Don't Take It Lying Down, came about in response to a significant rise in workers' compensation costs for back-pain claims which had tripled over the previous decade. The chapter also describes the results of similar interventions for back pain that have now been undertaken in other settings. It explores the strong rationale for using a social marketing approach to shift population beliefs about back pain, and discusses the advantages of changing a population's perspective on pain compared with more targeted interventions. It concludes with some considerations that may be helpful in planning and evaluating future social marketing campaigns targeting population perceptions about pain.

This chapter discusses the epidemiology of pain in children. It summarizes key data in the field, focusing on three of the most common childhood pains: low back pain, abdominal pain, and headache. It also considers potentially modifiable risk factors.

To become relevant from a population and social medicine perspective, a chronic disorder and its implications and consequences must become clinically or otherwise visible, interfere with social roles and relations, impact on social institutions, and/or elicit organized responses from the health care, social, and/or welfare system. This chapter presents and discusses a limited number of variables characterizing the social implications and consequences of chronic pain. It covers the predicament of chronic pain, using the example of back pain; classifying the impact of chronic pain; and the consequences of the chronic pain syndrome with population impact, using back pain as the example.

Musculoskeletal disorders are a very common and distinct form of injuries affecting the musculoskeletal system in that they develop over a period of time with repeated strain, usually due to adverse ergonomic factors. They are chronic rather than acute and affect muscles, nerves, joints and connective tissues such as tendons and ligaments, but not bone. Chronic low back pain is most common and in one study 15 to 30% of subjects in one study had back pain at the time of interview and up to 70% had it over the course of their lifetime. Musculoskeletal disorders can be very painful and may limit a worker's ability to work and to conduct the normal activities of life, especially if they involve the hands and back. Chronic pain syndrome is a condition in which the pain continues long after the injury and sometimes gets worse. Repetitive strain injury is a class of musculoskeletal disorders that are caused by numerous repeated movements of an intrinsically weak body part, causing strain, inflammation and often swelling, which results in chronic discomfort and pain and loss of function. This category of disease includes tension neck syndrome, tendonitis and tenosynovitis and nerve and blood vessel disorders. Psychological factors play an important role in the response to and recovery from musculoskeletal disorders.

The chapter reports a study that provided an opportunity to examine the impact of voluntary control over facial activity on the response to painful events. It specifically examines the relationship between the spontaneous facial reaction of patients during a painful physical manipulation, administered in the course of a standard physiotherapy examination, with the reaction of the same people when they were requested to (1) mask the facial expression during the same painful movement and (2) pose an expression of painful distress. The study clearly indicated that facial activity reflected lower back pain exacerbated by physical manipulations of the leg. Self-report of pain on several scales confirmed that the physical manipulations could be described legitimately as painful. Some features of studies subsequent to the reprinted paper are also described, namely voluntary control of pain expression.

Recent years have seen a shift in the perception of communication skills from being considered subjective personal traits, to an objective, evidence-based curriculum of skills and techniques. This development was founded on the recognition that core communication skills are identifiable, can be taught, and form the basis of the majority of professional encounters. The core skills required for the patient interview in the MRCP (PACES) examination can be broadly divided into three areas: content skills, process skills, and perceptual skills. The content of the medical interview refers to the information the candidate is attempting to gather, or to give, during the course of the interview. The detail of this content is covered in the subsequent case histories of this book. However, the ability of the candidate to communicate or acquire this content depends largely on the process of the interview, and their perceptual skills. The process of the interview refers to the manner in which the candidate communicates with the patient. Although the candidate’s agenda may be to establish the content of the interview, this will not be successful unless the patient’s agenda in considered. In Stations 2 and 4 of the PACES examination, the candidate is provided with clear written instructions (such as a GP letter), followed by 14 minutes for patient interaction. The candidate then has 1 minute for reflection, followed by 5 minutes of discussion with the examiners. Despite the limited time available in the PACES Stations 2 and 4, the examiners will expect the candidate to develop rapport, show empahty, appropriately use silencce during the interview, and interpret non-verbal cues. Indeed, these processes are the key to obtaining the content of the interview, not just for the examination but also for clinical practice. Perceptual skills refer to the candidate’s decision making, problem solving, and clinical reasoning skills. These are complex, higher-order skills, which reflect the individual’s attitudes, beliefs, and self-perception. Indeed, if the content of the interview reflects the candidate’s ‘knowledge’, and the process of the interview is a reflection of ‘technique’, then these perceptual skills are a demonstration of appropriate ‘behaviour’ or ‘performance’.

Chapter Six is intended for advanced musicians, from college students up to professionals, as well as professors who teach at the college level. For professionals, constant travel and the stress of performance along with long periods of practice without rest can lower the immune system, cause fatigue, and impede performance. These unhealthy behaviors put them at great risk for the development of injury and stress-related disorders. This chapter includes postures to lower the risk of developing an overuse injury, including stretches for mid-practice breaks. It also contains a thirty-minute “heart and hip opener” sequence that might be used on a regular basis before performance, as well as an hour-long sequence to boost confidence. Perhaps the most useful section of this chapter features three fifteen-minute pre-performance routines that combine yoga and breathing; videos of these routines can be found on the companion website.

Pain has been defined as ‘‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’’ (Lindblom et al., 1986). Table 5–1 contains definitions of terms commonly used to describe pain sensations (Merskey et al., 1986). Pain is the most common reason a patient presents to a physician for evaluation. The U.S. Center for Health Statistics found that 32.8% of the general population suffers from chronic pain symptoms (Magni et al., 1993). Many factors can influence patients’ reports of pain, including medical and psychiatric disorders, social circumstances, disease states, personality traits, memory of past pain experiences, and personal interpretations of the meaning of pain (Clark and Treisman, 2004). There is no simple algorithm for determining whether the cause of pain is psychologic or neurologic (Clark and Chodynicki, 2005). The clinical evaluation of patients complaining of pain should be comprehensive and incorporate the patient’s descriptions of pain (ie, location, intensity, duration, precipitants, ameliorators); observations of pain-related behaviors (eg, limping, guarding, moaning); descriptions of problems performing activities; and neurologic and psychiatric examinations (Clark and Cox, 2002). Post-herpetic neuralgia (PHN) is defined as pain persisting or recurring at the site of shingles at least 3 months after the onset of the acute varicella zoster viral rash. PHN occurs in about 10% of patients with acute herpes zoster. More than 50% of patients older than 65 years of age with shingles develop PHN, and it is more likely to occur in patients with cancer, diabetes mellitus, and immunosuppression. During the acute episode of shingles, characteristics such as more severe pain and rash, presence of sensory impairment, and higher levels of emotional distress are associated with developing PHN (Schmader, 2002). Most cases gradually improve, with only about 25% of patients with PHN experiencing pain 1 year after diagnosis. Approximately 15% of patients referred to pain clinics suffer from PHN. Early treatment of varicella zoster with low-dose amitriptyline (25–100mg QD) can reduce the prevalence of pain at 6 months by 50% (Bowsher, 1997).

This chapter describes the nature and magnitude of work-related musculoskeletal disorders (WRMSDs) and their prevention and control. The incidence and severity of musculoskeletal disorders is described by body region and by occupation, and a conceptual model for the contributors and pathways to developing WRMSDs is described. Neck disorders and upper-extremity disorders as well as low back pain and lower-extremity disorders are described in detail, including evaluation, diagnosis, and prevention. Personal factors, physical exposures, and psychosocial stress that contribute to the development of WRMSDs are described. Ergonomic interventions to reduce or eliminate physical exposures are stressed as critically important preventive measures.

The new Station 5, Integrative Clinical Assessment involves two 10-minute encounters, each known as a ‘Brief Clinical Consultation’. Following an introductory referral, the candidate has 8 minutes to undertake a focused history and examination to solve a clinical problem, answer any questions the patient may have and explain their investigation and/or treatment plan to the patient. The remaining 2 minutes are spent with the examiners, to relate the relevant physical findings and differential diagnosis. Remember, you are not expected to take a complete history or conduct a complete and thorough examination, as you would in the other stations. Candidates should be prepared to encounter scenarios relating to: 1. Old Station 5 cases, i.e. skin, eye, locomotor, and endocrine systems. 2. Other stations of the examination (stations 1 and 3). 3. Medical problems encountered in everyday practice, i.e. chest pain, hypotension, jaundice, and deterioration in renal function. In principle, this station can include any possible inpatient and outpatient medical scenario, and therefore providing a comprehensive selection of cases will never be feasible. Some patients may not display a wealth of clinical signs, and this often occurs in everyday practice. The candidate should understand the key principles, and develop the art of integrative clinical assessment. This will ensure success in any clinical scenario provided. This integrated approach is a test of higher clinical reasoning and professionalism, rather than a simple test of clinical skills— this should be kept in mind when preparing for this station. The compilation of 20 cases in this section is designed to achieve this, and encourages the candidate to adopt a uniform style, and a thoughtful approach and strategy in tackling this station. • Explanatory referrals are provided in the 5 minute interval before the station. • Read these carefully, and identify the clinical problem(s). • Develop a differential diagnosis based on the limited information available, even before seeing the patient. • A preliminary differential diagnosis will initially help guide the focused history. • The history and examination should not be seen as separate components, where the history is followed by the examination. • Instead, both history and examination should be integrated.

To pass the written part of the FRCA, candidates must achieve the pass mark for the SAQs and the MCQ/ SBA papers combined. Therefore, doing particularly well in one paper, or one area, can compensate for another in which you have scored poorly. The 30 SBA questions is an area that candidates commonly find difficult. There is a feeling these questions are unjust and that it is impossible to second guess the examiners and choose the correct option. They feel further punished that four marks are awarded for each correct answer or lost for an incorrect choice. While this reflects the fact that four answers have been eliminated in the course of choosing the best answer, candidates often state it is an unfair ‘all or nothing’ way to mark these questions. They can commonly narrow the choice down to a final two options but report finding it difficult to then choose between them. They receive no credit having successfully eliminated three of the options and cite the SBA element as being the reason they failed the examination. These comments however are not supported by examination success data published by the RCoA. The pass rate for this paper was consistent at around 70% before and after the introduction of the SBA component in September 2011. We believe the concepts behind the SBAs are misunderstood by many. When asked to write a SBA question, candidates inevitably produce a five- part A to E multiple choice question but with only one correct answer. The finer points of SBA questions are lost among quickly written revision aids containing what the authors believe to be examination standard questions, when often they are not. Further, because SBAs are a relatively new element to the FRCA there is a limited bank of questions, and a highly restricted number in the public domain. Both these factors make practice of these questions difficult. Part of exam success is practice of the technique and question type in advance. We believe the practice of SBAs is an area to which candidates do not give enough attention.

When patients are diagnosed with fibromyalgia, one of their first questions to us relates to its outcome. “Is there hope, doc?” and “Will the pain ever go away?” are two of the more common queries we hear. Unfortunately, few surveys have addressed this issue, and some have arrived at contradictory conclusions. This chapter will try to put these studies in their proper perspective. Yes, there is hope! When discomfort is limited to a specific region of the body and is not widespread, the outlook for long-term relief of pain is usually quite good. With local physical measures, injections, emotional support, and anti-inflammatory and analgesic medication, as well as instruction in proper body mechanics, over 75 percent of regional myofascial pain syndrome patients have substantial pain relief within two–three years. Unfortunately, there is little middle ground. For example, in an 18-year analysis of 53 patients with low back pain followed by musculoskeletal specialists, 25 percent ultimately developed fibromyalgia. Therefore, we believe that myofascial pain should not be shrugged off or given short shrift. A problem that is addressed early and effectively saves patients, health plans, and society money. Also ameliorated are the heartaches of patients and those close to them. Improved productivity promotes a feeling of relief, as well as a better quality of life. When a practitioner prescribes Advil and says that this is all that can be done for TMJ dysfunction syndrome, it is penny wise but pound foolish. The outcome of fibromyalgia depends on who sees the patient and calls the shots. For example, in one report that tracked family practitioners, internists, or other primary care physicians familiar with fibromyalgia’s diagnosis and management, 24 percent of patients were in remission at two years and 47 percent no longer met the ACR criteria for the syndrome. This implies that early intervention by a knowledgeable community physician is the first line of therapy. Children with fibromyalgia also have a favorable outcome. In the largest study to date, symptoms resolved in 73 percent within two years of diagnosis. The outlook in tertiary care settings is not as rosy. Once the symptoms and signs of the syndrome are serious enough to warrant referral to an academically oriented rheumatologist who is involved in fibromyalgia research, improvement is common but recovery rare.

Back pain has serious impacts on individual people and society, but its causes remain poorly understood. One long-standing hypothesis contends that many common back problems may be due at least partly to the stresses caused by our evolutionarily novel form of bipedalism. This chapter discusses this hypothesis and shows how recent palaeopathological, comparative and clinical evidence has been interpretated within an evolutionary framework to develop a new version of the hypothesis. We begin by outlining how the spine in humans differs from those in the great apes. We then review clinical evidence that suggests that there is a link between spinal column and individual vertebral shape on the one hand, and spinal diseases on the other. Next, we outline palaeopathological and comparative anatomical evidence that also supports the link between spinal/vertebral shape and disease. Thereafter, we discuss recent studies that not only indicate that two important acquired spinal diseases—intervertebral disc herniation and spondylolysis—are associated with vertebral shape, but also suggest that the pathology-linked morphologies can be understood in terms of our evolutionary history. Subsequently, we discuss potential biomechanical explanations for the putative link between vertebral shape and intervertebral disc herniation and spondylolysis.

This specialty has been described by the British Society of Rheumatology as the ‘branch of medicine that deals with the investigation, diagnosis, and management of patients with arthritis and other musculoskeletal conditions’. These include inflammatory arthritis, autoimmune disorders, vascultides, soft tissue disorders, spinal problems, and metabolic bone disease. Simplifying the assessment and approaching the patient in a logical manner, using history taking and examination, make it possible to narrow your differential: ● Is there any pain? ● How many joints are affected? ● Which joints? ● Is there swelling? ● Is there erythema? ● Is there loss of function? ● How is their gait? ● Is there any morning stiffness? ● Is there systemic upset? ● Are there extra- articular symptoms? ● Are there any related diseases? ● What is the patient’s drug history? Diseases that one comes across in the specialty of rheumatology vary between being ubiquitous (rheumatoid arthritis and osteoarthritis) to the vanishingly rare (scleroderma), and affect over 10 million adults and 12 000 children. As such, it is easy to feel out of one’s comfort zone when discussing the possible causes of a patient’s joint pain during a consultation. It is, however, a core skill for the budding physician to be able to assess and diagnose potential septic joints, flares of rheumatoid arthritis, and other autoimmune conditions. These conditions are often multi- system in nature, and it is crucial to recognize other organ involve­ment such as the kidneys or lungs, or indeed extra- articular signs in the generally unwell patient that may point one in the correct diagnostic direction. There is significant morbidity from these conditions, with disability and loss of working days a problem, and it is important for the junior doctor to be aware of yellow and red flag symptoms. The impact on the ageing population also needs to be recognized, and involving the multidisciplinary team of physiotherapists and occupational therapists is essential. Although debilitating, joint problems are also often treatable. Treatment of rheumatological conditions invariably involves the use of systemic corticosteroids as first- line treatment, but this is now an exciting field itself with various biologic disease- modifying anti- rheumatic drugs (DMARDs) in use and in development, owing to a better understanding of the mechanisms driving these conditions.

To pass the written part of the FRCA, candidates must achieve the pass mark for the SAQs and the MCQ/ SBA papers combined. Therefore, doing particularly well in one paper, or one area, can compensate for another in which you have scored poorly. The 30 SBA questions is an area that candidates commonly find difficult. There is a feeling these questions are unjust and that it is impossible to second guess the examiners and choose the correct option. They feel further punished that four marks are awarded for each correct answer or lost for an incorrect choice. While this reflects the fact that four answers have been eliminated in the course of choosing the best answer, candidates often state it is an unfair ‘all or nothing’ way to mark these questions. They can commonly narrow the choice down to a final two options but report finding it difficult to then choose between them. They receive no credit having successfully eliminated three of the options and cite the SBA element as being the reason they failed the examination. These comments however are not supported by examination success data published by the RCoA. The pass rate for this paper was consistent at around 70% before and after the introduction of the SBA component in September 2011. We believe the concepts behind the SBAs are misunderstood by many. When asked to write a SBA question, candidates inevitably produce a five- part A to E multiple choice question but with only one correct answer. The finer points of SBA questions are lost among quickly written revision aids containing what the authors believe to be examination standard questions, when often they are not. Further, because SBAs are a relatively new element to the FRCA there is a limited bank of questions, and a highly restricted number in the public domain. Both these factors make practice of these questions difficult. Part of exam success is practice of the technique and question type in advance. We believe the practice of SBAs is an area to which candidates do not give enough attention.

A week doesn’t go by without a patient wanting my reassurance that he or she is not seriously ill or making it all up. “Are you just telling me it’s fibromyalgia because you don’t want me to be upset?” “A friend of mine told me that fibromyalgia is a ‘garbage can’ diagnosis that doctors give when they don’t know what you have.” These are frequent remarks or queries. How is your doctor really sure that something is not being missed? This chapter reviews some diseases with features that can overlap with or be mistaken for fibromyalgia. Fibromyalgia can seem to be working in concert with other diseases. For example, untreated inflammation associated with an autoimmune disease (such as rheumatoid arthritis or systemic lupus erythematosus), other forms of inflammatory arthritis (such as ankylosing spondylitis), or a chest disease known as sarcoidosis are associated with coexisting fibromyalgia. Withdrawal from or tapering of medications such as corticosteroids typically precipitates or aggravates fibromyalgia. Many disorders interact with or can be mistaken for fibromyalgia. They are reviewed here, as well as in other parts of this book, and listed in Table 11. Linda was not herself. Over a period of several months, she found it increasingly difficult to make it through the day. Her muscles started to ache, she gained 15 pounds while on the same diet, found it difficult to tolerate cold weather, and her voice became husky. Dr. Bridges did a complete blood count and a blood panel that was normal. He was impressed with her muscle aches and diagnosed her as having fibromyalgia. When Dr. White saw Linda in a rheumatology consultation, certain things did not fit. Weight gain, a hoarse voice, and cold intolerance of recent onset are not typical features of fibromyalgia, so she obtained additional tests that included a complete thyroid pel (triiodothyronine [T3], thyroxine [T4], thyroid-stimulating hormone [TSH]). Although the T3 and T4 levels were normal (as they had been with Dr. Bridges), the TSH (which was not part of Dr. Bridges’s panel) was quite high, indicating hypothyroidism. Linda was started on thyroid replacement therapy and was back to herself within a few weeks.

Basic sciences: Applied anatomy

Which among the following statements regarding the functions of the extraocular muscles is incorrect?

The inferior oblique muscle abducts the eye and moves it upwards

The superior rectus muscle abducts the eyes and moves it laterally

The...

You should ask the nurse: • What the trend is in urine output—has it been gradually decreasing, or suddenly stopped? If the latter, have they checked if the urinary catheter is blocked by flushing it? This is a rapidly reversible cause of poor urinary output. • What the observations are for the patient. Ask for the heart rate, blood pressure, respiratory rate, oxygen saturations, and temperature, so you can get an idea of how unwell the patient is. This will help you prioritize how soon you need to see the patient. Healthy adults have a urine output of about 1 mL/kg/hour. Oliguria refers to a reduced urine output and is defined variously as <400 mL/day, <0.5 mL/kg/hour, or <30 mL/hour. Anuria refers to the complete absence of urine output. Decreased urine output should be taken very seriously as it may be the first (and only) sign of impending acute renal failure. Untreated, patients may die from hyperkalaemia, profound acidosis, or pulmonary oedema due to the kidneys not performing their usual physiological role. Normal urine output requires: • adequate blood supply to the kidneys • functioning kidneys, and • flow of urine from the kidneys, down the ureters, into the bladder, and out via the urethra. Pathology affecting any of these requirements can result in poor urine output, which is why the differential diagnosis for poor urinary output is often classified as shown in Figure 22.1. In practice, as a junior doctor you want to diagnose and treat the prerenal and postrenal causes. If you come to the conclusion that it is a renal cause (by exclusion), call the renal physicians for an expert opinion. This is crucial in determining the diagnosis: • Adequate intake? Remember that an adult of average size will require about 3 L of fluid intake per 24 hours (30–50 mL/kg/day). Febrile patients will require an extra 500 mL for every 1 °C above 37.0 °C to compensate for increased loss of fluids from evaporation and increased respiratory rate.

Case 3.1

Clinical details

A 35-year-old female patient with a short history of progressive shortness of breath and dry cough.

Imaging

Chest radiograph.

Axial HRCT chest, supine images.

Observations and interpretations

Figure 3.1a shows diffuse...