Shoulder pain is the third most common cause for musculoskeletal consultation in primary care

Edel Comer and Victoria Percy look at the physiotherapy management of common shoulder-joint problems in the primary care setting.

Shoulder pain is the third most common cause for musculoskeletal consultation in primary care. Self-reported shoulder pain has a prevalence of 16 per cent, which rises to 26 per cent in the elderly. This article discusses the diagnostic and evidence-based management of shoulder pathology, including the conditions that respond well to physiotherapy and the appropriate pathway of care.

The shoulder (glenohumeral joint) is a synovial ball-and-socket articulation in which the freedom of movement has been developed at the expense of stability. It demonstrates a unique functional balance between mobility and stability.

Successful function depends on the interaction of the shoulder girdle articulations, cervical spine and thoracic spine. Imbalance of the static and dynamic components supporting these joints can result in microtrauma and pathology. To ensure effective management of shoulder pathologies, it is essential to consider the interaction of spinal, neuro-meningeal, musculotendinous and capsuloligamentous structures in the function of the shoulder complex.

Due to the complexity of the joint and surrounding structures, dysfunctions often co-exist and the primary diagnosis may not always be clear. This is what makes this joint so difficult to assess and manage efficiently. It is of paramount importance to recognise and exclude many non-musculoskeletal and spinal causes of shoulder pain.

Assessment and management
There have been some attempts to standardise assessment guidelines for shoulder pain, but treatment standards are still evolving. There are often conflicting criteria defining the same conditions, making it difficult to review the evidence. Soft-tissue lesions are the most common cause of shoulder pain, with 75 per cent of patients presenting with impingement or rotator-cuff tendinopathy. The occurrence/presentation of soft-tissue lesions increases with age, as tendon tissue progressively weakens or degenerates. However, repeated microtrauma or overuse from work-related or athletic activity can also cause soft-tissue problems in all age groups. It should be noted that the incidence of adhesive capsulitis (frozen shoulder) is relatively low at 15 per cent.

Overall, patients with shoulder pain of musculoskeletal origin have been shown to respond well to physiotherapy intervention

Shoulder-impingement syndrome has been described as any reduction in the sub-acromial space compromising the passage of the soft tissues through this area, including rotator cuff tendons, bursa and long head of biceps. There are many causes of symptoms of shoulder impingement, including rotator-cuff pathology, acromio-clavicular joint dysfunction and underlying gleno-humeral instability. The Neer/Welsh Classification (1977) is widely used and accepted within the literature and provides a comprehensive categorisation of the different stages of impingement syndrome.

The classification of shoulder impingement is as follows:
•    Stage 1 – subacromial oedema and haemorrhage, usually in under 25s and usually due to overuse;
•    Stage 2 – fibrosis and tendonitis, usually in 25-  to 40-year-olds, following repeated episodes of mechanical inflammation and irreversible by conservative treatment;
•    Stage 3 – bony changes and cuff tears, usually in the 40+ age group.
Diagnostic imaging of the shoulder is indicated in the obvious circumstances of suspected fracture/dislocation but can also be useful as outlined below:
i) Subacromial impingement syndrome
•    X-rays — three views (AP/sub-axial/outlet);
•    MRI/ultrasound — for full-thickness cuff tears and candidates for decompression surgery;
•    MRA (arthrogram) — partial-thickness tears and superior labrum from the anterior to posterior tear (SLAP lesion).
ii) Joint instability
•    X-rays — two views (AP/sub-axial);
•    MRA (contrast arthrogram) for complex instabilities or failed rehabilitation. Rarely required.
iii) Adhesive capsulitis
•    X-rays — AP view (30 degrees oblique or add sub-axial).

Summary
The cause of shoulder pain is difficult to establish and therefore can be problematic to manage effectively. In clinical practice, physiotherapy of the shoulder is based on symptom relief while also identifying and treating the underlying causes such as instability, postural dysfunction, muscle imbalance, cuff dysfunction and poor ergonomics.

Prognostic indicators for outcome of this patient group highlights the importance of early and effective intervention to reduce initial pain levels and prevent persistent disability. It has also been reported that only approximately 50 per cent of all new episodes of shoulder pain presenting in primary care show complete recovery within six months.

Overall, patients with shoulder pain of musculoskeletal origin have been shown to respond well to physiotherapy intervention. In this article, we have focused on the most commonly-presenting conditions, but it is also important to bear in mind other sources of shoulder dysfunction that respond well to physiotherapy — for example, proximal humeral fractures and patients presenting with shoulder lesions/dysfunction post breast reconstruction surgery or mastectomy.

Consequently, a further comprehensive physiotherapy  assessment may be advocated for appropriate patients for a more in-depth musculoskeletal assessment, treatment and onward referral when indicated.

• Edel Comer MISCP, MCSP and Victoria Percy MISCP, MCSP.
• See www.findaphysio.ie.

Hip fractures have more serious consequences and there are high rates of mortality and morbidity

In his latest Clinical Update, Gary Culliton examines recent developments in the field of osteoporosis, including diagnostic tools and issues related to glucocorticoids.

Osteoporosis is a progressive, systemic skeletal disease characterised by low bone mass and micro-architectural deterioration of bone tissue. There is a consequential increase in bone fragility and susceptibility to fractures. There are changes in bone density with increasing age. Peak bone mass is reached in the 30s, according to Prof Oliver FitzGerald, Consultant Rheumatologist and National Programme Lead in Rheumatology. “Thereafter, there’s a fall in bone mass — at a more pronounced rate following menopause,” he added.

Risks are also present for males. Hip fractures have more serious consequences and there are high rates of mortality and morbidity, said Prof FitzGerald.
Osteoporosis can be diagnosed using DXA (dual-emission x-ray absorptiometry) to measure bone mineral density (BMD). Overall, assessing risk for a major osteoporotic fracture — using the World Health Organization fracture risk assessment tool (FRAX) — is a more clinically-relevant measure. FRAX estimates the 10-year probability of hip fracture and major osteoporotic fracture in untreated patients. This uses bone mineral density T-score. It takes into account clinical risk factors for osteoporosis — including increasing age, sex (females more than males), low body weight, height, previous fracture, parental history of fractured hip, current smokers and alcohol consumption (more than three units per day).

A full blood count and an erythrocyte sedimentation rate (ESR) test are typically considered. Bone function tests are done (for serum concentrations of calcium, phosphate, alkaline phosphatase and vitamin D). Evidence of chronic diseases — such as renal and liver function abnormalities — is sought.

Basic investigations also include examinations of thyroid function, Prof FitzGerald said.

Eye surgery, including for cataracts, can be important in preventing falls. Regular weight-bearing and resistance exercise helps to retain bone mass and prevents bone loss. Increasing calcium intake may slow the rate of bone loss — but not to a substantial degree. It is not a substitute for other bone-sparing therapies in patients with established osteoporosis.

Vitamin D should be administered routinely to frail, elderly patients who have poor diet and lack of sunlight. Inadequate vitamin D may result in secondary hyperparathyroidism and increased risk of fracture and osteomalacia.

“There’s increasing understanding of the role of vitamin D in contributing to imbalance and muscle weakness and possibly other defects in the immune system,” said Prof FitzGerald.

It has been shown that daily supplementation with 1.2g of calcium and 800IU of cholecalciferol over three years to frail, elderly patients in nursing homes substantially reduces the risk of hip fractures. Conclusive evidence in the community is required.

“There’s certainly a role for bisphosphonates,” said Prof FitzGerald. “All of the bisphosphonates remain first-line treatment.” Bisphosphonates are potent inhibitors of bone resorption and are the most prescribed medication in the management of osteoporosis (Liberman UA, 2006; McGowan B et al, IMJ 2008).

All the authorised bisphosphonates (alendronate, risedronate, ibandronic acid, zoledronic acid and etidronate) reduce the risk of vertebral fractures.

(Sambrook P, Cooper C, The Lancet, 2006; MacLean C et al, Annals Internal Medicine 2008).

Alendronate, risedronate and zoledronic acid have also been shown to reduce the risk of non-vertebral fractures, including hip fractures (National Osteoporosis Guideline Group; Drug and Therapeutic Bulletin 2008).

Post-hoc analysis revealed reduced non-vertebral fractures for ibandronic acid (National Osteoporosis Guideline Group).

Zoledronic acid is a once-a-year IV infusion given slowly, which usually takes at least 15 minutes. Ibandronate also acts on bone and has an inhibitory effect on osteoclasts. It decreases bone resorption and decreases risk of fractures.

Bisphosphonates have been used in trial extensions for up to 10 years, which suggest that bone quality remains normal and that reductions in fracture risk are sustained for as long as treatment continues (Liberman UA, 2006). However concern has been expressed about over-suppression of bone turnover, leading to fractures later (Boonen S et al, J Intern Med 2008).

Further assessment of prolonged use is required and the optimum duration of therapy remains unclear. (Edwards B et al, Lancet Oncology 2008; Sambrook P, Cooper C, The Lancet 2006).

Corticosteroid prescribing is linked to bisphosphonates by Irish study

A study of Irish prescribing patterns identified that the longer a patient was prescribed the corticosteroid prednisolone, the greater the likelihood of subsequently being prescribed a bisphosphonate (B McGowan et al. IMJ 2008). Approximately 65 per cent of patients (total 60,000) were dispensed either alendronate (once weekly) or risedronate (once weekly). The majority of the patients (69.3 per cent) were over 70 years.

Approximately 50 per cent of patients on long-term steroids did not receive prophylaxis for osteoporosis. There were low levels of co-prescribing (2.5 per cent) with potentially interacting drugs. Levels of co-prescribing with proton pump inhibitors (PPI) was 22 per cent.

The published results of a study involving the General Practice Research Database, a computerised medical record system of a selected group of general practices in the UK, identified significantly increased risk of hip fractures associated with long-term users of high-dose PPI (Yang, JAMA 2006).

It has been demonstrated that corticosteroids increase the risk of vertebral fractures six-fold and double the risk of hip fracture

There has been an increased awareness of the association between long-term use of both inhaled and oral corticosteroids and the subsequent development of osteoporosis (Arthritis Rheumatology 2001; Eastell R, Journal of Internal Medicine 1998; Leong GM, Osteoporosis 2001). A threshold dose of over 7.5mg/day of prednisolone seems to be required for the development of osteoporosis. Previous studies have identified that corticosteroid use is a risk factor for fractures, irrespective of the fact that patients may present with normal BMD levels.

It has been demonstrated that corticosteroids increase the risk of vertebral fractures six-fold and double the risk of hip fracture (Cooper C, Ann Rheum Dis 1995; Scane AC, Osteoporosis Int 1999). Studies have also shown that approximately 50 per cent of patients who are receiving long-term corticosteroids experience fractures (Lukert BP, Ann Intern Med 1990). Kanis et al identified that approximately 20 per cent of patients who have an osteoporotic hip fracture die within six months (Kanis JA, Bone 1992).

The McGowan study showed that approximately 50 per cent of patients treated with prednisolone (over 7.5mg per day) for greater than three months did not receive treatment for the prophylaxis of osteoporosis and the co-prescribing rate for PPIs was 22 per cent, which may be related to gastrointestinal adverse events.

Other treatments and ‘drug holidays’

“PATIENTS ON long-term bisphosphonates appear to be presenting now — in small numbers — with atypical fractures on the medial side of the femur,” according to Prof Oliver FitzGerald.

A ‘drug holiday’ has been advocated by some physicians — namely, stopping the bisphosphonate for one or two years and reassessing — but the evidence is not definite. “The Medicines and Healthcare Products Regulatory Agency’s advice is that without an atypical fracture, if a patient is at high risk of fracture, the benefits outweigh the risks and there’s no indication to stop treatment,” said Prof FitzGerald.

Selective oestrogen-receptor modulators (SERMs) are non-steroidal agents, which act as agonists on bone and reduce the rate of bone loss in PM women. (Kanis JA, Osteoporosis International 2008). Raloxifene has been shown to reduce the risk of vertebral fractures in post-menopausal women with low bone mass. However, there is no significant reduction in non-vertebral fractures. Raloxifene helps to maintain bone density and reduce fracture rates, specifically at the spine.

For patients not responding to bisphosphonates who might have severe osteoporosis, parathyroid hormone could be considered. Parathyroid hormone increases bone remodelling and increases bone formation (anabolic agent) (Rosen C, NEJM 2005). Treatment with either the intact molecule (recombinant PTH 1-84) or the 1-34 N-terminal fragment (teriparatide) reduces vertebral fractures (National Osteoporosis Guideline Group).

Teriparatide has also been shown to reduce non-vertebral fractures in post-menopausal women and it has efficacy in men and glucocorticoid-induced osteoporosis (Kanis JA, Osteoporosis International 2008). BMD reduces rapidly after discontinuation, unless followed by an antiresorptive agent.

Parathyroid hormone can only be prescribed by a consultant, as it is a high-tech drug for severe osteoporosis. It is a bone-forming agent that stimulates the formation of new bone.

Strontium ranelate may also be considered, said Prof FitzGerald. Strontium ranelate has antiresorptive properties and possibly increases bone formation. (O’Donnell S et al, Cochrane Database of Systematic Reviews 2006). It has been shown to reduce vertebral and non-vertebral fractures. It can also help decrease the pain of vertebral fractures.

Denosumab may be considered for patients who have not responded to bisphophonates or who are unable to take them, added Prof FitzGerald. It reduces the risk of vertebral, non-vertebral and hip fractures.

Other treatments include oestrogen, Prof FitzGerald said. Sex hormones play a vital role in determining the onset of osteoporosis. Both testosterone in males and the female hormone oestrogen have a protective effect on bones. Oestrogen deficiency at any age — but particularly after the menopause in thin females — is one of the main reasons for bone loss. Oestrogen/hormone therapy (HRT) is not usually recommended just for prevention or treatment of osteoporosis, unless the person has had an early menopause. HRT prevents the relatively rapid bone loss in the first three-to-five years following menopause, and maintains this.

It is important to minimise the use of glucocorticoids, said Prof FitzGerald. Calcium and vitamin D supplementation should be considered, especially in the elderly.

Trauma or repetitive activity may implicate hip pathology. It is important to discern the mechanism of the traumatic incident, along with the positioning of the hip joint at the time of impact/fall

Margaret Hanlon looks at some common musculoskeletal problems of the hip-joint and how physiotherapy can help.

Hip-joint pain may be related to arthritic diseases or stresses resulting from work or sporting activities. Postural and movement abnormalities will commonly contribute to these pathologies. The aim of this article is to outline the common hip conditions and to explain the benefit of early physiotherapy intervention.

•  Subjective examination Groin pain with referral to the medial aspect of the knee is the predominant indicator of hip-joint pathology. Pain can be experienced in the buttock region (mainly from the posterior capsule) or lateral aspect of the hip. As lumbar spine and hip problems may often coexist, a differential diagnosis is required to rule out lumbar spinal or sacroiliac joint involvement.

A useful differential indicator is that hip-joint pain will rarely refer beyond the knee joint. Pain is usually related to a particular movement or position of the hip joint or the prolonged maintenance of a particular posture.

Trauma or repetitive activity may implicate hip pathology. It is important to discern the mechanism of the traumatic incident, along with the positioning of the hip joint at the time of impact/fall. This information can then be considered in relation to the physical findings to help form an accurate diagnosis.

Developmental dysplasia
A history of congenital defects such as a developmental dysplasia or a previous history of hip epiphyseal injury is relevant to the development of joint degeneration and movement abnormalities.

• Physical examination

Genetic variations in the angle and orientation of the femoral neck can lead to femoral anteversion or retroversion. The altered alignment of the joint predisposes to excessive wear and tear of the acetabulum or femoral head and may contribute to the development of altered muscle length, i.e. hamstrings or hip flexors, and consequently strength imbalances. An indicator of femoral anteversion is internal rotation of the femur in standing with hyperextension of the knee.

An excessive range of internal rotation will be evident. Conversely, a larger range of external rotation is found with femoral retroversion. A reduction of muscle bulk in the gluteal area indicates poor control of hip extension and/or abduction effecting gait control. Patients with unilateral hip-joint pathology exhibited marked side-to-side differences in the size of gluteus maximus muscle, which is specific to the stage of pathology.

Pain on muscle testing indicates muscle/tendon pathology, while weakness suggests muscle tearing (providing neurological compromise has been ruled out). Functional testing such as squatting and full rotation while standing on one leg are useful indicators of joint dysfunction.

Common musculoskeletal conditions
• Osteoarthritis (OA) of the hip-joint has an estimated prevalence of 5 per cent in those over 60 years, with superolateral joint degeneration most common. The causes can be congenital, traumatic or as a result of a neuromuscular or articular deficit. In many cases, stiffness after rest may be more troublesome than pain, especially morning stiffness. Physical examination reveals a pattern of capsular restriction, i.e. reduced flexion, rotation and adduction. Gait abnormalities, such as a trendelenburg gait, contribute to the development of lumbar spinal problems and accelerate wear and tear on the articular surfaces of the hip joint.

The Royal Australian College of General Practitioners has provided a diagnosis and management algorithm for adults presenting with suspected hip or knee OA.

Physiotherapy intervention is helpful in the early and middle stages of the disease to relieve pain, maintain or increase range of motion and improve functional outcomes. Manual therapy aims to restore normal movement patterns to the joint through joint mobilisation or capsular stretching.

A recent review indicated that manual therapy has a role in the short-term management of hip OA, but the evidence for weight reduction and range of motion exercises, soft tissue mobilisation, muscle strengthening and stretching is stronger.

Multimodal therapy generally includes manual therapy consisting of muscle stretching and passive range of movement exercise as an adjunct to an active exercise component of treatment and it is recommended as (4) physiotherapy treatment for hip OA. Postural advice and gait re-education also play a role, along with the use of appropriate appliances and aids in more severe cases of OA.

• Femoroacetabular impingement (FAI) causes damage to the articular cartilage or labrum. FAI generally occurs as two forms: cam and pincer.

The cam form describes the aspherical relationship between the femoral head and neck. This loss of roundness contributes to abnormal contact between the head and socket.

The pincer form describes the situation where the acetabulum has too much coverage of the femoral head. This over-coverage typically exists along the front-top rim of the acetabulum and results in the labral cartilage being ‘pinched’ between the rim of the socket and the anterior femoral head-neck junction. The pincer form of the impingement is typically secondary to ‘retroversion’, a turning back of the socket.

A recent review indicated that manual therapy has a role in the short-term management of hip OA, but the evidence for weight reduction and range of motion exercises, soft tissue mobilisation, muscle strengthening and stretching is stronger

Most of the time, the cam and pincer forms exist together, i.e. ‘mixed impingement’. FAI is associated with cartilage damage, labral tears, early hip arthritis, hyper-mobility, sports hernias and low back pain. FAI is common in high-level athletes, but also occurs in active individuals.

• Labral tears occur secondary to a traumatic incident or repeated trauma relating to a movement abnormality. Almost 80 per cent of cases have no known cause. Symptoms include pain/stiffness in hip/groin area, locking and clicking with movement. The objective examination reveals restricted range of motion with a positive quadrant test (passive flexion, adduction and compression) and FABER test (flexion, abduction and external rotation). Diagnosis should be confirmed with MRI/arthroscopy.

• Muscle tears around the hip region are a common source of injury generally involving the adductor muscle group and iliopsoas/rectus femoris (hip flexors). Pathology is evident when there is pain on resisted contraction of these muscles. Weakness on testing would infer a disruption of muscle fibres.

• Among the sporting community, Gilmore’s groin (‘Sportsman’s hernia’) involves tearing of the aponeurosis of the external oblique muscle and/or a tear to the tendon of the internal oblique muscle as they converge at the inguinal ligament. Symptoms are characterised by groin pain, particularly with twisting and turning movements, usually radiating to the adductor muscle region and even the testicles, although it is often difficult for the patient to pinpoint.

Diagnosis of Gilmore’s groin is based on the patient’s history and clinical signs, following sporting activity the patient will be stiff and sore; getting out of bed or a car may be difficult. In the early stages, the person may be able to continue playing their sport, but the problem usually gets progressively worse.

• Trochanteric bursitis is characterised by pain and swelling on the lateral aspect of the hip over the greater trochanteric region. Resisted abduction will be painful. Over time, the bursa can become thickened, which can increase inflammation, causing limited movement and weakened abduction. It can occur when there is infection or bony spurs present, in conditions such as gout and rheumatoid arthritis.

Hip pain among children covers a wide range of potential causes. Readers are referred to the pGALs assessment format(5). Constant hip pain/limping in children is often indicative of serious pathology and should be investigated.

How can physiotherapy help?
Physiotherapy can help in the rehabilitation of all the conditions outlined through systematic assessment of the following factors:
A detailed assessment of the biomechanical factors enables the physiotherapist to identify the predisposing causal factors contributing to degeneration or tissue injury; and a specific treatment programme can then be formulated to target these vulnerabilities, thereby preventing further tissue damage.

Physiotherapy treatment will aid tissue healing and normalise movement patterns by:
•    Identification and adaptation of structural deficits;
•    Identification and correction of relevant muscle imbalances by means of manual therapy and a targeted exercise programme;
•    Advice on modification of lifestyle activities including ergonomic assessment and training modification;
•    Advice on weight-reduction programmes;
•    Advice on the use of aids and appliances including orthotic prescription.

References on request.

• Margaret Hanlon MSc, BSc (Hons) MISCP works in private practice. See www.findaphysio.ie.

The Irish Society of Chartered Physiotherapists would like to gratefully acknowledge the editorial and academic overview contributed by Cillin Condon BSc, MSc, Clinical Teacher, Discipline of Physiotherapy, Trinity College Dublin.

• This article is part of a series of articles pertaining to peripheral and spinal joints commissioned by the Irish Society of Chartered Physiotherapists and edited by Aileen Murphy MISCP. Any queries may be addressed to info@iscp.ie.

Dr Carla Moran, Dr Eric Heffernan and Dr Malachi McKenna examine the features and treatment of atypical femoral fractures and the links with bisphosphonate therapies.

Recently, clinicians have raised concerns regarding the association between bisphosphonate use and so-called ‘atypical femoral fracture’ (AFF).

Here we review the definition, clinical and radiographic features, and treatment of AFF, along with an exploration of the possible link with bisphosphonate therapy.

With regard to definition and epidemiology, AFFs can occur anywhere along the femoral diaphysis from just distal to the lesser trochanter to proximal to the supracondylar flare of the distal femoral metaphysis. They occur most commonly in the proximal one-third of the femoral shaft. They may be complete, or (more often) incomplete.

They usually occur as a result of minimal or no trauma and are often preceded by a prodrome of thigh or groin pain. There is commonly some periosteal stress reaction and thickening of lateral cortex at the fracture site. They do not include fractures of femoral neck, intertrochanteric fractures, periprosthetic or pathological fractures.

Until 2010, there was no uniform definition of AFFs, making comparison of published data difficult. The American Society of Bone and Mineral Research established a task force, which subsequently published a report that year on AFFs (1).

One of the task force’s stated aims was to unify the definition of AFFs so that future studies could be easily compared and standardised. The task force identified five major and seven minor features of AFFs.

All major features are required to satisfy the case definition of AFF; minor features may or may not be present.

It is important to note that AFFs can occur in individuals who have not been exposed to bisphosphonates (BPs). The incidence of atypical fractures in the general population is unknown, however subtrochanteric and diaphyseal fractures account for 5-10 per cent of all hip/femoral fractures, of which approximately 17-29 per cent are atypical (1).

Fig 1: Incomplete AFF. Left: AP radiograph of right hip of 79-year-old asymptomatic woman shows focal area of cortical thickening in lateral, subtrochanteric cortex of femur. Right: magnified view of abnormality confirms presence of linear fracture line associated with ‘beak’-like focus of cortical thickening on the surface of femur

In one recent retrospective Dutch study, only 1.1 per cent of all hip/femoral fractures treated over an 11-year period in a university teaching hospital were atypical femoral fractures (2).

Association with BP use and putative mechanisms
Over 300 case reports of AFFs associated with BP use have been reported. Almost all were receiving oral bisphosphonates for treatment of osteoporosis. The duration of BP therapy ranged from 1.3 to 17 years, with a median duration of 7 years; some 28 per cent were bilateral (1).

In the Dutch study, 40 per cent of those who sustained an AFF were current BP users, compared with 3.8 per cent of those who had subtrochanteric/femoral shaft fractures without atypical features (2).

In a large, population-based study of postmenopausal women with femoral fractures over one year in Sweden, only 59 of 12,777 fractures were atypical; some 78 per cent of those who had atypical fractures had received BPs, compared with 10 per cent of a representative cohort with ‘typical’ femoral fractures (odds ratio of 33).

The longer the duration of use, the higher the risk. The risk reduced by 70 per cent per year after BP withdrawal. Although the risk of AFF is much higher in those on BP therapy, the absolute risk is very small (3).

There are radiological and clinical similarities between stress fractures and AFFs. For example, most patients with a stress fracture report prodromal pain and have a periosteal callus present on x-ray. Stress fractures occur at sites of high tension, such as the proximal lateral femoral shaft, where AFFs also occur.

BPs reduce bone resorption, produce changes in collagen cross linking and cause microdamage accumulation. The resultant reduced remodelling may impair the healing of a stress fracture. The dosing schedule for all BPs is devised to maximise the anti-efficacy efficacy but by doing so maximises the potential for stress fractures.

Presentation, diagnosis and management
Patients often present following a low-impact fall. Some 70 per cent will have had a prodrome of groin or upper-thigh pain. The presentation may be bilateral. Incomplete fractures may be detected incidentally on plain films, bone scans or DXA images. If the initial plain film does not detect an abnormality, a technetium bone scan or MRI may be required to detect a periosteal stress reaction or fracture.

Even when an AFF is visible on plain film, these imaging modalities are useful for identifying radiographically-occult abnormalities on the opposite side, which are not infrequent.

The typical radiographic features of an incomplete AFF have been well-described in the literature (4). A linear lucency is usually visible passing through the lateral cortex of the subtrochanteric region of the femur, but is often quite subtle. This is typically transversely-oriented, perpendicular to the cortex, but it may also be slightly oblique.

Fig 2: Complete AFF. AP radiograph of the pelvis, also in a 79-year-old woman, performed following mild trauma. Lateral aspect of fracture line is transverse in orientation and associated with cortical beaking (arrowhead), while medial component of fracture is oblique, producing a ‘medial spike’ (arrow)

There is commonly some focal thickening of the cortex at the site of the fracture, which produces a ‘beak’-like appearance (see Fig. 1). Completed AFFs maintain the transverse orientation of the fracture through the lateral cortex, however as the fracture extends through the medial cortex it often takes a more oblique trajectory, producing a medial ‘spike’ (see Fig. 2).

Areas of uncertainty and conclusion
The optimum duration of BP therapy is unknown. The European Medicines Agency in April 2011 recommended that a ‘drug holiday’ be considered after a period of five years. The decision on whether to continue treatment after five years should be re-assessed annually and individualised.

If BPs are discontinued, there is no evidence to support a decision as to whether or when BPs should be restarted and this decision should be individualised.

AFFs are rare fractures with distinct clinical and radiographic features. While there is evidence linking bisphosphonate use and this type of fracture, it must be remembered that typical femoral fractures are very common and these atypical fractures are rare.

Bisphosphonates are highly effective in reducing incidence of vertebral and non-vertebral fractures. If prescribed appropriately for individuals at risk of osteoporotic fracture, the benefit of fracture reduction far outweighs the harms such as AFF.

Clinicians need to be aware of the possibility and presentation of AFFs, particularly amongst those on BP therapy, and investigate as appropriate.

Treatment with BPs should pause at five years without need for substitute therapy or re-initiating for another two years, due to ongoing effect of BPs.

References:
1.    Shane et al. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. JBMR 2010;25:2267-2294.
2.    Giusti et al. Atypical fractures and bisphosphonate therapy: a cohort of patients with femoral fracture with radiographic adjudications of fracture site and features. Bone 2010;48:966-971.
3.    Schilcher et al. Bisphosphonate use and atypical fractures of the femoral shaft. NEJM 2011;(364)18:1728-1737.
4.    Porrino JA Jr, et al. Diagnosis of proximal femoral insufficiency fractures in patients receiving bisphosphonate therapy. AJR 2010;194:1061-1064.

• Dr Carla Moran, Dr Eric Heffernan and Dr Malachi McKenna, Departments of Endocrinology and Diagnostic Imaging, St Vincent’s University Hospital, Dublin

The IV bisphosphonate zoledronic acid improves bone density in children with secondary osteoporosis but larger studies are needed, researchers say.

The industry-sponsored study of 20 children with a variety of underlying primary diagnoses found that zoledronic acid (0.1mg/kg/year) every three months for two years increased bone mineral density (BMD) — particularly in the lumbar spine — and cortical thickness. There was also evidence of vertebral modelling.

Although all of the children had previous fragility fractures, none experienced a fracture during the two-year study period, the authors found.

The changes seen in BMD were consistent with a real increase in bone mass accrual, the researchers said, as there was no significant change in height Z score. Bone age also progressed at the expected rate, showing that accelerated maturation was not driving the increase in BMD.

However, despite their findings, the best treatment regimen (in terms of choice of drug, route of administration, dosing schedule and treatment duration) was yet to be determined, the study authors said.

While three-monthly treatment gave a good response, it may be possible to get similar results if the zoledronic acid was administered less frequently, for example six monthly, they said in Bone, noting that there were still some concerns about the safety of bisphosphonate therapy in children.

Bone 2011; doi:10.1016/j.bone.2011.07.031.

'Broadly speaking, options include either fasciotomy, in which the cord is simply divided, or fasciectomy, in which the diseased fascia is excised'

Recurrence is a feature of the hand condition Dupuytren’s contracture. However, new treatments offer the possibility of reduced contractures and an improved range of motion, writes Gary Culliton.

Dupuytren’s disease is a slowly progressive condition affecting the layer of connective tissue in the palm of the hand and the fingers (the palmar fascia). Dupuytren’s disease starts in the palm of the hand with the appearance of a number of nodules, made of cells that can produce collagen.

Variables that could explain the onset of development are, in decreasing order: age; total alcohol consumption; sex (male); and previous hand injuries, according to P Attali et al (Arch Intern Med, 1987).

An epidemiological study on Dupuytren’s disease in Bosnia and Herzegovina (D Zerajic and V Finsen. BMC Musculoskelet Disord, 2004) examined the hands of 1,207 men and women over the age of 50 years. It reported that prevalence was highly age-dependent, ranging from 17 per cent for men between 50-59 years to 60 per cent in the oldest men.

The prevalence among women was lower. The great majority only had palmar changes without contracture of the digit. As the disease progresses, excess collagen continues to build up and may eventually form into a rope-like cord under the skin.

The cord extends from the palm into the finger and can gradually contract the finger permanently toward the palm. This is known as Dupuytren’s contracture. A small number of patients with Dupuytren’s disease will go on to develop Dupuytren’s contracture.

Fibroblast proliferation is a key feature of early Dupuytren’s disease and manifests clinically as the nodule. In these early stages, Dupuytren’s disease shares certain properties with malignant tumours and, histologically, it often resembles fibrosarcoma.

There is an increase in the number of myofibroblasts — not mature fibrocytes — in the proliferative phase of Dupuytren’s disease. As the disease progresses, proliferation fizzles out and connective tissue assembles, manifesting clinically as the cord.

The disease follows a more benign course in diabetic patients, with fewer cases presenting for surgery (MG Hart and G Hooper. Postgrad Med J 2005).

Patients typically present with a small, pitted nodule (or multiple nodules) on the palm, which slowly progresses to contracture of the fingers. The disease initially can be managed with observation and non-surgical therapy. It will regress without treatment in approximately 10 per cent of patients. Steroid injection into the nodule has been shown to reduce the need for surgery.

The insidious disease process in Dupuytren’s disease is often unnoticed by the patient until the disease has suddenly progressed from a simple, painless nodule to a severely contracted digit, noted a Manchester-based study by A Bayat and DA McGrouther (Ann R Coll Surg Engl, 2006).

Steroid injections
A steroid injection can be effective in causing nodules in the palm to shrink, said Mr David Warwick, Consultant Hand Surgeon at Southampton University Hospitals NHS Trust. This can be painful and the skin can lose some of its thickness through atrophy.

A study by Ketchum et al (J Hand Surg, 2000), found that intralesional injections with the steroid triamcinolone acetonide, directly into the area of disease, could modify its progression.

The researchers found that after an average of 3.2 injections per nodule, some 97 per cent of hands showed regression of disease as exhibited by a softening or flattening of the nodule(s). Although some patients had complete resolution of the nodules, most experienced definite but incomplete resolution in the range of 60 per cent to 80 per cent.

In all, 50 per cent of patients experienced reactivation of disease in the nodules one to three years after the last injection, necessitating one or more further injections.

Radiotherapy (RT) can prevent progression of Dupuytren’s contracture. It is unknown whether there is a dose response and which dose is sufficient. After a mean follow-up of 13 years, radiotherapy has been found to be effective in prevention of disease progression and improves patients’ symptoms in early-stage Dupuytren’s contracture (N Betz et al. Strahlenther Onkol, 2010). In case of disease progression after radiotherapy, a ‘salvage’ operation is still feasible.

The one-year results of a prospective, randomised trial compared two different RT dose concepts with each other (MH Seegenschmiedt et al. Int J Radiat Oncol, 2001). Both prophylactic RT concepts were equally effective to prevent further disease progression of Dupuytren’s and were reported to obtain “considerable symptomatic improvement”.

Surgical referral should be made when metacarpophalangeal joint contracture reaches 30 degrees or when proximal interphalangeal joint contracture occurs at any degree (Trojian and Chu. Am Fam Physician, 2007).

Surgical treatment
The mainstay of treatment for Dupuytren’s contracture is hand surgery. Needles can be used in different ways in Dupuytren’s disease, said Mr Warwick. Broadly speaking, options include either fasciotomy, in which the cord is simply divided, or fasciectomy, in which the diseased fascia is excised.

Fasciotomy is indicated for isolated metacarpophalangeal joint contracture and can be done as an open procedure or percutaneously (needle fasciotomy) in the outpatient setting. Percutaneous needle fasciotomy results in good short-term improvement, but the recurrence rate is often high (AL van Rijssen AL. J Hand Surg Am, 2006).

Early recurrence is a common complication after simple fasciotomy, making it most suitable for patients in whom major surgery is contraindicated.

Analysing 100 percutaneous needle fasciotomy patients, Foucher et al (J Hand Surg Br, 2003) found a recurrence rate of 58 per cent after a mean follow-up of 3.2 years (recurrence was defined as the need for another treatment).

Short-term and five-year outcomes after non-surgical treatment of Dupuytren’s contracture by needle fasciotomy were studied by Badois (Rev Rhum Ed Fr, 1993) and the five-year recurrence rate was 50.4 per cent.

Needle fasciectomy has been particularly popular in France, where a number of rheumatologists popularised it. It is not particularly precise, however, and recurrence rates are high with needle fasciectomy.

A study by Andreas Mavrogenis of Athens University (J Surg Orthop Adv, 2009) examined 196 patients with Dupuytren’s contractures who were treated by partial fasciectomy and who had adequate post-operative rehabilitation. At the latest examination, some 72.5 per cent of the patients had complete range of motion of the metacarpophalangeal and proximal interphalangeal joints.

Surgery for Dupuytren’s contracture achieved a high rate of full, or almost full, correction in 75 per cent of patients in a study by Dias (J Hand Surg Br, 2006) but had a high incidence of post-operative patient-reported complications of 46 per cent.

A higher complication rate was seen in those patients with worse initial deformities. The rate of contracture recurrence or persistence was 15 per cent.

'Surgical referral should be made when metacarpophalangeal joint contracture reaches 30 degrees or when proximal interphalangeal joint contracture occurs at any degree'

It will soon be possible to inject a chemical that ‘dissolves’ some of the Dupuytren’s problems.

A paper by WA Townley et al (BMJ, 2006) concluded that “surgery readily corrects contracture, but recurrence remains an unsolved problem”.
It found that injection with collagenase showed early clinical promise for mild disease limited to the metacarpophalangeal joint. Collagenase clostridium histolyticum (Xiapex) was licensed by the Food and Drug Administration in the US last year.

“It acts like a ‘surgical drug’,” Mr Warwick said. “Dupuytren’s is caused by collagen, which thickens and contracts. Collagenase is an enzyme that dissolves collagen. Xiapex is designed to dissolve precisely the collagen mix that is in Dupuytren’s — it ‘cuts through’ a section of the Dupuytren’s.”

CORD studies
The Collagenase Option for the Reduction of Dupuytren’s (CORD I) study (L Hurst et al. NEJM, 2009) found that collagenase clostridium histolyticum significantly reduced contractures and improved the range of motion in joints affected by advanced Dupuytren’s disease. Overall, the range of motion in the joints was significantly improved after injection with collagenase, as compared with placebo (from 43.9 to 80.7 degrees vs. from 45.3 to 49.5 degrees).

The primary endpoint of CORD I was the percentage of patients achieving a reduction in contracture of the selected primary joint to five degrees or less, approximately 30 days after the last injection of that joint.

The CORD II study was detailed in a paper last year (D Gilpin et al. J Hand Surg Am, 2010). This judged injectable collagenase to be “highly effective and well tolerated” in patients with Dupuytren’s contracture with a palpable cord. In the CORD II study, 64 per cent of joints became essentially straight.

“Collagenase is injected into the collagen and the next day, the finger is straightened,” said Mr Warwick, who is UK Chief Investigator for the ongoing POINT X study into Xiapex.

He also gives the drug in his private practice. Dupuytren’s surgery is set to decrease because it will be possible to inject collagenase, Mr Warwick said. “We now have something that can have a surgical effect without doing an operation,” he added.

A specialist procedure
Collagenase needs to be injected once and it is a specialist procedure. “It’s important not to go too deep with the injection, as one of these collagens is the same one that exists in tendons,” said Mr Warwick. Local anaesthetic is injected into the palm, 24 hours after the injection. The doctor then positions the finger into a straightened position.

If contracture remains four weeks after treatment with collagenase, another injection can be administered into the same cord, and the finger extension procedure can be carried out again if necessary (the cord may also break on its own). Injections and finger-extension procedures may be administered up to three times per cord, at approximately four-week intervals.

In CORD II, more cords (44.4 per cent vs 4.8 per cent) injected with collagenase than placebo achieved a reduction in contracture of their primary treated joint to five degrees or less, 30 days after the last injection.

Although a majority of therapists use splinting, there is a wide variation in how frequently it is applied. There is empirical evidence to support the use of low-load prolonged stretch through splinting after hand surgery and trauma, (D Larson and C Jerosch-Herold. BMC Musculoskelet Disord, 2008).

The benefits of vertebroplasty have been overstated and it has no place in first-line treatment of vertebral fractures, even in selected subgroups of patients, a new review has concluded.

Despite two randomised trials showing no advantage of vertebroplasty over local anaesthetic infiltration for osteoporotic vertebral compression fractures, some proponents still claim the technique may help with recent-onset fractures or severe pain.

However, a new review in the BMJ addresses these claims by pooling data from the randomised trials. The meta-analysis confirmed the original findings of no benefit from vertebroplasty.

Despite the larger sample size, subgroup analyses also failed to show an advantage of vertebroplasty for patients with pain of recent onset (≤6 weeks) or severe pain.

There was also no benefit seen when the analysis was extended to include data from a recent open trial that had shown some benefit for vertebroplasty.  The researchers say this benefit may have been due to lack of blinding.

An accompanying editorial said the lack of evidence for vertebroplasty meant it could not be recommended as the first-line treatment.

BMJ 2011; doi: 10.1136/bmj.d3952.

Higher serum uric acid levels in older men are strongly associated with increased bone mineral density (BMD) and markers of calcium homoeostasis and bone resorption, new research has shown.

A study led by Prof Markus Seibel at the ANZAC Research Institute in Sydney examined 1,705 community-dwelling men aged 70 or more who participated in the Concord Health and Ageing in Men Project (CHAMP).

After adjusting for possible confounders, BMD at all sites was significantly higher among those with uric acid levels above the group median.

Uric acid levels were also positively associated with serum calcium, parathyroid hormone and 25-hydroxy-vitamin D levels. They were negatively associated with urinary NTX-1, a marker of bone resorption.

Above-median uric acid levels were also associated with a lower prevalence of osteoporosis at the femoral neck and lumbar spine, and a lower prevalence of vertebral and non-vertebral fractures.

The researchers said their study was the first to examine links between uric acid levels and bone health.

Uric acid had traditionally been viewed as a waste product that caused gouty arthritis and kidney stones, and also led to endothelial damage and increased cardiovascular risk.

However, it was also thought to provide an evolutionary benefit by helping to maintain blood pressure under low-salt conditions.

Emerging evidence suggested that uric acid was a powerful antioxidant that could help protect against conditions including Alzheimer’s disease, and possibly osteoporosis.

The cross-sectional nature of the study did not allow any cause-and-effect mechanisms to be explored, but there were several other plausible explanations for uric acid’s apparent benefits, including a direct effect on bone resorption, the researchers said.

J. Bone Miner. Res.
DOI: 10.1002/jbmr.286

Chronic pelvic pain is a poorly understood and underdiagnosed condition. Maeve Whelan offers advice to doctors who encounter patients with it

Millions of men and women suffer from chronic pelvic pain (CPP). The symptoms are of rectal, genital or abdominal pain or discomfort, pain or discomfort associated with sexual activity and often symptoms of urinary frequency, urgency and hesitancy. Chronic prostatitis (CP) is poorly understood, often inadequately treated and extremely bothersome to patients with this diagnosis. In fact, it is one of the most common diseases diagnosed by urologists in clinical practice.
It is generally recognised that the confusion surrounding the diagnostic and treatment strategies in this disease is related to the lack of uniformity in the definition, entry criteria, classification system and outcome measures in the many small poorly designed prostatitis studies available in the literature.
The consensus classification of prostatitis is outlined in Fig 1:
Category 1:
Acute bacterial prostatitis
Category 2:
Chronic bacterial prostatitis
Category 3:
Chronic pelvic pain syndrome
A. Inflammatory
B. Non-inflammatory
Category 4: Asymptomatic inflammatory prostatitis
The broader definitions of chronic pelvic pain are outlined in the European Association of Urology guidelines. This classification is set out on a series of axes in an effort to suggest avenues for further management, see Fig 2.
In the US, the term for these syndromes is chronic prostatitis (CP)/ chronic pelvic pain syndrome (CPPS) as defined by the NIDDK in 2007 under the umbrella term of urologic chronic pelvic pain syndromes (UCPPS). The incidence of CPP is quoted as being between 2.6 per cent and 6.3 per cent.
CPP – a diagnosis of exclusion
CP/CPPS should be viewed as more than an organ-specific disease but rather a biopsychosocial disorder where the central problem is pain. Typically, the patient who ends up in a physiotherapy clinic will have failed all medical treatments; this is the patient group that is presented here.
The patient will have had a full examination by the GP and urologist, including the following: physical examination of abdomen and organs, prostate examination, prostate massage for collection of prostate fluid for testing, ruling out of any urethral prostate or bladder disease.
He may have had serum lab test PSA. Cystoscopy, transrectal ultrasound, CT scans, urodynamic studies or MRI may all have been done.
Where antibiotics, alpha-blocking agents and anti-inflammatory agents have failed, other medication may have been tried, medications for neuropathic pain, medications to treat muscle spasticity and medications that are also used to treat interstitial cystitis or bladder pain syndrome.
Surgeries may include anaesthetic injection for diagnosis as well as for treatment; neuromodulation or botulinum toxin and bladder neck incision may also be tried.
Pain mechanisms
The primary presenting symptom with all these patients is pain; there is usually no actual tissue damage. The mechanism for the setting up of pain starts with ‘noxious stimuli’ increasing production of pain promoting substances at nerve free endings of primary afferent nociceptors; there is release of neuro peptides, nitric oxide substance P, calcitonin gene-related protein amongst other substances leading to neurogenic inflammation, vasodilation, oedema and hyperalgesia. Referred pain is felt in a part of the body other than where the pain originates. Visceral referred pain is thought to happen when the organ is innervated by the same nerves that innervate a somatic dermatome or myotome.
Convergence occurs when neuronal changes occur in an area of referred pain, which then becomes sensitised or in which neuroinflammation occurs. This in turn will lead to sensitisation of the spinal cord and supraspinal structures by means of continued nociceptive afferent barrage.
Underlying this mechanism will always be a series of trigger points in the affected tissue.
Nature of a trigger point
The most recognised description of a trigger point is that by Travel & Simons: “A hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle fascia, that is painful on compression and that can give rise to characteristic referred pain, tenderness and autonomic phenomena.” It may be active or latent and may or may not elicit a twitch response.
When there are trigger points in a muscle, the muscle will weaken and cannot accomplish full range of motion; muscle and fascia contract, establishing shortened position, and surrounding muscle groups compensate, become overloaded and develop trigger points.
The integrity of the dysfunctional endplates within the trigger area is mechanically disrupted in order to inactivate a trigger point, resulting in mechanical and physiological resolution. Ischaemic pressure, stretch, connective tissue manipulation, dry needling, injection are the treatment options.
Connective tissue restrictions
The viscero-somatic reflex was first documented in 1894 by Henry Head, and this reference is still used in teaching today. Connective tissue restrictions will occur as a result of visceral referred pain in dermatomes associated with the nerve roots of an inflamed peripheral nerve, superficial to muscles with myofascial trigger points and to areas of joint dysfunction. Connective tissue restrictions can be present with or without hyperalgesia.
In manipulating the connective tissue to release it, the goals are to improve circulation, restore tissue integrity, decrease ischemia, reduce chemical irritants, eliminate adverse reactions in viscera and decrease adverse neural tension of peripheral nerve branches.
Neuromuscular evaluation
A study by Anderson et al in 2009 involving 72 men with symptoms of UCPP described the location of trigger points and the areas of referral. Tenderness of the pubococcygeus and/or puborectalis were associated with highest scores on the visual analogue scale. These muscles elicited pain in the penis in 93 per cent of patients. The most reactive muscle were the rectus abdominis and the external obliques and palpation of these sites elicited pain in the penis, the perineum, the rectum and the suprapubic area. Coccyx or buttock pain could be elicited by palpation of the gluteus maximus.
The musculoskeletal causes and associations with chronic pelvic pain are poor posture, often associated with sedentary jobs, coccyx injury, sports e.g. cyclists, gym/abdominal over-trainers, abdominal holders and holding patterns associated with stress.
Physiotherapy assessment of the patient with CPP involves a full musculoskeletal examination of the pelvis, lumbar spine, thoracic spine, abdomen, hips, laterally thighs and inner thighs. Asymmetry of the pelvis, short muscles and postural adaptations are evaluated and addressed.
The perineum, perineal connective tissue, scrotal tissue, penis, superficial pelvic floor muscles, bulbospongiosus, transversus perineii, perineal body and ischiocavernosus are assessed. Internally the sphincter, the prostate, the attachments of the levator ani at the pubic bone, the levator ani as they extend back to the coccyx, the obturator muscles and the ischiococcygeus are all assessed.
Systematically each of these structures is palpated for taut bands and trigger points and the connective tissue manipulated for restrictions. Neural assessment involves pudendal nerve, obturator, posterior femoral cutaneous nerve and nerves of thoracolumbar origin.
Physiotherapy treatment
The NIH chronic prostatitis symptom index (NIH – CPSI) is a useful measurement tool for these patients before treatment starts. Postural asymmetries and short muscle groups are identified and treated. The connective tissue over the perineum is manipulated, symptomatic taut bands or trigger points are treated externally by flat palpation or by pincer palpation externally to the opposing palpating finger internally.
The deep muscles are palpated per rectum and trigger points reproducing the pain are treated using ischaemic pressure and stretch. The pressure is held for up to one minute until the referring or localised pain eases and the therapist moves on to the next point. Gradually the tension eases.
Dry needling can also be used on the pelvis externally and on the perineum, and in the ideal situation the physiotherapist would work with the urologist or anaesthetist to manipulate tissue following an anaesthetic injection to the localised point causing pain, first identifying that this is the cause of pain diagnostically and then to maximise the effect of the manipulation.
Frequently there will be good relief on numerical rating scale during treatment, but because the pain will come back, treatment is required over time, and the patient must learn breathing and release exercises to keep the tone down and to stop feeding into the pain tension pattern. A book called A Headache in the Pelvis by psychologist David Wise and urologist Rodney Anderson describes systematic relaxation for these patients and is a ‘must’ for any patient with chronic pelvic pain or any physician treating it.
The patients will typically need to be followed up over a few months with frequency of treatment varying from patient to patient. A recent pilot study in the US with good results in favour of connective tissue manipulation recommends ten one-hour sessions in order to be able to make the required changes where treatment may be ongoing after this period of time.
This study shows a 57 per cent improvement in those patients with UCPPS who received connective tissue manipulation against a 21 per cent improvement in those who received general massage.
Chartered Physiotherapists in Women’s Health & Continence has a list of therapists who are trained to carry out these assessments and treatments. This recently updated list is soon to be distributed by Pfizer and is available from the ISCP office at www.iscp.ie.
l Maeve Whelan, Specialist Chartered Physiotherapist, Milltown Physiotherapy Clinic, Milltown, Dublin 14
References on request.

Rory Hafford sits down with the straight-talking Prof Moira O’Brien to discuss bone health, the teaching of medicine and the lure of the Olympics

Talking to Prof Moira O’Brien is a bit like being caught in a wind tunnel! In fact, ideas and words can come hurtling towards you like a runaway train, or bang into you with the force of tiny meteors. She certainly makes you think: about how medicine is practised here in Ireland; about how medicine is taught in this country; and about the treatment options employed in the specialty with which she is mainly associated — osteoporosis.
Operations
When I caught up with her, she was recouping from the ‘mild inconvenience’ of a leg operation; her second in recent years. Dangerous ground, because you get the distinct impression that this woman is well used to cranking out regular 14-hour days and addressing assemblies numbering in the hundreds. Being cooped up in a hospital ward, in a room on her own, results in a lot of free time to think. Consequently, I got both barrels.
“They have made a mess of teaching anatomy in the colleges…
“The way the diagnosis and treatment of osteoporosis is handled in this country leaves a lot to be desired…
“Awareness is key. We need to be putting resources into getting the message out that this is a preventable disease… if managed properly.”
The professor’s words carry weight. When she talks, people listen. You can’t but. Behind the words is a world of real and relevant experience, not least of all her 25 years teaching at the Royal College of Surgeons, followed by another 25 years in Trinity College, where she still plies her trade. Allied to this, her enthusiasm is infectious. She is animated in her delivery, powerful in her pronunciation (50 years of teaching will do that to you) and passionate about medicine. She describes herself as a ‘people person’. And it shows.
She embraces change and pushes back boundaries. She was the first person to introduce a DEXA machine to this country, back in 1990; she set up the first student Sports Medicine body in Trinity College in 1985; she was one of the pioneers in the advancement of osteoporosis treatment in Ireland.
In some respects, her life reads like something out of an action/adventure novel. She was born in Malaysia, where both her parents worked as doctors. She was then shipped off with the family to Australia at the age of eight, earning the status of ‘refugee’. Shortly afterwards, her father became a prisoner of war, courtesy of the Japanese.
The life aquatic
Fast forward a number of years and Moira O’Brien, who by this time had qualified in Medicine, was moving to Sheffield, England, with her new husband, who had just landed a medical post with the Coal Board. But she didn’t like Sheffield. All her life she had lived near water: Sheffield was nowhere near water.
She applied for a number of jobs in Ireland and, in her own words, took the one with “the shortest hours and the longest holidays”.
Her love of sports was one of the main factors leading to her taking up a post with the Irish Olympic team, a role with which she is today well identified. “I swam, played hockey and ran. I loved sports,” she says.
Olympic physician
Working as the Olympic physician was where she was first exposed to the problems of osteoporosis. “When the girls overtrained they lost their periods; when the guys overtrained they lost testosterone. The fractures began to mount up and I knew we had to do something to address the problem at source.”
She certainly loved her time working with the Olympians. “I suppose I rubbed a few people up the wrong way because I really enjoyed what I was doing – and I did it in the days when you didn’t get paid for it. You did it because it excited you and because you could make a difference to the performance of the athletes.”
It’s the same, it could be argued, with osteoporosis. She has long been one of the main drivers behind the Irish Osteoporosis Society, attempting to damn up the tsunami of fractured and brittle bones that threatens to leave the health system awash with collateral damage.
She puts the problem into stark focus: “Osteoporosis is the commonest bone disease worldwide. One in two women and one in five men over the age of 50 will go on to develop an osteoporotic fracture. I see an awful lot of anorexic people and stressed people who are suffering with compromised bond structure as a result. The economic climate that we are currently faced with is also a causative factor. Think about it; if you lose your job, your stress levels kick up and your hormones are affected. This, in turn, has a knock-on effect on your bones.”
She is a big believer in going back to source and trying to head the problem off at the pass, as it were. Let’s take the sun, for instance.
Sun exposure
“We looked at 200 patients in the last year who have low bone densities and, of those, a large proportion have low vitamin D levels (below 50 n/mls per litre). With this in mind, here’s what we are advocating… ten minutes in the sun without sunblock to help absorption. I know this could be seen as a bit controversial in some circles, but ten minutes is not going to cause any burn damage.
“We have to remember that 70 per cent of the vitamin D you get is through the skin and we need to encourage this. What is happening now, apart from sunblock, are moisturisers and make-up which are also carrying sunblock. If I’m controversial in this it’s because I want to get to the source of the problem; I want to treat the cause. Osteoporosis is a condition that is wholly preventable, provided we act in time.”
She says that one of the commonest causes of this condition in Ireland is steroids.
“People are being given steroids for asthma and fibromyalgia and cancer… You need to treat the cause and, if you are putting somebody on a medication that can exacerbate the problem, then you need to do something about that.
“If your patient has two or more risk factors [for osteoporosis] then they need to have a DEXA scan. It’s as simple as that. Why wait? Why wait until they fracture? It doesn’t make sense.”
She pauses for a beat, perhaps to let the point sink in… and then continues: “I suppose I belong to the old school, where the patient always came first.”
I’m almost afraid to ask how she feels the condition is treated in the community. But I do.
“There are some excellent GPs, who are genuinely interested in this condition. But there are also others who are slightly dismissive towards it, saying it’s an old ladies’ disease, or a condition that was developed by some elements in the pharmaceutical industry. This is rubbish. It is totally preventable. But we have to be vigilant towards it early on.
“Between the ages of eight and twenty are the most important years, when bone is laid down. When we were kids we had PE every day. Nowadays kids aren’t encouraged to do weight-bearing exercises. We need to be encouraging the proper supplements and oily fish and super milk. These little things could make all the difference.”
Anatomy
She likes things done properly. And simply. Take the teaching of anatomy, for instance. “I really feel they have destroyed the way anatomy is taught. The big issue, in my opinion, is the problem-based learning approach. Look at it this way: they give you a problem and tell you to go solve it. But you can’t build a house unless you have the basic building bricks to do so and, if you haven’t been taught the basics [in anatomy], you can’t solve the problem. If you don’t know what is normal, you can’t tell what is abnormal.
“The basic principles need to be explained simply. The way they are doing it now is wrong,” she stressed.
There’s a theme emerging with Prof O’Brien: go back to basics; approach things simply; and keep the patient front and centre. And make no bones about it!