Journals watch: Hip replacements and back pain

Running short of time to read the journals? Allow Dr Raj Thakkar to be your guide to the latest findings

Total hip replacement surgery is opted for when pain levels become severe or when mobility and hip function becomes impaired

Research of the week  

Regular physical activity and COPD  

Thorax 2006; 61: 772–8  

COPD is a difficult condition to manage well.  

Many patients with COPD fear hospital admission, and frequency of hospital admissions is a common clinical end-point in trials.  

This Danish cohort study assessed the influence of exercise on hospital admissions for COPD and mortality.  

Investigators gathered information about physical activity levels among the 2,386 cohort (very low, low, moderate and high).  

Significant reductions in hospital admission were found in all outcome groups in those who exercised regularly.  

It is important we encourage and motivate our patients with COPD to exercise.  

Decision to perform total hip replacement  

Ann Rheum Dis 2006; 65: 1,346–50     

There is often vagueness in making the decision to perform total hip replacement (THR). Opinions between surgeons appear to vary widely, as do those of GPs. In this study, 304 orthopaedic surgeons and 314 referring doctors took part, spanning 12 countries across Europe.  

Each participant was asked to state what importance different domains (pain, physical examination and radiographs) had on their decision to recommend THR. The questionnaire included levels of severity for each parameter beyond which surgery was recommended. Surgeons and referring doctors were able to suggest personal and environmental reasons for surgery. Pain and function appeared to be the most important factors in the decision to refer for and perform THR.  

Agreement of severity of each parameter, beyond which surgery was indicated, varied. Referring doctors tended to have a higher threshold before considering surgery.  

Diagnosis and management of ankylosing spondylitis  

BMJ 2006; 333: 581–5  

Back pain is all too common in our daily practice, and this clinical review summarises the diagnosis and management of ankylosing spondylitis, a chronic inflammatory rheumatic disorder that primarily affects the axial skeleton. The article reviews the main features that help us distinguish simple back pain from ankylosing spondylitis.   

The diagnostic criteria include back pain that is persistent for at least three months. Inflammatory type pain is worse in the morning and after other periods of immobility.  

Reduced lumbar motion can be demonstrated using Schober’s test. Reduced chest expansion and evidence of sacroiliitis also form part of the criteria.  The ‘question mark’ posture due to loss of lumbar lordosis and exaggerated kyphosis and associated extra articular features are also important determinants.  

Acupuncture for low back pain  

BMJ 2006; 333: 623  

There is a catalogue of evidence supporting the use of acupuncture in a variety of medical conditions. This open study looked at the management of simple low back pain.  

It involved 241 patients aged between 18 and 65 with non-specific low back pain, all based around in the York region. The study compared usual treatments such as physiotherapy and analgesia, to acupuncture.  

Using the SF-36 pain score, the researchers found acupuncture improved symptoms after a two-year period. Other scores did not prove to be statistically significant.  

While the researchers admit to flaws within the study, perhaps the argument for the increased use and availability of acupuncture has been made. At the very least, more rigorous trials are required.  

Cardiovascular risks and deprivation  

Heart 2006; 92: 1,198–206  

We have been taught that the individuals with a low socioeconomic status have greater morbidity and a lower life expectancy. This UK-based screening study looked at 37,161 women and 33,977 men aged between 35 and 60 years.  

The analysis looked at risk factors over a 10-year period from 1989. The study confirmed that those in deprived groups had a greater overall cardiovascular risk factor profile compared to affluent groups and were more likely to smoke over the period of analysis.  

It is intuitive that we should not neglect those most in need. However, by 1999, affluent men had a higher BP, and both affluent men and women had higher cholesterol compared to those in lower socioeconomic groups.  

Dr Thakkar is a GP in Woodburn Green, Buckinghamshire, and a member of our team who regularly review the journals 

The quick study  

Hip pain and function are important factors in recommending replacement surgery.  

Persistent back pain could be a sign of ankylosing spondylitis.  

Acupuncture can give some relief to lower back pain.  

Affluent men are most likely to have high BP and cholesterol. 

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