Journals Watch - MRIs, migraine and Bell's palsy

Too busy to catch up on the latest research? Let Dr Katrina Ford update you on recent papers.

GP access to MRI for knees is effective - Br J Gen Pract 2008; 58: 767-74
An MRI scan of the knee is often only performed after consultation with an orthopaedic surgeon.

This study looked at 553 patients aged 18-55, with continuing knee problems, suspected to have injury to the menisci or ligaments, rather than osteoarthritis, and for whom their GP was considering referral.

Patients were randomised to MRI within 12 weeks of direct GP referral or an orthopaedic appointment within nine months of GP referral. The primary outcome measure was a 36 item physical functioning scale and the Knee Quality of Life 26 item questionnaire.

Credit: SPL

Direct GP referrals for knee MRI scans led to an improved quality of life for the patients

Access to MRI did not affect GPs' decisions on the need for referral to a hospital specialist and orthopaedic surgeons performed more arthroscopies in the MRI group - perhaps reflecting the ability of the GPs to accurately assess and refer for MRI the patients most likely to have pathology needing surgical intervention.

Physical functioning scores in the MRI patients improved by 2.81 (p=0.072) more than those referred to orthopaedics and the Knee Quality of Life score improved by 3.65 (p=0.007).

Migraine prophylaxis with topiramate and amitriptyline - Clin Neurol Neurosurg 2008; 110: 979-84
Both antidepressant and anti-epileptic drugs are well established in the prophylaxis of migraine, and indeed monotherapy is still recommended, but dual/combination therapy is a widely accepted standard practice due to the involvement of multiple mechanisms in the pathophysiology of pain.

This double-blind randomised controlled trial (RCT) looked at the efficacy and tolerability of amitriptyline and topiramate in combination for the prevention of migraine, in comparison with monotherapy with these agents.

The researchers evaluated frequency, duration and severity of migraine attacks, accompanying symptoms, depressive state, consumption of medications, side-effects and patient satisfaction in 73 patients.

All patients received drug therapy and all treatments resulted in significant improvements in all efficacy measures (p<0.001). Patients receiving combination therapy had higher satisfaction scores and those receiving amitriptyline (alone or in combination) had better depression scores.

Amitriptyline caused more side-effects, which can limit use but it would be a good choice with co-morbid depression.

Prednisolone and valaciclovir in Bell's palsy - Lancet Neurol 2008; 7: 992-1,000
There is evidence that Bell's palsy, previously thought to be idiopathic, is due to latent herpes viruses. The treatment debate continues, but many physicians use steroids and antiviral drugs for those patients presenting with moderate/severe facial nerve palsy, within 72 hours.

Previous trials have been underpowered or had insufficient follow-up. This double-blind multicentre RCT studied 829 patients with 12 months of follow-up.

Patients received two placebo drugs, valaciclovir + placebo, prednisolone + placebo or valaciclovir + prednisolone.

The primary outcome event was time to complete recovery of facial function.

Time to recovery was significantly shorter in the patients who received steroids but there was no difference in those treated with valaciclovir compared to those who did not receive the antivirals.

Risk of subarachnoid haemorrhage - Brain 2008; 131: 2,662-5
This Swedish population-based case-control study analysed the risk of an aneurysmal subarachnoid haemorrhage (SAH) in first degree relatives of patients with this type of stroke.

The first degree relatives of all patients diagnosed with SAH in 2001-2005 (5,282 people) were checked (130,373 relatives in total) for a diagnosis of SAH. For each SAH patient, five controls were identified.

The odds ratio of SAH for patients with one affected first degree relative was 2.15 (95% CI 1.77-2.59) and 51 for patients with two affected first degree relatives (95% CI 8.56-1,117).

This hugely increased risk of SAH corresponds to a considerable absolute lifetime risk and individuals with two affected relatives should probably be screened.

Foot orthoses and physio for patellofemoral pain - BMJ 2008; 337: a1735
Runner's knee (patellofemoral pain) is a dull aching pain around the patella, often called chondromalacia patellae, and is a common cause of anterior knee pain.

Physiotherapy and foot orthoses can be used to treat the condition.

In this study, 179 patients were randomised, who had at least a six-week history of the condition and had not been treated in the previous 12 months. Flat inserts were compared with orthoses, or physiotherapy alone.

Six weeks of treatment followed and the main outcome measures were global improvement, severity of usual and worst pain, a knee pain scale and a functional index questionnaire at six, 12 and 52 weeks.

Foot orthoses were superior to flat inserts at six weeks (25 vs 58 per cent moderately or markedly improved). No significant differences were found between foot orthoses and physiotherapy, or between physiotherapy and physiotherapy + orthoses. All groups did, however, show long-term improvement and so GPs could try to speed up a patient's recovery by recommending that patients use orthoses.

It is not clear whether those purchased in a pharmacy would be as effective as custom built ones obtained from an orthotic department.

  • Dr Ford is a GP in Worcestershire and a member of our team who regularly review the journals

The quick study

  • MRI scans for knees are used appropriately when directly accessed by a GP.
  • Migraine patients benefit from combination therapy of amitriptyline and topiramate.
  • Bell's palsy patients have a shorter time to recovery when treated with prednisolone but valaciclovir did not affect facial recovery.
  • Subarachnoid haemorrhage risk is considerably higher in first degree relatives of patients with SAH.
  • Foot orthoses are useful for patients with patello-femoral pain.

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