Physical Medicine and Rehabilitation
Patients with spinal cord injury and other conditions that cause neurogenic bladder are at higher risk of developing complications of urinary tract infections, which can drive over-investigation and over-treatment. However, several high-quality studies have demonstrated that screening for and treating asymptomatic bacteriuria (outside of pregnancy and urologic procedures) increase the risk of microbial resistance and the emergence of symptomatic urinary tract infection (UTI). Clinicians should order urine cultures if there are signs and symptoms of a urinary tract infection. Clinicians should treat suspected UTI only with evidence bacteriuria with accompanying signs or symptoms.
Craven BC, Alavinia SM, Gajewski JB, et al. Conception and development of Urinary Tract Infection indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project. J Spinal Cord Med. 2019 Oct;42(sup1):205-214. PMID: 31573440. https://pubmed.ncbi.nlm.nih.gov/31573440/
Kavanagh A, Baverstock R, Campeau L, et al. Canadian Urological Association guideline: Diagnosis, management, and surveillance of neurogenic lower urinary tract dysfunction – Executive summary. Can Urol Assoc J. 2019;13(6):156-165. PMID: 30763235. https://pubmed.ncbi.nlm.nih.gov/30763235/
There is insufficient evidence that a mandatory period of physical and cognitive rest following concussion (mild traumatic brain injury) minimizes concussion symptoms or promotes recovery. Patients, rather, should be counselled to return to normal activity as tolerated after a brief period of rest. Athletes should return to competitive sport on a graduated basis following concussion.
McCrory P, Meeuwisse W, Dvořák J, et al. Consensus statement on concussion in sport-the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017 Jun;51(11):838-847. Epub 2017 Apr 26. PMID: 28446457. https://pubmed.ncbi.nlm.nih.gov/28446457/
Marshall S, Bayley M, McCullagh S, et al. Guideline for Concussion/Mild Traumatic Brain Injury and Persistent Symptoms: 3rd Edition (for Adults 18+ years of age). Toronto, ON: Ontario Neurotrauma Foundation, 2018. https://braininjuryguidelines.org/concussion/fileadmin/pdf/Concussion_guideline_3rd_edition_final.pdf
There is insufficient evidence that opioids for chronic pain management improves symptoms or enhances function. Conversely, opioid usage is associated with side effects and carries substantial risks, including of dependency and poisoning. Opioids for chronic noncancer pain should be initiated only after other nonopioid options have been exhausted. Prescribers are encouraged to escalate opioid doses judiciously with a view to stabilizing patients on the lowest effective dose that will enable patients to achieve their treatment goals. Moreover, opioids should be discontinued if clinically important goals, such as reduction in pain or improved function, are not achieved.
Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659-E666. PMID: 28483845. https://pubmed.ncbi.nlm.nih.gov/28483845/
Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015 Feb 17;162(4):276-86. PMID: 25581257. https://pubmed.ncbi.nlm.nih.gov/25581257/
Health Quality Ontario. Opioid Prescribing for Chronic Pain [Internet]. 2018 [cited 2022 June 1]. https://www.hqontario.ca/portals/0/documents/evidence/quality-standards/qs-opioid-chronic-pain-clinician-guide-en.pdf
In the absence of red flags, most patients with acute low back pain will improve, and do not require imaging for diagnosis. Patients without red flags should be treated with at least a 4-6-week trial of conservative management. Red flags for low back pain include but are not limited to severe or progressive neurologic deficit, cauda equina syndrome, or suspected cancer, infection, compression fracture, epidural abscess, or hematoma.
Canadian Association of Radiologists. 2012 CAR Diagnostic Imaging Referral Guidelines [Internet]. 2012 [cited 2022 June 1]. https://car.ca/patient-care/referral-guidelines/
Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72. PMID: 19200918. https://pubmed.ncbi.nlm.nih.gov/19200918/
Interventional pain treatments can include injections in or around joints, bursae, nerves, and tendons, with or without the guidance of imaging modalities such as fluoroscopy or ultrasound. Risks and side effects are uncommon but can be serious. Injections should only be repeated if previous injections have demonstrably resulted in the achievement of goals such as reduction of pain or functional improvement.
Health Quality Ontario. Chronic Pain: Care for Adults, Adolescents, and Children (Updated Draft) [Internet]. 2018 [cited 2022 June 2]. https://www.hqontario.ca/portals/0/documents/evidence/quality-standards/qs-chronic-pain-clinical-guide-1810-en.pdf
Health Quality Ontario. Chronic Pain: Care for Adults, Adolescents, and Children (Updated Draft) [Internet]. 2018 [cited 2022 June 2].
Carpal tunnel release is a highly effective treatment for Carpal Tunnel Syndrome (CTS). Clinicians considering referral for surgical management should be aware that good surgical outcome is best correlated with a combination of positive clinical and positive electrodiagnostic studies (EDx). More recently, ultrasound has also been established as an accurate test in diagnosing CTS. Clinical tests together with a supportive diagnostic investigation, such as EDx or ultrasound, have a better association with surgical outcome than either alone. Surgery for CTS is typically reserved for patients who fail conservative measures, such as an adequate trial of splinting.
Cartwright MS, Hobson-Webb LD, Boon AJ, et al. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve. 2012 Aug;46(2):287-93. PMID: 22806381. https://pubmed.ncbi.nlm.nih.gov/22806381/
Basiri K, et al. Practical approach to electrodiagnosis of the carpal tunnel syndrome: A review. Adv Biomed Res. 2015 Feb 17;4:50. PMID: 25802819. https://pubmed.ncbi.nlm.nih.gov/25802819/
Bland JD. Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle Nerve. 2001 Jul;24(7):935-40. PMID: 11410921. https://pubmed.ncbi.nlm.nih.gov/11410921/
Encouraging thoughtful conversations about the harms associated with opioid prescribing.
Using Antibiotics Wisely in Long-Term Care
A campaign to help clinicians use antibiotics wisely in long-term care.
Using Antibiotics Wisely in Primary Care
A campaign to help primary care clinicians use antibiotics wisely in practice.
Imaging Tests for Lower Back Pain
When you need them and when you don’t.
Treating Lower Back Pain
How much bed rest is too much?