Medical Forum – March 2022 – Public Edition

COVER STORY

What’s in a name?

Pain Management | Managing chronic back pain, cervical radiculopathy, rhizotomy, injections MAJOR PARTNERS

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EDITORIAL BACK TO CONTENTS

Cathy O’Leary | Editor

Namecalling “And if you think medical doctors are the only ones grappling with the term surgeon, spare a thought for the garden business.”

As specialists and hospitals juggle with changing rules over what elective surgery can be carried out in WA, it seems an apt time to consider just what is a surgeon?

It may seem straightforward enough, especially for readers of this magazine, but history suggests otherwise.

Confusion over the use of the title ‘surgeon’ can be traced back to 16th century London, when barbers and surgeons were in the same guild, known as the Company of the Barber-Surgeons.

They were effectively GPs of the day, but doing anything from amputations, to bloodletting and syphilis treatment, as well as haircuts and beard-pressing.

No wonder surgeons decided to break away in the mid-1700s so they wouldn’t be asked to do a short-back-and-sides instead of an appendectomy.

Fast-forward 200 years or so, and ‘surgeon’ is still an unprotected title and causing grief, as this month’s cover story explains.

Adding to the confusion for patients is that many doctors currently practising have a MBBS which clearly states a Bachelor of Surgery – so little wonder patients might consider anyone with that degree is a specially trained surgeon.

Only time will tell whether the newish MD (Doctor of Medicine) degree for medical graduates will make it any less confusing to the punters.

And if you think medical doctors are the only ones grappling with the term surgeon, spare a thought for the garden business.

Apparently, tree surgeons are the ‘paramedics’ and arborists are the ‘doctors’ of the industry. Tree surgeons prune, fell and remove trees, limbs and stumps, while arborists have specific qualifications to look after the entire ‘body’ or garden.

Perhaps an orthopaedic surgeon trimming a tree limb in their backyard would be considered more than qualified?

SYNDICATION AND REPRODUCTION Contributors should be aware the publisher asserts the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publisher for copyright permission.

DISCLAIMER Medical Forum is published by Medical Forum WA as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Competition and Consumer Act 2010 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. Medical Forum has no professional involvement with advertisers other than as publisher of promotional material. Medical Forum cannot and does not endorse any products.

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MARCH 2022 | 1

CONTENTS | MARCH 2022 – PAIN MANAGEMENT

Inside this issue 18 22

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16

FEATURES

IN THE NEWS

10 Cover Story: Surgeons – carving

1

Editorial: Name-calling – Cathy O’Leary News & views

18 Medicinal cannabis gains traction 22 Close-up: Dr Richard Magtengaard

4 6 8 30

LIFESTYLE

39 Necessity the mother of invention

out a name

16 Q & A: WA Health Minister Amber-Jade Sanderson

58 59 60 61

Alliance Francais French Film Festival Sculpture by the Sea

In brief Letters to the editor Action needed on trachoma – Dr Melissa Stoneham PhD – Dr Kieran Hennelly

40 Support crucial for complex conditions – Rachel Seeley

ThornBird takes flight

43 Rethinking pain management

Wine Review: Fermoy Reserve – Dr Craig Drummond

– Dr Joe Kosterich

57 Living with chronic pain

62 Declutter your life

– Jenn Morris

ANOTHER LUCKY WINE WINNER Dr Clare Matthews will soon be enjoying some iconic Sandalford wine after winning the December doctors dozen. This month, Dr Craig Drummond returns to Fermoy Estate to taste two of its premium wines – see his review on P61 – and we have another dozen bottles to win.

Go the competitions tab at wwww.mforum.com.au or enter via our weekly e-newsletter.

CONNECT WITH US /medicalforumwa

/medical-forum-wa-magazine

/MedicalForum_

info@mforum.com.au

2 | MARCH 2022

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CONTENTS

PUBLISHERS

Clinicals

Fonda Grapsas – Director Tony Jones – Director tonyj@mforum.com.au

ADVERTISING Advertising Manager Andrew Bowyer 0424 883 071 andrew@mforum.com.au

EDITORIAL TEAM

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Bilateral total knee replacement Dr Philip Finch

Lifting & back pain Ben Davis

Managing the person with back pain Dr JP Caneiro PhD

Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Production Editor Ms Jan Hallam 08 9203 5222 jan@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au

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The ‘psych’ in ‘biopsychosocial’ for pain Dr Rob Schütze PhD

Acute Cervical radiculopathy Dr Reza Feizerfan

What exactly happens in a rhizotomy?

Dr Brian Lee

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Image-guided lumbar spine injections Dr Sven Klinken

Medicinal cannabis & IBS A/Professor Alistair Vickery

Clinical Services Directory Editor Andrew Bowyer 08 9203 5222 andrew@mforum.com.au

GRAPHIC DESIGN Ryan Minchin ryan@mforum.com.au

CONTACT MEDICAL FORUM Suite 3/8 Howlett Street, North Perth WA 6006 Phone: 08 9203 5222 Fax: 08 6154 6488 Email: info@mforum.com.au

Guest Columns

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After-life care Dr Jodi White

Public Health’s election wish-list Terry Slevin

Are our hospitals at risk of cyber attack?

Jeremy Hulse

At-home rehab opens possibilities Jonathon Moody

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MARCH 2022 | 3

NEWS & VIEWS

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Diabetes test hope One of the State’s leading medical researchers will help drive a new national diabetes research push to develop a virtual research centre connecting hubs around Australia.

The Australian Centre for Accelerating Diabetes Innovation will also link in with key industry partners and diabetes organisations to help develop new treatments, technologies and behavioural interventions to meet the challenges of the diabetes epidemic.

As part of the initiative, Diabetes Research WA is funding work by the head of WA's Centre for Diabetes Research, Professor Grant Morahan, who is based at the Harry Perkins Institute.

He said his project would focus on developing a genetic test which could predict which Australians with diabetes were more at risk of developing diabetic kidney disease.

Professor Grant Morahan

“DKD is the most frequent cause of kidney failure, leading to dialysis or kidney transplant, and is a risk factor for cardiovascular disease, a leading cause of death in diabetes,” Professor Morahan said.

“A test has the potential to diagnose risk status years before the onset of symptoms, and those found to be at high risk of DKD could be managed more tightly to delay or prevent diabetic complications.”

Timely warning As fires threatened lives across large tracts of WA, and floods disrupted food deliveries, doctors have been urging State and Federal governments to take urgent action to mitigate the worst effects of climate change.

Doctors for the Environment Australia member Dr Richard Yin said West Australians have faced a triple whammy of fires, heatwaves and food insecurity this summer.

Bubbles may hold cancer key Curtin University researchers will investigate the make-up of cancercarrying ‘bubbles’ with the ultimate aim of detecting pancreatic cancer in its early stages, thanks to funding from PanKind, the Australian Pancreatic Cancer Foundation.

“More frequent, prolonged, and severe heatwaves, bushfires, droughts, and disruption to vital infrastructure from storms and floods are all predicted with a warming climate. What we’re experiencing now has occurred with just 1°C of warming. The trajectory is clear, and it will have devastating outcomes.”

Led by Professor Marco Falasca from the Curtin’s Medical School, the research will focus on bubbles located in pancreatic cancer cells that can be discovered in blood and other body fluids.

DEA WA chair Dr Emma-Leigh Synnott said the group was 4 | MARCH 2022

“These bubbles, which are called exosomes, are used by cancer cells to communicate and help spread the cancer,” he said. “By identifying the molecules transported by exosomes that are unique to pancreatic cancer, we are aiming to use them as markers that will hopefully mean we are able to help detect pancreatic cancer in its early stages.”

“As health professionals, we urge all parties and candidates in the next Federal election to commit to act on climate change for the sake of human health.”

“Life with COVID has been unsettling enough, and the fires have added another level of uncertainty,” he said. “This is a looming crisis, and we need governments to recognise that and act immediately.

Dr Yin said the psychological impacts of heatwaves, bushfires and floods were also consistently underestimated.

the development of effective drug therapies.

calling on governments to adopt ambitious plans to cut emissions this decade, ban new coal, gas and oil projects and provide greater support for renewable energy.

Professor Falasca said the research ultimately aimed to help detect pancreatic cancer – one of the deadliest and most aggressive forms of cancer – in its early stages, allowing for early intervention and

Plastic not-so-fantastic King Edward Memorial Hospital is taking part in a pilot project to reduce single use plastics from health care going into landfill and the ocean, in a bid to tackle the sector’s significant contribution to plastic waste.

Health care generates hundreds of thousands of tonnes of waste each year and one-third of its general waste is plastic. The 12-month project is the first of its kind for health care providers, run in partnership with Plastic Oceans Australasia and the Climate and Health Alliance. This project has been supported Minderoo Foundation’s Flourishing Oceans Initiative and it is hoped results will be available early next year.

continued on Page 6

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Spinal surgery & pain management Meet our specialists ORTHOPAEDIC SPINAL SURGEONS Dr Farhaan Altaf Dr Ed Baddour Dr Greg Cunningham Dr Eamonn McCloskey Dr Siamak Seresti Dr Braad Sowman

NEUROSURGEONS

For complex spinal cases, refer your patients to St John of God Subiaco Hospital.

Dr Graham Jeffs

Our highly experienced spinal specialists collectively undertake over 2,000 back and neck procedures a year.

Professor Chris Lind

They are supported by our hospital’s growing Procedural Pain Service and have access to leading innovations and technology to ensure optimum outcomes.

Dr George Wong

After becoming one of the first hospitals in Australia to commission an Airo Mobile Intraoperative CT Scanner in 2016, St John of God Subiaco Hospital was the first private hospital in Western Australia to purchase an O-Arm last year.

The O-arm is a mobile x-ray system, which provides 360 degree, 3D images in real-time, and can be used at any stage before, during and after spinal surgery.

Enhanced imagery improves surgeons’ visibility of anatomy, optimising clinical decision making and surgical accuracy.

Dr Michael Kern Dr Mark Lam Professor Gabriel Lee Dr Andrew Miles

PROCEDURAL PAIN SPECIALISTS Dr Duane Anderson Dr Chin-wern Chan Dr Daniel Ellyard Dr Alireza Feizerfan Dr Michael Kent Dr Brian Lee Dr Vince Mondello Dr Jenni Morgan

For more information To learn about the expertise and interests of our specialists, visit bit.ly/FaS-Subiaco subiaco.cpd@sjog.org.au MEDICAL FORUM | PAIN MANAGEMENT

(08) 6462 9689

sjog.org.au/subiacoGPs MARCH 2022 | 5

Fremantle GP and UWA senior lecturer Dr Brett Montgomery has been appointed by the National Asthma Council of Australia to its committee which helps develop guidelines for its national handbook on asthma management.

This year’s Science on the Swan, which showcases the best of WA research, has the theme Creating Impact through Healthcare Innovation and Commercialisation. The conference is on May 9-11 at the Perth Convention and Exhibition Centre.

A Curtin University nutritional epidemiologist has been awarded a three-year fellowship by MS Australia. Associate Professor Lucinda Black from the School of Population Health will study a possible link between diet and multiple sclerosis progression.

NEWS & VIEWS The study co-led by Harry Perkins Institute geneticist Professor Nigel Laing has topped its target of 1340 WA couples, who were screened for more than 750 severe genetic diseases, including many that lead to death before the age of four.

continued from Page 4

Winning ways Two WA-based health services have taken out gongs in the latest HESTA awards.

The Australian Red Cross Lifeblood team has been recognised for its microbiome program, created in partnership with Fiona Stanley Hospital, to supply faecal microbiota for transplant to patients suffering from recurrent Clostridioides difficile infection.

This potentially fatal illness occurs when the balance of healthy bowel bacteria is disturbed.

Microbiota transplants have successfully treated 70-90% of patients with recurrent Clostridioides difficile infection.

Shelly Skinner has been recognised for her Lionheart Camp for Kids which provides quality care and support to young people and families following the death of a loved one. With over 20 years’ experience as a hospital social worker, Shelly recognised the impact death has on families, particularly young children. She went on to create the two-day bereavement program that aims to support grieving children aged five to 17.

Baby screening is tops Joondalup Health Campus has signed a long-term agreement with medical data and technology company HeraMED which allows pregnant women to monitor their baby’s heart rate at home and doctors to remotely check on the mother and baby.

Medicinal cannabis producer Little Green Pharma plans to set up a separate arm, Reset Mind Sciences, to develop its psychedelics business.

Harry Perkins Institute has received a $483,000 development grant from the National Health and Medical Research Council to evaluate novel RNA-based treatments for liver cancer.

6 | MARCH 2022

WA has exceeded its target of couples enrolled in pre-pregnancy screening in the $20m national program, Mackenzie’s Mission.

Rare diseases and malformations cause 51% of deaths in the first year of life.

Professor Laing said couples from across the State have taken up the opportunity to be screened.

“So far, nearly 70 different diseases have been identified for couples across the country. It’s not just the three diseases most often screened for – cystic fibrosis, fragile X and spinal muscular atrophy,” he said. “We have identified couples who individually have no genetic conditions in their family, but together carry a risk of having an affected child.

“Nearly 90% of couples at risk of having babies with severe genetic conditions have no family history of the disorders, no idea they are carriers, or that they are at risk of having an affected baby.”

Clarification In the February edition of Medical Forum, an opinion piece by Dr David Prentice noted him as GP/ stroke physician. GP was intended to denote general physician, not general practitioner. continued on Page 8

Parlez-vous Français?

Vous souhaitez travailler comme médecin en France? For those who understood, read on, this might be for you.

Starting in April, Alliance Française in Nedlands will be holding a short course in French medical terminology for people in the medical and medical research fields interested in working in France.

There will also be a separate workshop about working in France.

For details phone 9386 7921 or email reception@afperth.com.au.

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IN BRIEF

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MAJOR PARTNER

Family History of Breast Cancer Breast cancer is common, with a lifetime risk of one in eight for women. It is usually the result of chance and ageing with lifestyle and environmental factors also contributing. Five-year survival is greater than 90% due to early detection and advances in treatment.

In 5% of cases, there is an underlying genetic fault with either maternal or paternal inheritance. Red flag features in a particular family include multiple close relatives with breast or related cancers, cancer diagnosed at a young age (under 40) and more than one related cancer occurring in the same person.

Risk categories Risk is estimated by assessing a woman’s first- and second-degree relatives with breast or ovarian cancer using the Cancer Australia publication Advice about familial aspects of breast and epithelial ovarian cancer. Alternatively, a validated risk assessment tool can be used.

Category 1 (average risk) comprises 95% of women. The lifetime risk of breast cancer is 1-1.5 times average (<17%).

Category 2 (moderately increased risk) comprises less than 4% of women. The lifetime risk of breast cancer is 1.5-3 times average (between 17% and 30%).

Category 3 (high risk) comprises less than 1% of women. The lifetime risk of breast cancer is greater than 3 times average (>30%). iPrevent is a breast cancer risk assessment and management decision tool for clinicians and patients accessed at www.iprevent. net.au. It calculates a woman’s risk of breast cancer and facilitates prevention and screening discussions.

The CanRisk Web Tool found at www.canrisk.org is a comprehensive algorithm for use by clinicians to calculate patients’ risk of developing breast or ovarian cancer and their likelihood of carrying a genetic mutation.

Dr Pamela Thompson MBBS (Hons), FRACGP, DRANZCOG, DCH, Breast Physician Pamela graduated from UWA and began her medical career as a rural General Practitioner with a special interest in women’s health, obstetrics and paediatrics. Since 2013, she has been practising as a Breast Physician. She has a public appointment at Fiona Stanley Hospital and is in the multidisclipinary team at Perth Breast Cancer Institute.

Managing Women at increased risk Lifestyle factors such as breastfeeding, healthy diet and weight, minimising alcohol and regular physical activity are often underestimated in importance. Hormonal contraceptives and menopause hormone therapy may increase risk and should be carefully considered on an individual basis.

Breast surveillance comprises breast self-awareness, clinical breast examination and surveillance imaging.

Risk reducing bilateral mastectomy may be appropriate for some high-risk women, particularly those who carry a genetic fault. Referral to a Breast Surgeon for further discussion is important to allow women to make an informed decision.

Some genetic faults also confer an increased risk of ovarian cancer and gynaecological-oncology referral may be required to discuss risk management options. Ovarian surveillance with ultrasound or serum CA 125 is not recommended.

Mammography reduces breast cancer mortality and morbidity through early detection. The age of commencement and frequency of screening depends on a woman’s individual risk category.

Women at average risk usually commence two-yearly screening at age 50. Mammography should start earlier and be performed more often (annually) for women in a higher risk category.

Genetic testing

Additional surveillance such as breast MRI or ultrasound may be required for women at higher risk. Breast MRI should be considered as part of an overall high-risk management strategy in a designated breast clinic, as specific MBS criteria apply.

Referral to a genetic counsellor is important. Private testing is available for women who do not qualify for MBS funded testing, although the result may be uninformative.

Prevention of breast cancer Chemoprevention may be prescribed to women at moderate or high risk. Tamoxifen is on the PBS for this indication and results in a risk reduction of at least one third when taken daily for five years with benefit lasting at least 20 years. The potential risks need to be carefully balanced against the benefit for each individual by an experienced doctor.

MBS-funded genetic testing may be accessed if there is a greater than 10% chance of identifying a gene fault using a validated risk calculation tool. Initial testing (mutation search) is ideally performed on an affected family member with predictive testing offered to blood relatives if a pathogenic mutation is found.

High-risk breast clinics These operate at both tertiary public and private breast clinics. A detailed assessment of a woman’s family and personal history is performed with implementation of personalised risk management strategies. Referral for genetic testing can also be made if indicated.

PBCI Breast Clinic Suite 404, Level 4, Hollywood Consulting Centre 91 Monash Ave, Nedlands, WA 6009 Healthlink EDI: breastci Telephone: 6500 5576 Fax: 6500 5574 Email: reception@bcrc-wa.com.au www.bcrc-wa.com.au MEDICAL FORUM | PAIN MANAGEMENT

MARCH 2022 | 7

Philanthropists and private ancillary funds are being asked to fill the Federal Government’s grant funding shortfall in medical research, which is taking a disproportionate toll on the careers of young and midcareer scientists.

continued from Page 6

Young scientists given safe harbour

Harry Perkins Institute director Professor Peter Leedman said they were testing the new program to see if it could fill the funding gap affecting Australia’s scientific future.

A fund to retain outstanding young scientists in WA has awarded its first fellowship, worth $850,000, to French neuroscientist Dr Olivier Clement, whose research aims to unravel the molecular mechanisms that control how memory is formed and retained.

The plan, called Safe Harbour, is the brainchild of the Harry Perkins Institute and is designed to provide more sustainable career paths for scientists establishing their scientific careers, allocating funds raised by West Australians.

Early to mid-career researchers are considered the engine room of laboratories, with each typically having 10-15 years intensive post-secondary education and training, averaging an investment of $500,000.

“But the incomes and careers of these scientists are dependent on their ability to secure research income from the major grant funding bodies such as the National Health and Medical Research Council and the Australian Research Council and those grants are extremely difficult to get,” Professor Leedman said.

LETTERS TO THE EDITOR Dear Editor, Christopher Chi, newly minted graduate of the first cohort of graduates from the Curtin Medical School, has written a charming article about his development from raw student to raw intern.

On the adjacent page of Medical Forum (February p29), Curtin Vice-Chancellor Professor Hayne is reported as saying that this inaugural medical cohort, “has been trained to address the needs of under-serviced areas of the health care of Western Australians.”

Her comments take me back to 1956 when I stood outside the Bank of New South Wales in Hay St rattling a tin to collect donations to set up the first medical school in WA. Our three themes were: Grow Your Own Doctor, Worth not Wealth (referring to the cost of having to live in the Eastern States to study medicine) and Solve forever the shortage of doctors in the country.

In time, Dr Chi may add a knowledge of medical history – the good, the bad and the indifferent – to his definition of what makes a good medical student and doctor. To know where your profession came from, how we got to where we are today and what more can be and needs to be done.

Dr Chi agreed to be the founding secretary of the Curtin Medical

8 | MARCH 2022

Students Association, so he has organising skills. He could, or encourage others from this pioneer cohort, to record and write their story. Who did what and why? Who specialised in disorders of the well-todo and who tried to meet the needs of the poor and underserviced?

The petition was started By ICU doctor Luke Torre and promoted as “we the undersigned doctors” but because there was no vetting, people other than doctors also signed the petition before Dr Torre closed it down, with more than 6000 signatories.

It would make for a fascinating article in the 2062 New Year edition of Medical Forum.

Dear Editor, I’m pretty pleased with the hard border as we are 2,500km away from an ICU.

Dr Max Kamien

Most of our patients are doublevaccinated, however, the higherrisk patients who only qualified for AstraZeneca have only just become eligible for the booster and there are large numbers of immune compromised and chronic disease patients here.

Dear Editor, I am deeply disappointed at the poor quality of journalism that went into the recent e-newsletter article “Doctors lose patience over hard border” (January 28, 2022).

It’s no better than what I would expect of ‘Karen from Facebook’.

Also, antivirals for the majority of moderate COVID have yet to arrive in the region, so we would have experienced a disproportionate level of death in the Kimberley.

I compared the first 40 signatories on the petition to the AHPRA registers and only 11 of first 40 signatories are WA doctors.

So, the phrase ‘according to more than 5000 doctors from across WA’ cannot possibly be true.

Dr Neil Ozanne EDITOR’S NOTE: We received considerable feedback about the e-newsletter story reporting on a petition signed by doctors calling for WA’s hard border to be lifted.

The RFDS is already fully booked for critical patient transfers.

I think the doctors who are unhappy with the hard border have no understanding of the logistics for patient above the 26th parallel in WA accessing timely critical care.

Doctor’s name withheld by request Broome

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NEWS & VIEWS

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MARCH 2022 | 9

Surgeons – carving out a name Outrage over rogue cosmetic surgery practices has triggered not only a probe into the multimilliondollar industry – it has renewed calls to tighten which doctors can call themselves surgeons.

Cathy O’Leary reports

10 | MARCH 2022

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COVER STORY

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COVER STORY

When an Australian television program aired videos last year of medical staff dancing as they performed liposuction on unsuspecting patients, many people were rightly horrified. But perhaps more worrying, for some doctors it did not come as any great surprise.

Cosmetic surgery is big business, with an estimated half a million Australians spending $1 billion a year on it – more per capita than in the US. But there have long been concerns within the medical profession about some outliers carrying out questionable surgical procedures, seemingly in plain sight but never challenged.

It took a couple of whistle blower nurses and social media analysts to lift the lid off practices at celebrity cosmetic surgeon Dr Daniel Lanzer’s clinics, which at the time operated in several cities, including Perth.

Dr Lanzer trained as a specialist dermatologist but had worked as a cosmetic surgeon for many years.

He built a huge profile thanks to media appearances, TV shows and millions of followers on TikTok and Instagram.

But Cosmetic Cowboys, a joint investigation by ABC Four Corners and several newspapers, revealed an astonishingly cavalier attitude towards surgical procedures at his clinics, with doctors and other medical staff seemingly more intent on entertaining a social media audience than delivering safe care to patients, some of whom were under general anaesthetic.

A young woman was seen with an arm across her bare breasts while being asked by two male staff how much fat she thought they would be able to suck out of her abdomen during liposuction.

Pictures taken inside the clinics showed human fat stored in kitchen fridges, syringes sitting alongside water bottles, and surgical instruments stored in a suitcase.

Perth plastic surgeon and AMA WA president Dr Mark Duncan-Smith described it as “spine-chilling”.

“It was atrocious, it gave me goose-

MEDICAL FORUM | PAIN MANAGEMENT

bumps when I saw it – it was just awful,” he told Medical Forum.

WA specialist plastic surgeon Dr Brigid Corrigan, a member of the Australian Society of Plastic Surgeons, agreed there was no way to sugar-coat practices that appeared both unprofessional and unsafe.

“If you’ve undergone a surgical training program, you understand the basic principles of sterility,” she said. “And when I saw that program, I thought, ‘Oh my god’.

It might have been selective in the way it was edited, but if you watched that, anyone would be rightly horrified by what they saw.”

Soon after the damning program aired, Dr Lanzer surrendered his registration and retired, while the continued on Page 12

MARCH 2022 | 11

Surgeons – carving out a name continued from Page 11 Australian Health Practitioner Regulation Agency and the Medical Board ordered a review of patient safety issues in the cosmetic surgery sector.

The review is now underway, being led by former Queensland Health Ombudsman Andrew Brown, who is due to hand down a report by the middle of the year.

Areas to be examined include better ways to protect patients, the unfettered use of social media by some cosmetic surgeons to promote their services and why medical practitioners and clinicians are not fulfilling their mandatory requirements to report wrongdoings.

AHPRA chief executive Martin Fletcher conceded the inquiry was triggered by the media exposure.

“Obviously we were very concerned by the material that was broadcast … and although some of that was known to us and were matters we were actively investigating, there was an awful lot of information we didn’t know,” he said at the time.

Debate rages The fallout from the program has seen the many vested interests and professional organisations arguing their case – and claims of turf war tactics.

The Australasian Society of Aesthetic Plastic Surgeons said that only doctors who had successfully completed Australian Medical Council-accredited training could use legitimate, approved specialist surgical titles. But most practitioners who used the title ‘cosmetic surgeon’ were not registered surgical specialists and had not completed AMC accredited training.

ASAPS president Dr Robert Sheen told Medical Forum the whole system of a presumption of safety and public trust was being jeopardised.

“It’s not the fault of 12 | MARCH 2022

“Patients have a presumption that the health care system is safe, and because it’s regulated by the government and they know doctors need to have licences, patients go along and think everything is going to be safe and hunky dory. ”

can self-refer. So, the GP’s gatekeeping role has dropped out in the process.

the media program because what they’re doing is exposing things that people need to know, but it damages people’s confidence in the system itself, and that’s across the board not just in cosmetic surgery; everyone gets tarred with the same brush,” he said.

“Patients have a presumption that the health care system is safe, and because it’s regulated by the government and they know doctors need to have licences, patients go along and think everything is going to be safe and hunky dory.

“If someone calls themselves a cosmetic surgeon, then the patient makes a bunch of assumptions that these people are highly qualified specialists in cosmetic surgery.

“While some practitioners are very well qualified, some are not, but patients don’t understand the difference and can have poor outcomes as a consequence, and that’s very problematic.”

Dr Sheen said circumstances had changed from the days when there was a small number of specialists, and patients went through their GP, who had some knowledge of the specialists so could act as a type of gatekeeper.

“But what’s happened is that the number of doctors has multiplied, and the advertising – particularly online – has just exploded and because cosmetic surgery doesn’t attract Medicare benefits, patients

“We’re not saying that this doctor should or shouldn’t be allowed to do whatever – it’s actually not our role – but we do believe medical practitioners should tell the truth to their patients as part of open disclosure.

“It’s very simple – make doctors say what they are, not what they’re not.”

Dr Sheen said ASAPS believed that the national law needed to be tightened.

“We’ve said to AHPRA we will lobby to get the laws made more explicit so you can do your job,” he said.

“The current status quo doesn’t help AHPRA, it doesn’t help practitioners and it certainly doesn’t help patients. We’re keen to work constructively with AHPRA to facilitate them to be much more proactive looking after patients.”

National register call But while the Australasian College of Cosmetic Surgery and Medicine (ACCSM) has welcomed the AHPRA review, it wants a single national register of cosmetic surgeons.

It argues that because the current system allows any doctor to call themselves a cosmetic surgeon, patients cannot easily identify whether a doctor had the necessary specific training to be competent and safe.

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COVER STORY

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He said “fringe activity” by some doctors was bad for the whole profession and AHPRA “had a lot of egg on its face” over the recent bad media.

“They were embarrassed at a bureaucratic level by that program Cosmetic Cowboys, but it’s actually nothing to do with a turf war, it’s about patients having a reasonable expectation that when they see someone calling themselves a surgeon, that person has recognised training.

“What we saw last year is terrible, and we’ve seen other clowns doing liposuction from back offices, so it’s not about what doctors want to call themselves, it’s about safety.

“It’s an interesting phenomenon when someone who’s not really trained as a surgeon all of a sudden thinks they are somehow religiously gifted in this area.”

The college has also weighed into the turf war argument, claiming Royal Australasian College of Surgeons’ specialist surgeons are trying to secure a monopoly in advertising themselves as surgeons to patients seeking cosmetic surgery, when many of these doctors have little or no training in cosmetic surgery.

plastic surgery, because cosmetic surgery is done to change the appearance of healthy tissue, not to reconstruct after disease or injury.

It maintains the skills needed for cosmetic surgery are very different from those for reconstructive

Dr Duncan-Smith rejected claims it was a turf war between plastic surgeons and cosmetic surgeons.

And it says only a minority of specialist surgeons obtain formal cosmetic surgical training either overseas or by completing the ACCSM’s postgraduate training program and examinations.

AHPRA REGISTERED SPECIALIST PLASTIC SURGEON

MEDICAL FORUM | PAIN MANAGEMENT

VS

The bigger picture And there is a lot more at stake than issues within the cosmetic surgery industry.

AHPRA’s inquiry has an obvious bedfellow – the ongoing review into the use of the term ‘surgeon’ which has been languishing on the backburner for more than three years.

continued on Page 15

UNREGISTERED “COSMETIC” SURGEON

MARCH 2022 | 13

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Surgeons – carving out a name continued from Page 13 The country’s health ministers have been consulting on reforms to the regulatory scheme governing all health practitioners in Australia since 2018. They supported restrictions to the use of the titles surgeon and cosmetic surgeon, but argued more work was needed.

The Victorian Government is leading that public consultation, which closes next month (April), with health ministers due to consider the matter over the next 12 months.

Options on the table include restricting the title of surgeon under national law; strengthening the existing framework; undertaking major public information campaigns, or maintaining the status quo.

Dr Corrigan said it was the title surgeon that was most confusing to patients.

“It comes back to the crux of the issue – what you need to call yourself a surgeon,” she said.

“While cosmetic surgery is the one that gets the attention, it goes back to the basic issue that someone shouldn’t be calling themselves a surgeon if they haven’t had specialist training.

“But a lot of practitioners will have glossy magazines, brochures and websites and come across as quite experienced and well-trained, so it becomes hard for even medical practitioners to know.”

The real deal Dr Duncan-Smith said the fundamental question the public wanted to know was if were they dealing with a real surgeon or not.

“And that’s where the term ‘surgeon’ from the point of view of a doctor, really should be reserved for someone who has a FRACS or equivalent.

“You can’t protect the term surgeon altogether, because you can have an arborist or tree surgeon, and dental surgeons, but there has to be a greater good we’re trying to achieve.

“You do have dermatologists who have training in Mohs surgery (for

skin cancer), but just as equally it could be called Mohs skin cancer treatment.

“Because if the word surgeon is associated with a medical doctor, the public has the right to expect that the doctor has a FRACS or equivalent.

“Now if a doctor who has no formal surgical training wants to do tummy tucks, or breast augmentation or liposuction, then they should do that without misleading the general public by using the word surgeon.”

More than skin-deep But the Australasian College of Dermatologists (ACD) told Medical Forum there was already public confusion over the types of practitioners working in the skin cancer space.

“Using terms like ‘skin cancer doctor’ only adds to the confusion, because in Australia anyone with a basic medical degree is able to call themselves a skin cancer doctor or similar,” it said.

Surgical techniques were an essential part of specialist dermatology practice, and the development of skin surgery skills and expertise comprised a significant proportion of the four-year AMC-accredited ACD specialist training program.

“Some specialist dermatologists have further focused their scope of practice to Mohs micrographic surgery by completing further ACD-accredited training. ACD maintains a register of specialist

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dermatologists who practise Mohs surgery, and they are required to complete ongoing medical education and quality assurance program activities.”

Dr Corrigan said concerns raised about practices at Dr Lanzer’s clinics only highlighted that being a surgeon was not just about techniques.

“In any surgical procedures there can be complications, and one of the things I’ve found troubling is that it’s not just about doing a course or being trained in a particular cosmetic surgery technique.

“If you’ve done surgical training, you have that background in core foundation skills in surgery, which are things like sterile techniques or managing bleeding or infections in sick patients.

“So, while in my practice I perform breast implants, if I have a problem and there’s a bleeding patient or someone with a catastrophic infection, I’m falling back on skills I learnt well before I learnt to put in breast implants.”

Read this story on mforum.com.au

MARCH 2022 | 15

Q&A with...

Amber-Jade Sanderson, WA Minister for Health and Mental Health.

Last December, Amber-Jade Sanderson was given an early Christmas present of sorts –the hot potato of the health portfolio amid a pandemic.

Here she explains why she is embracing the chance to deliver on the job dubbed the poisoned chalice of government.

MF: Firstly, congratulations on your ministerial appointment. What have the first few months in undoubtedly one of the busiest Government portfolios been like?

AJS: Thank you, it has been a busy time. It’s no secret the health portfolio is a challenging and complex one – and the pandemic has added another layer to that. I have never stepped back from a challenge and no job worth doing isn’t hard, so I’m looking forward to the challenge. There are few portfolios that can have a bigger impact on people’s lives than health and mental health.

MF: You’ve had a varied career, ranging from roles as media advisor to Carmen Lawrence through to assistant state secretary of the then-United Voice union. How have those roles helped prepare you for life as a health minister?

AJS: I think all my past roles have helped prepare me for this job. I have been a Member of Parliament for nine years and around the Cabinet table for five, and the one thing I have learnt is that you have to be ready for anything and be prepared to move quickly. Throughout my career I have always valued collaboration and consultation. This is how I approached previous challenges and it is how I will approach my new portfolios.

MF: It’s been something of a baptism by fire when it comes to managing COVID. Has it been difficult getting across all the issues that are required of a health minister in such a short time, and at such an important time?

AJS: We had an outbreak of Delta the day after I was sworn in as Health Minister, but that is just how things go with this pandemic. COVID-19 has turned our world upside down and we will continue to be challenged. I believe that no matter how complex a problem, there is always a way through – having the right people around you is key to finding that way.

MF: What aspect of WA’s handling of COVID has been most encouraging, and where do you think there is still room for improvement?

AJS: Since the start of the pandemic we have been following the health advice and undoubtedly it has served us well. We have been one of the safest places in the world while having one of the strongest economies. I will continue to rely on the health advice as I intend to make well-informed decisions. I will continue the cautious and sensible approach the Premier and the Government has taken to date, which has served the community well. One of the most encouraging aspects has been the community support for restrictions and their understanding that we are trying to protect people’s lives and health.

MF: There are concerns the WA public hospital system is not equipped to deal with the big numbers of COVID cases expected in the next few months.

How confident are you that it can cope?

AJS: The McGowan Government has invested heavily in resourcing our

16 | MARCH 2022

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Q&A hospital system so we can manage the unprecedented demand in our system. Through the Mid-year Review and the Budget, we have injected $3.2 billion into the health system, and it is expected an additional 530 beds will come online by the end of the year. I intend to oversee the delivery of these beds as a priority to ensure we are ready.

As I walk through our hospitals, I get a strong sense that staff are prepared and ready to meet the challenges that lay ahead, and I have every faith we will.

MF: How are you ensuring that issues that are not directly COVIDrelated, such as the general state of the WA public health system, are not left to languish during the pandemic?

AJS: Much of the work and preparation for COVID will help to support our health system for many years, but the challenges of workforce and meeting demand will stay with us post-pandemic. I will not be distracted by COVID when it comes to important reforms needed in areas such as infant, child and adolescent mental health – this is a priority for me.

MF: Many of our readers are GPs. Has the pandemic redefined the importance of primary care professionals, particularly when it comes to vaccination?

AJS: GPs are critical to a functioning health system, and they do not get enough support from the Commonwealth. The vastness of WA also means GPs have an important role in bringing vaccinations to our regional and remote communities.

I will always advocate for more GPs and more support for primary health.

MF: As Mental Health Minister, do you share concerns about the impact that COVID (through lockdowns, loss of income, separated families) is having on our mental wellbeing? Can we bounce back?

AJS: Because of our strong management of the pandemic, WA has been relatively insulated from the worst impacts – both health and economic. Even so, we are seeing far greater demands on services, particularly in the youth mental health space. The Government has made a significant $495 million investment last year in the mental

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health system to help people avoid hospitalisation and get the treatment and care they need in the community. Implementing the recommendations of the Ministerial Taskforce into Public Mental Health Services for Infants, Children and Adolescents aged 0-18 years in WA (ICA Taskforce) is a priority for me.

MF: The private hospital system in WA is undergoing significant expansion, including an increase from one private emergency department to four EDs. Do you see the private sector as a crucial part of any health system?

AJS: It is important the people of Western Australia have diversified health care options and more private emergency departments delivers more choice for patients.

MF: Many see you as one of Labor’s rising stars. Do you consider yourself politically ambitious or more go-with-the-flow?

AJS: I’ll leave that to the commentators. It is a privilege to serve in the McGowan Government and I make the most of everyday to make that changes that will improve people’s lives.

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MARCH 2022 | 17

Medicinal cannabis gains traction Not only are more doctors prescribing medicinal cannabis to patients, it is turning into big business.

Kathy Skantzos reports

18 | MARCH 2022

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It is still a slow-burn, but more doctors are prescribing medicalgrade cannabis each year as a viable treatment option for a range of conditions.

It was legalised in Australia in 2016 and even though research is still ongoing with a lack of longterm clinical data, modern science is backing the 10,000 years of anecdotal cannabis use for treating a range of ailments.

Medicinal cannabis is believed to act on the body’s endocannabinoid system which regulates mood, memory, sleep and appetite.

Studies show its efficacy in relieving chronic pain, insomnia, symptoms of Parkinson’s disease, severe epilepsy and seizures in children, multiple sclerosis, fibromyalgia and anxiety, among others.

There have been more than 217,000 SAS-B approvals for medicinal cannabis since it was legalised in Australia, with about 12,000 approvals a month and more than 650 authorised prescribers. Most approvals are for chronic pain (115,000), and about 20% (42,000) are for patients using medicinal cannabis to treat anxiety.

Emyria, the Perth-based drug development company that Andrew ‘Twiggy’ Forrest invested $5 million into in November 2021, has been prescribing and collecting clinical data on medicinal cannabis since December 2018 through its clinical arm Emerald Clinics. It has 6000 patients on its clinical trial database and a rotation of about 400 to 500 patients a month.

that medicinal cannabis was shown to be effective in chronic pain management in non-cancer patients.

“One of the pain specialists who works for us summarised it beautifully when he said this is the best product for chronic pain that he has used in the last 50 years of practice,” he said. “It’s safe and effective and makes people feel better.”

Body talks Prof Vickery said the clinical indications of medicinal cannabis were broad and could help in a range of illnesses because the endocannabinoid system was across almost all of the body’s systems, including the neurological, immune, respiratory and digestive systems.

When there’s a disturbance in the endocannabinoid system, the phytochemicals derived from the plants, which are partial agonists, may play a part in rebalancing that disturbance.

“We believe the endocannabinoid system is involved in homeostasis of intracellular signalling. The fact that it is not only ubiquitous in the human body but also through the animal kingdom suggests that the endocannabinoid system is evolutionarily essential,” Prof Vickery said.

Medicinal cannabis has Level 1 evidence for reducing pain and spasm in multiple sclerosis, chemotherapy-induced nausea and vomiting, and seizures in childhood seizure disorders, Prof Vickery said.

Emyria’s Medical Director, Associate Professor Alistair Vickery, a wellknown Perth-based GP and academic, told Medical Forum

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“The list is long, and when we look at the clinical indications for which we prescribe medicinal cannabis, there are more than 60 because of its ubiquity across the human body.”

A TGA-registered cannabis-based medicine, Sativex (nabiximol), a spray which contains both tetrahydrocannabinol (THC) and cannabidiol (CBD), has been shown to be effective in improving symptoms related to muscle stiffness in multiple sclerosis, and according to Prof Vickery, should be prescribed more.

The only other TGA-approved cannabis medication is Epidyolex (cannabidiol), an oral liquid shown to be effective as adjunctive therapy of seizures.

He added that medicinal cannabis can be used to treat pain in cancer patients without the same side effects as opioid drugs.

“It reduces pain, improves anxiety, and improves sleep. People with a diagnosis of cancer often have all of those symptoms. Medicinal cannabis has been shown it doesn’t cause the constipation or respiratory depression of opiates and doesn’t cause the muddied head of opiates and benzodiazepines, so it’s a superior drug in terms of reducing symptoms and making people feel better,” he explained.

Medicinal cannabis, overall, is well tolerated in patients.

Cannabis safety “If we compare it to other recreational drugs, we know that the safety of medicinal cannabis outweighs the safety of the most dangerous of the drugs, but it’s also safer than paracetamol and even caffeine in terms of its acute toxicity,” he said.

While caution should be taken when prescribing to young children, Prof Vickery said it’s safer than prescribing antipsychotics or antidepressants to people with underdeveloped brains. continued on Page 20

MARCH 2022 | 19

Medicinal cannabis gains traction continued from Page 19 “We’ve had 6000 patients that have taken it, so we have accurate adversity data, which shows that it has minimal and mostly doserelated side effects. That isn’t to say that there aren’t long-term effects that we aren’t aware of.

We do have some safety data on longitudinal use that suggests this is a safe drug,” he said.

The best way to optimise outcomes and manage adverse effects was to ensure the dosage and ratio of THC and CBD were carefully managed.

“The difference between recreational cannabis and pharmaceutical-grade cannabis is the doses we’re using. Medical cannabis has a tenth or a twentieth of the dose of THC compared with recreational cannabis, so it’s really a different beast in terms of management and treatment,” he said.

But Prof Vickery warned that people shouldn’t be growing their own or getting their hands on ‘green market’ products which can be harmful.

“Recreational cannabis is not only illegal it is an unregulated, unregistered product and it varies between each dose.”

He said batch-to-batch variability of approved products can vary about 10% so it’s important that patients are given the right medications and are monitored with the correct dosages.

“The future, I think, is in a highgrade pharmaceutical which enables a known dose of CBD and THC and contains no impurities and no other active components,” Prof Vickery said. “Our drug development program is looking at a bio-identical synthetic with known properties that is absolutely pure.”

Business moves In mid-2021, iron ore magnate Gina Rinehart invested $15 million into Little Green Pharma, another Perth-based medicinal cannabis company. Little Green Pharma 20 | MARCH 2022

National Education Manager Barb Fullerton, who has worked for Bayer and Pfizer, now educates doctors on the benefits of medicinal cannabis.

She told Medical Forum that medicinal cannabis was becoming more mainstream with more doctors prescribing it as they saw the range of benefits in patients.

“Approvals last year by the SAS-B pathway more than doubled from the previous year, and that’s just a single pathway – there’s also the authorised prescriber pathway, which is becoming more popular,” Ms Fullerton said.

“If people weren’t seeing results, they wouldn’t be using it. It’s definitely a good option for patients who have used other medications that haven’t been successful.”

While there was mounting clinical evidence the efficacy of medicinal cannabis, Ms Fullerton said some doctors were still hesitant and continued to rely on drugs they habitually prescribed.

“Opioids and benzodiazepines

have been around for years, and although there are side effects and are addictive, they are tried and true, and trusted and registered,” she said.

Some GPs weren’t prescribing cannabis because of the extra steps required to apply for approval, and the cost to the patient, compared with other medications, might be of concern. However, Ms Fullerton said the process was becoming simpler and patients were willing to pay if they saw the benefits.

“The approval process used to be very complex, but it is simpler now, although medical cannabis is more expensive than a PBS medicine,” she said, adding that there were compassionate access programs to buy the medication at cost at the doctor’s request.

“For the patients that respond well, it’s lifechanging and they will want to pay for it,” Ms Fullerton said.

“What we’re finding is that once doctors start to get feedback from patients, they start prescribing it more because they realise it’s a good option if patients have tried other things that haven’t worked.”

GP advocate Dr Brian Walker, chair of the Legalise Cannabis Western Australia Party and a practising MEDICAL FORUM | PAIN MANAGEMENT

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FEATURE medical practitioner, describes cannabis as “a wonderful healing herb” that should be prescribed more.

He’s seen good results in a range of health problems, from pain to neurological disorders and anxiety, with minimal side effects.

“Cannabis is a lot safer and healthier than other medications including heroin derivatives,” he said.

“It can help people in desperate situations where the pain is too much to bear, and they can’t tolerate it anymore. They’ll try it and say it’s better than anything they’ve ever tried.”

“I use it a lot for managing pain and neuropathic conditions.

I’ve used it with great success for autism and the same can be said for ADHD. I have patients with Parkinson’s that are doing very well. For anxiety, it has none of the other side effects.

It’s a lot safer than Xanax, a lot safer that diazepam and works better than temazepam,” Dr Walker said.

Dr Walker strongly advises prescribing cannabis over opioids, which will help minimise side effects while giving patients effective pain relief.

Even though more than 100 cannabis-related medicinal products were available as prescription medications, the rigorous regulations in WA and the cost passed on to patients were major barriers.

“If you’re prescribing heroin, start prescribing cannabis instead,” he said. “Compared with all the other medications I can prescribe, it has got almost no side effects and it is effective at what it does. I’ve not seen anything like the possible adverse side effects of other medications.”

“The hoops that doctors need to go through!”, he said.

“Another barrier is the cost.”

Dr Walker said there was still stigma attached to cannabis with many patients and doctors associating it with illicit drugs but hoped that would subside.

“I’m hoping barriers will be reduced, price will be reduced, and that cannabis will be on the PBS because people have been destroyed by having to pay large sums for what is actually a lifesaving medication,” he said.

Dr Walker encourages doctors to have an open mind as more research comes out and to not let the barriers stop them from prescribing it because its wideranging benefits could help patients.

“There’s a lot of excellent ongoing research. The psycho-neuron pharmacology of cannabis is being researched quite intensively and there is a lot to learn. I am looking forward to seeing what new advances there are going to be.”

“They have to fill out the SAS-B application to be able to prescribe and then wait two days,” he said.

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MARCH 2022 | 21

In his defence Psychiatrist Dr Richard Magtengaard has a soft spot for the hearts, bodies and minds of those in the military, veterans and first responders.

By Ara Jansen

“Simply, you have to be very comfortable with angry men,” says Dr Richard Magtengaard.

Fascinated by people’s stories, this psychiatrist works primarily with defence personnel, veterans and first responders and the interesting and unique mental issues they face as a consequence of their jobs and duty.

While some of issues can be similar to those we all face – fighting with a spouse or an issue with a colleague – there are also experiences specific to them such as PTSD from combat, attending serious vehicle accidents, violent crime scenes and feeling adrift after leaving service.

Richard’s empathy and ability to relate to his patients come not only from his years of practice but also from having been in the military himself. He’s either seen or experienced much of what these people are seeking help for.

22 | MARCH 2022

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CLOSE-UP

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CLOSE-UP Growing up in Ceduna, South Australia, Richard joined the Royal Australian Navy and was a commissioned officer for 10 years.

In his final two years he was posted to Fleet Base West on Garden Island off the coast of Rockingham. It was there he began studying medicine for the next step of his career. He went to Brisbane to continue his studies and returned in 2003 to Perth, where he bases his practice.

Richard initially worked in the public health system and went private in 2012. Now he specialises in mental health problems in veterans, defence personnel, first responders and their families. This includes post traumatic stress disorder (PTSD), mood disorders, chronic pain, obsessive compulsive disorder (OCD) and general adult psychiatry.

Uni v Navy “I realised I didn’t want to be an academic and the idea of being at a desk didn’t thrill me,” says Richard. “I had a scholarship to do a bachelor of science at Adelaide University, which included a lot of biology courses.

“I met a number of medical students who were doing their six years and while medicine interested me, I was also interested in joining the Navy as a Warfare Officer (or similar). In retrospect I really think my medical practice benefited from the life experienced prior to studying medicine.”

Richard’s father had a construction company, which worked on the naval ships and submarines, which as a kid and young man gave him a chance to look around the decks and engine spaces.

“The idea of sailing out on them was intriguing and my naval service was rewarding in many ways.

However, after 10 years I reached the point that many, if not all service personnel find themselves at. ‘Should I stay, or should I go?’

“The nature and rigours of service mean a lot of time spent away from home and that can have a detrimental effect on relationships with loved ones and time away from children that can never be retrieved.

Shared insight “Having this shared experience with patients is highly valuable within our therapeutic relationship. Shared hardships, the nuances of service life, all of the unspoken aspects that allow me to empathise and understand, causing my patients to feel heard and understood.

“So, I made the decision to leave and my interest in medicine was reignited, and after much application I gained my medical degree. I was fortunate to have this alternative plan, but I still found transitioning out of the navy a difficult period of adjustment.

“This is recognised as a highrisk period for personnel leaving service, so this is another aspect where my personal experience makes a real difference in my patient interactions.

“I wasn’t set on becoming a psychiatrist from the outset, but it was a specialty that always interested me and kept coming back to me. Surgery is often thought of as a military type of specialty and I was interested in obstetrics and gynaecology.

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Unsurprisingly though, babies don’t work to a regular timetable and proved to be almost as good as the navy at keeping me away from home.

“I really enjoyed the complexity of O&G and the interplay between the arrival of the children and the parents. I also liked the multidisciplinary team but was really fascinated by how parents would express themselves and what they wanted.”

Through his studies, training and general grounding, Richard discovered grief counselling before transitioning fully to psychiatry.

That’s where he really found his calling.

It has been in the past six to seven years that he’s come to focus on defence, veterans and first responders and the distinct set of issues they deal with.

“There are a number of studies that have come out that have validated just how tough it is to do these jobs. More recently, as a consequence of COVID, we really have to be looking after the people who are looking after us – and helping them look after themselves.

“It’s a validating space to work in.

Thanks to groups like Beyond Blue there has been a large leap with defence veterans seeking help.

You can be medically downgraded, which is a risk that comes with speaking out, depending on the area you work in. A lot of people feel stigmatised for speaking out, so it’s good to see help-seeking normalised.” continued on Page 25

MARCH 2022 | 23

Keith is a graduate of the University of Western Australia and complete the Fellowship of the Royal Australasian College of Surgeons in 1986. This was followed by a fellowship at North Sydney Orthopaedic and Sports Medicine Centre working for world renowned surgeons Dr Mervyn Cross OAM and Prof Leo Pinczewshki. Both of whom were pioneers of arthroscopic reconstructive surgery in the knee.

Following his time in Sydney, Keith undertook an arthroplasty Fellowships in Edinburg and Derby (UK) and he then toured the multiple centres of excellence in the USA visiting world leaders in arthroscopic knee and shoulder surgery at a time when the field was burgeoning.

Keith Holt Perth Orthopaedic and Sports Medicine Centre announce the retirement of their founding partner Mr Keith Holt at the end of March 2022. This follows an exceptional career spanning 35 years.

In June 1988 Keith returned to Perth and in partnership with Peter Hales he established the Perth Orthopaedic and Sports Medicine Centre. At the time tentative attempts at group practices had been unequivocally unsuccessful. Keith’s philosophy of forming a practice based on equanimity, collegiality and mutual co-operation has underscored the success and enduring model that has been replicated many times since. From the commencement of the practice Keith saw the advantages of surgeons, rheumatologists, sport physicians and physiotherapists working collaboratively under one roof.

Keith has been a prolific orthopaedic surgeon in the field of arthroplasty and arthroscopic reconstruction in knee and shoulder surgery. Keith is an exceptionally talented and skilled surgery who has lectured widely and is extremely well regarded by his peers. Keith has notably been responsible for bringing cutting edge new technological skills to Western Australia.

Recognition of his expertise has resulted in him having achieved the very rare honour of being the one time president of both the Australian Knee Society and the Shoulder and Elbow Society of Australia. He has been involved with many sporting teams and was the team surgeon for the Fremantle Dockers for many years from their inception as well as involvement with the Australian Hockey teams and the West Australian Institute of Sport.

Keith has been exceptionally generous with his knowledge and expertise. He founded a Fellowship Program at POSMC which has seen some 102 number of surgeons attend, study and learn under the tutelage of Keith and other surgeons from countries from Europe and all major English speaking countries.

Keith is looking forward to transitioning into retirement with his partner Anne and having time to pursue his hobbies. POSMC will be his enduring legacy.

The partners at POSM would like to extend their profound gratitude and indebtedness. We would like to extend our very best wishes to Keith and Anne on their retirement.

T +61 8 9212 4200 | F +61 8 9212 4264 PERTHORTHO.COM.AU 24 | MARCH 2022

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In his defence continued from Page 23

Bethesda focus While Richard has been working with clients at Veteran Central in ANZAC House he has recently taken up on of the role of the director of the Military, Veteran and First Responder Program for Bethesda Clinic, which opens in Cockburn in September. The role oversees the development of specialist mental health inpatient and day programs for defence personnel, veterans and first responders as the clinic will have a strong focus on bespoke mental health services for this group.

Richard is developing programs specific to assisting individuals and their families who have sustained physical and/or psychological trauma in the line of duty.

“What ANZAC House does, and Bethesda will do, is provide an integrative service to bring together care such as dental, psychiatry and appointments for ears and skin or referrals to art therapy or something which helps engage with society.”

For example, Richard may work with someone who has anxiety and who might grind their teeth and need dental treatment. Having a system at a location where a person can access each specialist is hugely helpful. First it means someone can be treated faster, plus they don’t have to keep repeating their story, which in these cases can be painful and triggering.

While his own military service gives Richard insight into the lives and mental health of the patients, he says it doesn’t necessarily result in immediate trust from his patients, but there’s definitely a level of rapport that comes from having been in similar situations.

“Veterans are very loyal and if they have found a place of support, they will push their colleagues towards it.

“These are people who go in the direction of danger when everyone else runs the other way. They are brave and successful and come here asking for help. If you can convince them you are going to help them better understand themselves, link

them to support and encourage things like exercise rather than just throwing drugs at them, that’s how you win them over.

“Plenty of people come out of the military and crush it. But others find dealing with these details causes significant anxiety.”

Military life is set out and runs to a schedule. When you leave it’s a case of relearning and retraining yourself around so many things, including some of the seemingly insignificant things such as what time you get out of bed.

Holistic care Richard is excited about what the Bethesda facility will offer, particularly for the local community in the southern suburbs. He’s also enthusiastic about the rounded medical care being offered alongside more novel aspects such as prescribing a sensory diet, if that’s a better option than drugs.

Or a green prescription – exercise and movement – if that will help alleviate an issue.

“If our first treatment step is to use drugs, then that informs our whole culture,” he says. “You have to get the setting right. I prescribe exercise as medicine and traumainformed yoga with all my patients.”

Daily exposure to other people’s trauma stories means Richard must consistently tend to his own mental health. As a dad and husband, like his patients he wants to be consciously present in their lives.

getting into the garden at home is one of his biggest pleasures.

The Magtengaard veggie patch is bountiful enough that it feeds the family of four a couple of meals a week. Richard’s eldest is a budding chef and makes a mean pasta dish fresh from the garden.

“I get to spend my whole day having interesting conversations with cool people,” says Richard. “It’s a privilege to hear about someone’s hard time. And it’s also great to hear they’re not yelling at their kids anymore. You’re getting to help them repair a rupture.

“I admire these people for their strength. I don’t know how they do it – and I don’t know if I would be that stoic.”

Now in his 50s, Richard believes it is a time in life when you think about leaving your world in better nick.

This is his way of doing that.

He’s found an ally in fellow veteran Dr Rory Morris-Butler, a retired British Army Medical Officer.

His work at London’s Maudsley psychiatric hospital and during a fellowship in Canberra showed him the experience of working in military psychiatry in the UK could benefit Australian veterans.

The pair share a passion and understanding of veterans’ sometimes unique experiences and needs. Together, Richard feels they can offer a special level of care and understanding underpinned by gold standard evidence-based care and a holistic approach.

While walking the dogs is relaxing,

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MARCH 2022 | 25

The vital role of after-life care As the State mortuary prepares for a major upgrade, forensic pathologist Dr Jodi White explains what happens at the facility, including the now routine use of CT scans.

The PathWest Forensic Pathology and State Mortuary Service is the sole provider of coronial and forensic services to the State Coronial Service. The service, based at QEII Medical Centre, receives and investigates all deaths reported to State and regional coroners across Western Australia.

Reportable deaths include natural but unexpected deaths, homicides, motor vehicle and other accidents, suicides, deaths of people held in care or custody, and some hospital and child deaths.

Our staff are highly skilled and are as diverse as the work we see each day.

26 | MARCH 2022

The staff take pride in their work and acknowledge the great responsibility and privilege afforded to our service in performing what will be part of a final investigation into a person’s life and death, providing the necessary answers to the courts and closure to the family.

The mortuary can be a difficult and confronting place to work, with all of us here having been at some stage affected by the stories that accompany those admitted to our care. It is certainly not an occupation for everyone, with the work being both physically and emotionally challenging.

It takes experience of exposure to the case work, time and the understanding and support of your colleagues to be able to navigate this role. If you asked each staff member, past and present, all could relate a particular case or two that really touched or affected them in some way and is still with them.

The importance of wellbeing in the workplace and, in our line of work, recognising vicarious trauma, has become more widely accepted.

Vicarious trauma is now better acknowledged with preventative strategies and managed to help those in frontline positions to deal with the daily exposure to traumatic circumstances often found in

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GUEST COLUMN our case work. Such support and training will soon form part of our annual staff wellness program.

mortem – for example in the case of a large stroke or cerebrovascular accident.

in the early 1970s. It has served WA for many years but the upgrade is essential to meet our future needs.

The service and discipline have seen major changes and an increase in total case work and complexity over the past 10 years.

The CT findings also assist the Coroner and families in managing objection cases, enabling a reasonable cause of death to be offered in many cases where there are cultural or other reasons why an invasive post-mortem examination is against the family’s wishes.

The works over the next 18 months will refurbish and expand the staff facilities, stores, cool-room, and admissions and tissue laboratory areas. Improvements to increase the clinical workspace will start later this year and include a new homicide theatre and infectious theatre, adding to the procedures and security surrounding criminal casework for the State and those cases proceeding to trial.

One of the most significant changes include the acquisition and implementation of a dedicated forensic pathology post-mortem CT service since April 2019.

Post-mortem CT scanning has become an integral part of coronial autopsy and forensic services nationally and internationally and is now considered best practice.

At present, all bodies admitted to the State mortuary receive a postmortem CT. This service, managed with the assistance of SCGH Radiology, has changed the way we approach and investigate the majority of cases.

A whole-body CT as a preliminary examination allows the forensic pathologist, when considering the deceased’s history and circumstances in some cases, to identify a cause of death without the need for a full or invasive post-

The CT helps investigate specialised deaths such as scuba diving fatalities and enhances our ability to identify and investigate pathology in areas usually difficult to access.

The CT images, coupled with 3-D printing, can also be considered as a permanent electronic record of the body for later review or audit, and be used in disaster victim identification and in criminal casework at trial to illustrate issues around injuries or other matters where graphic photographs may not be appropriate.

Other major changes underway include a comprehensive upgrade

by WA Health to the existing mortuary, which was commissioned

The teaching area remembered by many WA medical students from the past – also long overdue for a makeover – will be renovated to include new technologies to improve viewing and training.

The upgrade will add significantly to our total capacity and efficiencies and, along with the CT scanner, will mean a more seamless and capable coronial and forensic pathology service.

ED: Dr Jodi White is Consultant Forensic Pathologist and Head of Department with the Forensic Pathology and State Mortuary Service at PathWest.

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Mobile services: Physiotherapy | Exercise Physiology

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28 | MARCH 2022

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Public health’s election wish-list The upcoming Federal election can’t be a spectator’s sport, argues public health expert Terry Slevin.

No one should be surprised that the CEO of the Public Health Association of Australia looks to bang the drum about public health issues in the lead up to the 2022 Federal election.

But given the two years we have just endured, now more than ever the entire nation – and the world – might sensibly give thought to the public health policy. For Australia, it must turn its eye on current and future capacity to deal with the public health challenges that are so clearly before us.

We are asking all those aspiring to form government for the next three years to make clear their plans and commitments on the issues that we think are essential to advance the health of all Australians. And I invite you committed health professionals to do the same.

The key focus areas for PHAA in 2022 are:

Aboriginal health Despite heroic efforts from some in the public health world, particularly in WA, the low rates and barriers of access to COVID-19 vaccination among Aboriginal and Torres

Strait Islander communities are a clear example of the significant health disparities in Australia. The broader circumstances faced by our First Nations people, including the continuation of some systemic racism, means ‘closing the gap’ must remain a priority.

Invest in preventive health One in five Australians have multiple chronic conditions.

Australia cannot afford repeated disasters on the scale of COVID-19, whether they are triggered by the next pandemic, or from the rising chronic disease epidemic. The AIHW reported in December 2021 that preventive health expenditure in Australia in FY 2019/20 was 1.5% of total health expenditure. The WA government is unique in Australia to have set a target of reaching 5% of health expenditure on prevention (by 2029). All governments should be setting the same target. This was mentioned in the recently released National Preventive Health Strategy, but neither party has committed to meeting this target.

A well-worded strategy means nothing without it being enacted and funded.

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Invest in the national public health workforce The vital role for high quality policy, advice and implementation has never been clearer. Yet it is screamingly obvious that new and existing gaps in the public health workforce have been highlighted

by COVID-19. An adequately large and resourced public health workforce will be essential in building resilience of communities and health systems. A long-term commitment to training, recruiting and supporting high quality public health workers is not a luxury, but a necessity.

Establish a Centre for Disease Control & Prevention COVID-19 has demonstrated that we cannot go back to the way we did things before. National surveillance and response systems were not strong or fast enough to halt or control transmission. An expert, arm’s length, respected and properly resourced Australian Centre for Disease Control and Prevention, with structures that continued on Page 30

MARCH 2022 | 29

Action needed on trachoma More needs to be done to reduce a leading infectious cause of blindness in WA’s Indigenous communities, argues Dr Melissa Stoneham.

Australia, disappointingly, is the only developed country to have endemic trachoma, which is responsible for the blindness or visual impairment of about 1.8 million people worldwide and remains a public health problem in 42 countries.

Almost 100% of our trachoma cases occur in Aboriginal and Torres Strait Islander communities.

The World Health Organisation has set a target to eliminate trachoma worldwide and developed the SAFE strategy, which is a comprehensive approach including surgery, antibiotic treatment, facial cleanliness and environmental improvement.

The #endingtrachoma project focuses on prevention of trachoma by measures such as washing face and hands and being able to wash clothes and bed linen. Although this may sound relatively easy, there are several challenges, including the tyranny of distance for remote communities, which makes it difficult to access maintenance services or even basic hardware.

The level of disadvantage in remote communities also impacts

on the social determinants of health, choice and options and the consequences of acculturation and the loss of cultural cohesion impact on communities.

In 2019, the proportion of children aged 5-9 with active trachoma in screened communities was 15% in WA. Traditionally, the WA Trachoma Program focused on reducing infection rates by screening school children and providing treatment in line with national guidelines, as well as addressing behavioural barriers and raising awareness of facial cleanliness (such as promotion of trachoma and the “clean faces” concept in schools).

This approach has been effective in reducing trachoma to a point, but unless environmental conditions inside homes change, such as having a functional bathroom in homes, trachoma is unlikely to be eradicated.

The Environmental Health Trachoma Project was created to fill this gap. We aim to reduce the incidence of trachoma in 41 ‘trachoma at risk’ Aboriginal communities in remote WA through environmental health.

We specifically address risk factors inside the home with a combination of long-term planning processes that support the development of community-led prevention plans combined with hands-on service provision delivered by Aboriginal environmental health workers (AEHW) who are employed in remote communities.

The #endingtrachoma team builds capacity, mentors and supports the AEHWs. It also accesses and provides tailored resources for remote communities including videos, local messaging, community events and more substantial resources such as washer-dryer trailers, health hardware such as shower roses, soap, towels and towel hooks, mirrors, light bulbs and hygiene kits.

Our key message is Six Steps to Stopping Germs, which was produced by the Indigenous Eye Health Centre at the University of Melbourne. They include blowing the nose until empty; washing hands with soap and water; washing face to clean mucous and discharg eyes; brushing teeth with toothpaste morning and night;

Public health’s election wish-list continued from Page 29 ensure states and territories are at the table and contributing to decision making, will give us our best chance for a better, more consistent and hopefully less politicised approach to public health challenges, and crises. This is not about Commonwealth control, rather it is about creating the mechanism to get the best possible advice, openly and transparently communicated, to ensure the strongest possible 30 | MARCH 2022

public health response to whatever is thrown at us next. On this policy we have a clear commitment from the ALP to set up a CDC. The Coalition has so far rejected such calls.

Protect against unhealthy products We know that companies make substantial profits from unethical marketing and promoting of unhealthy commodities, including gambling, formula milk, fast and ultra-processed foods, sugar-

sweetened beverages, alcohol and tobacco (including e-cigarettes).

All of these are a well-established and unquestionably major cause of chronic disease and health inequities.

And they disproportionately effect the most vulnerable members of our community. Taking the foot off the accelerator (the marketing of unhealthy products) and putting the foot on the brake (e.g. taxes that generate a disincentive to consumption, while generating revenue that can finance solutions)

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sores, RHD, gastroenteritis, otitis media and of course, COVID-19.

To amplify this, given 30-50% of health inequalities experienced

by Aboriginal and Torres Strait Islander peoples can be attributed to poor environmental health, we expanded our training and mentoring to integrate a wholeof-house assessment. This allows AEHWs to take a more holistic approach to reducing transmission or the prevention of disease and have a soft conversation about the importance of hygiene in the home.

As important as it is to fix tapware and other health hardware, it is equally important to ensure tenants are aware of what they can do to keep their family and friends healthy.

A series of healthy homes workshops linking disease risk factors to houses and providing skills and confidence in having soft conversations about hygiene have been provided in six regional locations, with the most recent in Warakurna in the Ngaanyatjarra Lands (NG Lands).

having a shower with soap every day and not sharing towels.

key message as often and in as many settings as possible.

We have reproduced and refreshed this message in videos using local community members, which is shown in Aboriginal Medical Services’ waiting rooms, on regional TV and used as learning tools; on stickers left in people’s bathrooms and laundries; and on as many community resources as possible.

It is important for us to repeat our

Over the past few years, the project has focused on preventing trachoma through auditing and ensuring functional health hardware in bathrooms and laundries in remote homes. Although this prevented trachoma, it also addressed risk factors for a range of other environmental healthrelated conditions such as skin

are both essential and proven ways to improve the health of all Australians.

plans based on unsubstantiated assumptions about future developments don’t cut it.

Climate and health

Healthy democracy and public policy-making

The record-breaking heat waves in the West and associated health problems, particularly among the most disadvantaged among us, are the most recent harbingers of the effects of climate change.

The close and delicate relationship between people and planet has also been highlighted by the likely zoonotic origins of COVID-19 as well as previous disease outbreaks.

Specific and determined climate action is required, and vague

Having watched it close up in Canberra, I can attest to the fact that lobbying by commercial interests in Australia is highly coordinated and effective in influencing policy outcomes.

Corporate lobbying causes lacklustre public health policy and climate change policy, and an environment conducive to corruption. Reforms such as a federal Independent Commission

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The #endingtrachoma project will continue to build the skills of the AEHWs. It is an important part of our job so that when our funding runs out, we leave behind a skilled and confident workforce who can continue this important work.

ED: Dr Melissa Stoneham is lead of the #endingtrachoma project which is run out of the Public Health Advocacy Institute affiliated with Curtin University.

Against Corruption, genuine timely transparency on political donations, and better controls on industry lobbying are fundamental ingredients in improving public policy decision making in all areas of policy, with public health policy being one of the most important.

So that is our list. What’s yours? And ask your federal election candidate about theirs. True democracy is no spectator’s sport. Have your say, ask your questions, and use your expertise to give a better chance for a healthier future for Australia.

ED: Adjunct Professor Terry Slevin is CEO of the Public Health Association of Australia MARCH 2022 | 31

SPONSORED CONTENT

Medicinal cannabis study reports significant improvement in the impact of pain.

Since medicinal cannabis was legalised in Australia in 2016, prescribers have been demanding local research demonstrating its efficacy. A national study, supported

by WA manufacturer Little Green Pharma, provides promising results as it reports the positive effect of oral medicinal cannabis on chronic refractory pain in patients who have not experienced relief with existing pain medication including opioids, NSAIDs and steroids.

The research included 151 participants with common chronic pain conditions including arthritis, neuropathic pain and other musculoskeletal pain who had tried other pain therapies and failed to see improvement. Patients receiving LGP Classic 10:10 (a balanced ratio of THC and CBD) oral medicinal cannabis were monitored for an average observational period of 133 days.

Findings from this study have been peer-reviewed and published in the international scientific journal Medical Cannabis and Cannabinoids. Open Access to the published article is freely available online at: https://doi.org/10.1159/000521492.

47.9%

experienced an improvement in pain impact scores

Published February 2022, the observational, open-label study found almost half of the cohort (47.9%) experienced a significant improvement in pain impact scores, suggesting an improvement in their quality of life, which is ultimately what matters most to patients affected by chronic pain. Just under half the patients also reported improvements in sleep (49.3%) and fatigue (35.6%). More than one-third of patients (32.9%) benefited from oral medicinal cannabis with a reduction in overall pain intensity scores.

The study also assessed the safety and tolerability of the pharmaceuticalgrade cannabis product LGP Classic 10:10 and the severity analysis revealed the majority of adverse events (AEs) reported were mild. Somnolence and dry mouth/throat were the most common AEs experienced and no severe adverse events (SAEs) were reported within the observational period for this cohort of patients. This proportion of AEs is consistent with existing studies of registered medicinal cannabis products1,2 and analgesics3.

49.3%

reported improvements in sleep

35.6%

Commenting on the study, LGP Head of Research and Innovation and study author Dr Leon Warne has commented: “Little Green Pharma is extremely pleased with these results that show the LGP Classic 10:10 formulation has been scientifically validated and demonstrated a significantly positive effect on the impact of chronic refractory pain. This study is important as it provides an option for those patients who have not had success with other pain therapies and gives doctors some vital research they’ve been requesting since medicinal cannabis was legalised.”

“We believe that studies such as this, using quality, Australianmade medicinal cannabis, will continue to see an increase in confidence amongst doctors to add medicinal cannabis to their prescriber toolbox.”

Medical practitioners who would like to learn more about the study or how to prescribe medicinal cannabis can contact Little Green Pharma on 1300 118 840 or email medical@littlegreenpharma.com

improvements in fatigue

32.9%

a significant reduction in overall pain intensity scores

1. Vermersch P. Sativex(®) (tetrahydrocannabinol + cannabidiol), an endocannabinoid system modulator: basic features and main clinical data. Expert Rev Neurother. 2011;11(4):15–9.

2. Ltd GP. Sativex oromucosal spray: SmPC. Cambridge, UK: EMC. Available from: https://wwwmedicinesorguk/emc/product/602/smpc.

3. Moore RA, McQuay HJ. Prevalence of opioid adverse events in chronic non-malignant pain: systematic review of randomised trials of oral opioids. Arthritis Res Ther. 2005;7(5):R1046–51.

As Australia’s first producer, Little Green Pharma have been supporting doctors to understand how to access and prescribe medicinal cannabis since 2018.

We offer free education and TGA application assistance.

UPCOMING WEBINARS Register here: W https://qrco.de/bcmDEc

Contact us: P 1300 118 840 E medical@lgpharma.com.au

Crash course in medical cannabis

Chronic Pain and medical cannabis

Dr Joe Kosterich 3 March

Dr Phil Finch 31 March

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Are our hospitals at risk of cyber attack?

The biggest privacy risk for hospitals is not from centralised digital health records but security around medical equipment, says cybersecurity expert Jeremy Hulse.

The healthcare sector ranks among the top industries most targeted by cybercriminals globally and most health service providers have responded by beefing up their IT security.

Less extreme, but no less concerning, is the privacy aspect – the ability for external parties to access sensitive personal information such as an individual’s prognosis, medical testing and treatment.

But a narrow focus on IT alone leaves organisations still vulnerable to cyberattack, with operational technology (OT) presenting cyber criminals with the equivalent of an unlocked back door.

In Australia, Office of the Australian Information Commissioner (OAIC) statistics show the health sector consistently reports the highest number of data breaches, with 85 notifiable data breaches from January to June 2021 – 19% of all reports.

In March last year, hospitals in eastern Melbourne were forced to postpone elective surgeries following a suspected cyber attack and, in September 2019, a ransomware attack caused similar disruption for several major regional hospitals in Victoria.

A new report states that over half of internet-connected devices in hospitals may have vulnerabilities that leave them exposed to hackers and could endanger patient safety.

Infusion pumps, the most common type of internet-connected device in healthcare settings, are among the biggest concerns cited in the report, given the potential to interfere with correct medication levels.

In response to these risks, health service providers have reviewed and strengthened their IT security.

This is a good thing. But failure to consider the vulnerability of operational equipment, or overreliance on ‘air gapping’ or a virtual moat around their IT and OT systems can undermine those efforts.

OT systems work in the background

Despite some community concern, the collection of health data in centralised digital records is actually quite safe. There is significant security in place around these records, including encryption and access keys. of hospitals, maintaining vital networks including oxygen flow, ventilation systems, elevators, doors and lighting.

In theory, ‘air gapped’ systems are safe from unauthorised intrusion because they are physically isolated from external systems or the wider Internet. However, truly isolated systems are rare.

Adding to this risk, the assumption that specialised medical equipment, such as computerised tomography (CT) or magnetic resonance imaging (MRI) scanners, are disconnected from hospital IT systems and therefore safe from external attack is not only wrong but also makes them vulnerable from both a privacy and safety perspective.

While older legacy equipment might require staff to manually extract and transfer scans or test results, modern equipment will now take the scan, send the digital result to another machine, such as a PC, which may in turn send a report elsewhere for collation and analysis.

These machines use the same wires as all other equipment at a hospital.

At the most extreme end, unauthorised access to IT and OT systems can pose a risk to life, with the potential for equipment shutdown, medications to be altered and test results changed.

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The risk lies in where this patient health information comes from, the machines feeding in the data from the outer edges of the health network. It’s much easier to secure data in a central point than it is to secure individual machines.

It’s impossible to protect IT and OT systems if you don’t know what’s happening in them, which machines are connected to them and what they are sharing. And the situation is always changing.

Like attaching a heartbeat monitor to a vulnerable patient, continuous, real-time monitoring is the best way to identify the symptoms of cyber attack – including new connections, unusual data traffic or sharing – early enough to apply effective remedies.

Early response can be the critical difference between maintaining privacy, security and continuity of medical care and a cyber attack causing potentially irreparable harm through a health organisation’s IT or OT systems.

In the cybersecurity world, as in the medical one, prevention is always better than cure.

ED: Jeremy Hulse is chief strategy officer with Sapien Cyber.

MARCH 2022 | 33

SPONSORED CONTENT

Bush doctors – have skills, will travel Opportunities abound for doctors in all stages of their career to experience the rich rewards of rural medicine.

Line up any number of the many Western Australian doctors who work as rural generalists for the WA Country Health Service and there are recurring, impassioned themes.

The work is clinically challenging, varied and exciting, the communities are warmly welcoming and grateful for their doctors’ skills, and the collegiality is legendary.

Such is the experience of country clinical service that doctors of all ages and stages of their career say once they have put the toe in, total immersion is almost inevitable – if not on a full-time, live-in basis, then certainly by embarking on regular locums throughout the year.

And WA Country Health Service is part of that journey.

The well-travelled Dr Daniel Laubscher has found himself in Geraldton via Victoria after he migrated to Australia from South Africa. It wasn’t just the lure of great career opportunities.

“I first heard about Geraldton from a colleague in Victoria who came here as a locum. We were both big kitesurfing fans.”

Nine years on, Dan and his family say there is nowhere else they would rather be.

“I have four children and we fell in

Interested?

The next step 34 | MARCH 2022

love with the landscape straight away. They all take part in water sporting activities and there is a lot on offer from that perspective,” he says.

“We had a very good outcome in this case, and she has since bounced back and is in good health.”

Cases like these motivate Dan and the other doctors in his team, seeing patients well, happy and back in the community is a real highlight.

Dan is a Senior Medical Practitioner in the ED at Geraldton Regional Hospital.

Dr Lucia Wang is a District Medical Officer in WACHS’ Pilbara region.

Her North West journey began as a medical student from Sydney University on the John Flynn Placement Program.

“It is a very high-functioning unit and has been a real motivator in my decision to stay all these years. I really believe in my team and what we are delivering.

The work that we do is incredibly rewarding, but it is also challenging.

The lure of the country and the scope of work was irresistible.

“The country is a great set-up for doctors who have the ability and drive to develop their skills, and practise independently. It’s an environment where you can grow at an incredibly fast pace and it’s extremely satisfying.”

As for the patients who present to the ED, Dan says many are flown to Perth when in a critical condition, but a good proportion are treated in Geraldton.

“A recent case I can think of is a girl who presented to the ED with kidney failure. She’d recently had strep throat and had bad acute poststreptococcal glomerulonephritis.

“We quickly organised contact tracing and established a roadmap of where she had been. Her family didn’t want her to be transferred so we kept her in the ED and managed to treat her symptoms locally, with specialist advice.”

“I didn’t originally have rural practice in my career plan, but once I started, I was sold! What really motivated me was the balance I could achieve between acute and long-standing patient care,” Lucia says.

Once her internship was completed in Perth, she worked in Port Hedland, then did her obstetrics and gynaecology training in Perth, before moving back to the Pilbara where she’s remained ever since.

“With medicine being such a dynamic field, there is always more to learn, and working in rural regions presents a multitude of different cases and learning opportunities.

In the ED we get to learn from our FACEM colleagues and WACHS facilitates procedural skilling workshops through Rural Health West, which we can attend in Perth or in the regions.”

For doctors keen to explore a rural experience, the first step is to email WACHSDoctors.Senior@health.wa.gov.au or call 6553 0961 to discuss the varied opportunities and requirements to fulfil positions safely and confidently.

Scope of practice accreditation is done on an individual basis because every doctor comes to roles with their own skillset.

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Doctors are supported by WACHS throughout their rural adventure. Expertise is gained along the way. There is access to consulting non-GP specialists face-to-face in regional towns and centres, and by phone in more remote locations. There is a 24/7 emergency telehealth service with an emergency physician at your side via video. WACHS sets GPs up for success with lots of options, opportunities and support.

A greater scope of practice was the initial drawcard to go country for GP obstetrician Dr Kate Poland, who says working for WACHS provides the rare opportunity to split her time between city and country.

Kate started working for WACHS in 2014 while completing her GP training in Geraldton, and found her interest in obstetrics and gynaecology supercharged in the regional environment.

“Working in the country gives me the opportunity to work part-time as a GP and part-time as a GP obstetrician, while furthering my education in the area. It is the best of both worlds. Now, for the past six and a half years, I've been working part-time in Port Hedland."

The variety of medicine is what keeps Kate motivated – one day it might be

ED, the next surgical procedures or the labour ward.

“It's just so varied, you get to use a huge range of skills and it's never boring,” she says.

“Working regionally is a great way to specialise in your field of choice.

Mine was obstetrics but I have seen GPs specialise in all areas because there is so much more opportunity out here to develop your skillset.”

And it's not just the professional challenge that keeps Kate in the country.

“The lifestyle is great. My husband loves the outdoors and there’s really nice boating and fishing in the Pilbara. He loves getting lost in the mangroves.”

Kate's advice for any doctor thinking about pursuing a career in country health is to just give it a go.

“Don't be afraid to come out here and try it. I work on a fly-in-flyout arrangement, and I love it.

WACHS provides flexible working arrangements, so don't be afraid to reach out and start a discussion.”

WACHS veteran Dr Peter Smith is a Procedural Senior Medical Practitioner in Emergency Medicine and Obstetrics. He began his journey in Karratha while his children completed high school, then working in Carnarvon and Esperance, before moving to the Wheatbelt region 10 years ago.

WACHS can provide upskilling opportunities for the individual.

Further information about WA Rural Generalist Pathway, scan the QR code.

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His role focuses on procedural obstetrics and emergency care at Narrogin Hospital.

“What I really enjoy about operating in a rural hospital is being in a small team of dedicated doctors and nurses. We know and trust each other. There is a real sense of community here that you just don’t get in other places,” he says.

“As far as career progression and up-skilling goes, working in rural general practice is one of the best avenues you can take. As there are fewer trainees on the ground, you are presented with learning opportunities you won’t get in other hospital settings.

“It is demanding and challenging, but it allows doctors to try a bit of everything and then decide if they want to continue as a generalist or specialise.”

Peter’s message to aspiring rural doctors is simple.

“If you want to feel like you are part of a community, feel like you’re making a difference, or if you simply want to try living a different lifestyle, you should work for WACHS. “There are so many benefits to rural practice, and it is an area where, if you invest your time and energy, you can really flourish and grow as a doctor. It is an experience I believe everyone should try at least once in their career.”

Government of Western Australia WA Country Health Service MARCH 2022 | 35

36 | MARCH 2022

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MARCH 2022 | 37

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GUEST COLUMN

Necessity the mother of invention In COVID turbulent times, WA’s Royal Flying Doctor Service has spread its wings even further, as Dr Kieran Hennelly explains.

In Western Australia, we’ve had the advantage of time to ensure we are as prepared as we can be for community spread of COVID-19.

As well as observing the experiences in other States, the WA RFDS has learnt a lot from our own early experiences of COVID-19, having safely aeromedically retrieved 139 suspected or confirmed patients.

We have a team of dedicated clinicians who, alongside our pilots, engineers, logisticians and executives, have embraced agility and flexibility in the face of an everevolving landscape, and continue to embed those lessons into practice.

But the RFDS cannot do what we do on our own. COVID-19 has seen us collaborate with the WA health and emergency services network like never before, to actively plan and monitor any COVID-19 developments.

Prevention, preparation and planning have been key.

We have bolstered our frontline workforce by about 20%, boosted and diversified our aircraft fleet, integrated new technology to enhance infection control and decontamination processes, and ensured adequate PPE stocks, with our crews regularly refreshing infection control training.

Our objective is to provide uninterrupted services for the people of regional WA, and to protect the health of regional communities – some of whom are particularly vulnerable to the health impacts of COVID. Drawing on the legacy of our founder, Reverend John Flynn, the RFDS – nearly 94 years after its conception – continues to build upon his traditions of innovation and providing a ‘mantle of safety’ to the people of remote and rural Australia.

Over the past 20 months, we have further expanded our fixed-wing

fleet, both turboprop and the innovative Pilatus PC-24, a small jet designed with aeromedical retrieval in mind. It is a platform that allows us to work with our partners in health care to mitigate the tyranny of distance within WA, the largest health jurisdiction on the planet.

Additionally, we are in the process of integrating two EC-145 helicopters to improve our flexibility and speed of response, to adapt to challenges known and those not yet encountered.

Another key figure in our history was our Sugarbird Lady, Robin Miller, an RFDS pilot and nurse who worked tirelessly to deliver 37,000 Sabin polio vaccines to 45 remote communities across the Pilbara and Kimberley in the late 1960s.

Today, Robin’s legacy lives on in our COVID-19 remote vaccination program which, since its establishment in May 2021, has delivered more than 10,000 vaccines across the remote Kimberley, Pilbara, Goldfields and Midwest regions of WA. Standing proudly outside our Jandakot base is a replica of Robin’s Mooney aircraft which she flew in to deliver the vaccines – a

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stark reminder of our strong roots in primary healthcare in remote and rural WA. This combined with our relationships with our health partners and capabilities as both a transport organisation and a health service have enabled us to help with novel activities – swabbing sailors on offshore vessels, moving healthcare workers and pathology samples around the State and delivering COVID-19 vaccines to the most remote parts of WA. By doing so, everyone who lives, works and travels in our State can feel safe knowing that they are not forgotten.

This year will likely bring great challenge to many of us in health care. Some of those will be anticipated, some not.

We can take comfort in the fundamental simplicities of our role of compassion, inclusion and a determination to do whatever it takes to mitigate suffering and provide people with assurance that they are cared for in the year ahead.

ED: Dr Kieran Hennelly is Clinical General Manager with RFDS Western Operations.

MARCH 2022 | 39

Support crucial to manage complex conditions Rachel Seeley from Health Consumers’ Council looks at how frequent users of health services can be better supported.

Each year in WA, more than 500,000 people go to emergency departments for care, and while most only go once or twice, there are a small number who attend more frequently.

frightening having a feeling that you are drowning/can’t breathe. As with any other chronic condition, the patients and their support network need ongoing education and refreshers, as it will take several attempts for most before all is understood and accepted.”

In 2016, about 5% of patients who went to an ED averaged about nine visits, with some people going more than 100 times. These patients are classified as ‘high risk’ and are more likely to have complex needs.

This data comes from the Sustainable Health Review, which was was published in April 2019.

The broad-reaching consultation that informed the SHR resulted in eight enduring strategies and 30 recommendations which seek to drive a cultural and behavioural shift across the health system.

Recommendation 13 – Implement models of care in the community for groups of people with complex conditions who are frequent presenters to hospital – seeks to prioritise a systemwide approach to identifying and supporting people who are frequent users of health services, including emergency and outpatient services, to improve pathways of care and reduce hospital presentations.

In consultation with the recommendation 13 working group and key stakeholders, it was decided that the project would initially focus on strategies and models to support care for frequent hospital attenders diagnosed with chronic obstructive pulmonary disease and chronic heart failure.

A key principle of the SHR is the importance of having the consumer, carer and community voice at the health and human services decision-making table. Engagement work around recommendation 13 will explore the lived experiences and healthcare journeys of COPD and CHF patients and their carers, including barriers, enablers and contextual factors to receiving patient-centred care close to home.

40 | MARCH 2022

Another clinical survey participant stated, “Patients get scared and then have very little support networks to stay out of hospital.”

A survey of 215 clinicians collected input from hospital-based, primary care and community clinicians working inside or outside of the WA health system to understand their experience.

When asked to identify the most common reasons a person with COPD or CHF may frequently present to hospital, clinicians cited poor health literacy or disease knowledge regarding COPD or CHF and management strategies as the most common reason (130 responses).

Interestingly, anxiety resulting from COPD or CHF was identified as the second most common reason (110 responses), and lack of personal or social supports (such as family or social services) was identified as the third most common reason (104 responses).

In a separate survey, consumers were asked questions around hospital and healthcare use, healthcare preferences (such as home visits or telehealth), healthcare knowledge and skills, healthcare experiences, and personal and social factors, with 42% of participants responding that they often or always experience stress or anxiety from their COPD or CHF.

An upcoming focus group for people with COPD or CFH, as well as those who care for someone with COPD or CHF, will seek further consumer insight around experiences of receiving and accessing care across the health system.

In a separate study funded by the WA Health Translation Network and led by the Curtin research team in partnership with the WA Primary Health Alliance, consumers diagnosed with COPD, diabetes or CHF were invited to take part in a forum to explore the possibilities of integrating primary and secondary care using linked data across the continuum of care and the impact it would have on reducing preventable hospital admissions.

This is in light of the data currently collected in general practice and available through other areas of the health system. It sparked thoughtful consideration and discussion with a second consumer forum being planned, which, collectively, will inform a national study on consumer perceptions and willingness to share data in a de-identified manner.

ED: More information about both projects can be obtained by emailing info@hconc.org.au

As one responding clinician said, “We need to remember that it is MEDICAL FORUM | PAIN MANAGEMENT

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GUEST COLUMN

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GUEST COLUMN

At-home rehab opens possibilities The next logical step for telehealth is hospital in the home care, according to allied health provider Jonathon Moody.

Integrated care has long been the gold standard for healthcare outcomes. Comprising a multidisciplinary team of practitioners who communicate with each other to provide patientcentred services, integrated care not only offers people the healthcare functions they need but also takes into account the context of their environment and lifestyle.

The results speak for themselves.

If you can seamlessly move a patient from a hospital environment and get them home as soon as possible with the same integrated care approach, rehabilitation can be much faster in an environment that is meaningful to them. The rehabilitation process should be relevant and purposeful.

Hospital in the Home, also known as hospital substitute treatment, is a model that works well with integrated care. It’s designed to treat patients with illnesses or conditions that may need close monitoring, but who are not likely to deteriorate rapidly, at home.

This minimises disruption to their lifestyle and enables hospital beds to be used for more serious cases.

During HITH, specialists and allied health professionals that provide service inside hospitals, can also service patients in their home.

There are challenges, including costs that need to factor in issues such as travel time, which means practitioners see fewer patients.

Conversely, moving a patient out of the hospital helps free up much-

needed beds that improves the bottom line to the facility. However, currently in many cases, the patient or their insurer is required to meet those costs, which in the short term discourages adoption of the model.

Rethinking of the value proposition by insurers is required to more wholly embrace the concept and change policies on inpatient and outpatient cost coverage.

Telehealth & HITH Telehealth can assist in cases where patients need monitoring but don’t necessarily require inperson care. Continuing technology advancement means tools such as bluetooth-enabled monitoring devices are able to feed patient data to the practitioner.

The treatment can also be tailored to the home context rather than a clinical environment, which often doesn’t present an accurate picture of how the patient is tracking on a daily basis.

Telehealth is, of course, cheaper than travelling practitioners, but not a one-size-fits-all solution. I see good use of telehealth and HITH in situations as an adjunct for recovery from conditions that have may a standard rehabilitation protocol where the patient is charged with administering much of the therapy, but the practitioner is required to ensure compliance.

Factors, such as having a lower infection risk when the patient is treated out of hospital, support that position.

What COVID-19 and the emergence of telehealth technology and practices have taught us it that many telehealth treatments are very effective and hopefully that momentum carries through to the uptake of HITH in tandem.

System redesign Despite the obvious benefits of pairing telehealth and HITH, the healthcare system is focused on hospital-based treatment, with the bulk of the public health budget going towards building and maintaining this overhead-heavy system without regard for more targeted outpatient care.

An inpatient’s care is generally covered by Medicare, a health insurer or a combination of both, but once at home, if the healthcare provider is not on board with HITH or telehealth, then the patient faces significant out-of-pocket expenses.

The other consideration is that hospitals are a hub of medical practitioners, they concentrate specialists and doctors that are involved in a particular type of treatment in one place.

If we were able to deploy these practitioners efficiently under HITH, we could reduce hospitals to a quarter of the size. Considering a hospital may cost $2-3 billion to build for not that many beds in relative terms, and how that money may be been better spent on supporting the required labour under a HITH model, practitioners could treat more people, and likely achieve better outcomes.

In the end, we will need a tripartite solution between the public healthcare system, private health insurers and health practitioners.

Investing in home-based healthcare models takes effort and we need as much evidence as possible to prove its efficacy before we attract more interest to overhaul this area.

ED: Jonathan Moody is CEO and co-founder of Physio Inq.

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MARCH 2022 | 41

Complex non-melanoma skin cancer patients?

Dermatology Dr Kate Borchard Dr Judy Cole Dr Glen Foxton Dr Louise O’Halloran Dr Jamie Von Nida Dr Yee Tai

Refer cases to the Non-Melanoma Skin Cancer Advisory Service for multidisciplinary review

The benefits of a multidisciplinary approach to patient management are well known. The Non-Melanoma Skin Cancer Advisory Service (NMSCAS) has been established to enhance the care of patients with complex non-melanoma skin cancers.

To submit cases to the NMSCAS for advice or management, visit genesiscare.com/au/refer-a-patient then click on Refer to the WA non-melanoma skin cancer advisory service to download the forms. Case information must be received no later than 1 week prior to the scheduled meeting.

 NMSCAS meets every third Thursday of the month  Clinipath Pathology 310 Selby Street North Osborne Park WA 6017

NMSCAS specialist team:

Pathology Dr Trevor Beer Dr Gordon Harloe Dr Joseph Kattampallil Dr Stephen Lee Dr Ben Ryan Plastic Surgery Dr Adrian Brooks Dr Sharon Chu Dr Mark Hanikeri Dr Qadir Khan Dr Daniel Luo Dr Linda Monshizadeh Dr Remo Papini Radiation Oncology Dr Sean Brennan Dr Eugene Leong Dr Susan Mincham Dr Evan Ng Dr Kasri Rahim Dr Craig Wilson Dr Yvonne Zissiadis

All enquiries: mdtskinwa@genesiscare.com 42 | MARCH 2022

0452 277 752

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OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

Rethinking pain management For those old enough, cast your mind back to the mid-1990s. There were no oral opiate medications aside from those containing codeine, and these were used sparingly.

The AIHW reports 1849 drug overdose deaths in Australia in 2020 with 60% involving an opiate.

Does this mean we should not use these medications?

Of course not. It does mean that we need to be more judicious than in the past and look for other options.

Then two significant events occurred. Pain was declared the fifth vital sign and oral versions of morphine came on the market. Nobody wants to be in pain and no doctor wants a patient to suffer. However, the notion of everyone being totally pain free all the time was, and is still, not realistic.

History records that since the late ’90s we have had major problems with use of opioid medications leading to the term “opioid crisis” being coined. The CDC reports that in 2020 there were 91,799 drug overdose deaths in the US, with prescription opiates being a major contributor.

The AIHW reports 1849 drug overdose deaths in Australia in 2020 with 60% involving an opiate.

Does this mean we should not use these medications?

Of course not. It does mean that we need to be more judicious than in the past and look for other options.

To that end, this month we feature a number of articles which examine ways of treating pain that do not involve analgesics. This includes managing the psychological aspects and taking a patient-centred approach. Yes, I know that some if you will say this is a cliché, but it is still important. The roles of radiofrequency techniques and spinal injections are covered, and we bust some myths about what to advise the person with back pain.

IBS is a painful condition where pharmaceuticals have offered little.

Medicinal cannabis (full disclosure I am Medical Advisor to Little Green Pharma) shows promise and a trial based in Perth will explore this further. A view from a doctor on managing pain from “the other side” of the surgical knife makes interesting reading.

In January, Reuters reported that US cities and counties have “embraced a proposed settlement worth up to US$26 billion resolving lawsuits against three large drug distributors and drug maker Johnson and Johnson”. Other multibillion dollar claims have been made against Purdue and the Sackler family.

Going forward, the solution is not to totally reject the use of oral opiates – they have a role. We do need to better educate patients about pills not being the only answer, be open to other approaches and genuinely do our best to take a patient-centred approach. First do no harm!

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MARCH 2022 | 43

Bilateral total knee replacement

By Dr Philip Finch, Pain Specialist, South Perth Despite current myth, total knee replacement is not a painful experience. I can confidently vouch for this having just had both joints replaced at the same time (BTKR).

My knees have gradually degenerated after a rugby injury when I was a medical student. The medial meniscus was removed intoto by the late Bill Gilmour and I had few problems for many years.

Eventually, the knees developed loud crepitus when I bent down or attempted stairs in either direction.

A retired orthopaedic colleague, who still assists at knee replacement surgery, asked: “Do they hurt at night, can you sit without pain, and do you need to take analgesic drugs?” My answer was no to all three questions. “Then why are you thinking of having them replaced?” He also suggested

I was advised to have both done at the same time. Apparently, many males never return for the second side! The surgeon referred me to a physiotherapist who also encouraged me to have both replaced. Her father had undergone BTKR and has never looked back.

Key messages Total knee replacement is not a particularly painful experience Potent opioid analgesic drugs may not be necessary If both knees need surgery, have both replaced at once. that I may have no pain receptors in my knees!

I then consulted my chronic pain patients who have had knee replacements and I received differing opinions. When I told them that I was thinking of having both replaced at once they screwed up their faces and told me I was very brave (or very stupid)!

An EOS scan showed one knee in valgus and the other in varus.

As the six months slowly passed before surgery, all manner of complications of TKR presented themselves at my rooms including sequelae from infected joints, neurological injuries and the development of Complex Regional Pain Syndrome (CRPS).

I had repeated conversations with my wife, seeking her opinion on whether she thought I was doing the correct thing by going for surgery. She said, “try doing this in 10 years’ time”. The surgeon, the physiotherapist and the

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44 | MARCH 2022

24/01/2022 2:50:53 PM

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CLINICAL UPDATE

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CLINICAL UPDATE preoperative physician all said the same thing, so I signed a consent and thought little about it for five months. I did, however, swim almost every day and felt reasonably fit.

both knees, especially at night and often remedied by a change of joint position or a small amount of NSAID.I am now walking reasonable distances and at day 24, managed 1.5km in the Wesley pool.

I contacted the anaesthetist and was told that the surgery would be performed under spinal anaesthesia plus sedation. I then started to see patients who had undergone procedures under spinal blocks and who had developed spinal tap headaches, spinal infections, and neural stick injuries. “Doctor, you are very brave” my patients kept telling me!

In the operating theatre anaesthetic room, I spoke to the surgeon, requesting that he not use a tourniquet as I had seen sciatic nerve injuries following the use of a tourniquet. The spinal needle was inserted without difficulty, and I started to experience a pleasant sensation in my legs. The next thing was a painless awakening as if I had had an afternoon snooze.

The adductor canal catheters were very effective and there was little pain. I eventually asked for them to be removed early on day three and was told I might regret this decision, which I didn’t.

My conclusions from this surgery have been remarkably positive.

BTKR has not been a painful experience. Bilateral adductor canal blockade, a simple drug regimen and early mobilisation have provided a comfortable peri-operative experience. Also, the surgical technique may temporarily alter genicular nerve function (afferent pain fibres from the knee).

I was offered opioids but had the pleasure of refusing them, finding paracetamol to be quite adequate.

The hospital physiotherapists wanted me to take a few steps using crutches which were soon dispensed with. I managed to leave hospital on day four carrying the crutches which I have now handed back to their kind owner.

The subsequent post-operative course has not been painful. At day seven, I switched from paracetamol to the occasional NSAID. The main discomfort has been aching in

Patients can be confident that acute pain should not be an issue and recovery can be swift. If you have painful arthritic knees, have both replaced at once. But I wonder how I will respond to my chronic pain patients when I return to work, and they request large doses of oxycodone for their aches and pains!

The author acknowledges the surgeon and nursing staff at Hollywood Private Hospital, his physio, and his wife for her support.

Author competing interests – nil

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MARCH 2022 | 45

Lifting & back pain: a literature review

By Ben Davis, Exercise Physiologist, Perth There is a common belief that when lifting from the floor, a neutral spine should be maintained.

Fundamentally, this view has been constructed under the belief that the spine, particularly the vertebral discs, are a series of fragile structures highly susceptible to injury when loaded.

However, this narrative has been comprehensively disproved within the contemporary scientific literature, with research showing that deviating away from a neutral spine when lifting is not a risk factor for either the onset or persistence of low back pain.

Common myths “There is much more pressure on my discs if my back is bent.”

• There is only 4% different in pressure on the discs between a stooped and squat lift “I am likely to slip a disc if I lift something too heavy with a bent back.”

• Disc related back injuries only account for about 10% of back pain and, in the absence of significant trauma, discs don’t slip anywhere.

“I should keep a straight back and bend my knees” • There is no high-quality evidence to suggest that lifting in this way prevents injury. It is more likely to do with the frequency of lifting, how much you lift and if you are used to it.

Core stability Core stability training is the staple of traditional biomechanically focused rehabilitation for low back, based on the assumption that specific activation of “core” muscles can both prevent low back pain and is required to be optimal as part of low back rehabilitation. In fact, research shows an increased likelihood of core muscle bracing as a protective mechanism in those experiencing low back pain.

A 2014 systematic review revealed strong evidence that stabilisation exercises are not more effective 46 | MARCH 2022

to delaminate and herniate upon repetitive end-range spinal flexions.

Key messages Advise lifting in a manner that feels comfortable and efficient for the individual, which may or may not involve spinal flexion Encourage structured exercise with progressive loading principles to provide exposure to lifting in various spinal postures Provide evidence-based education to reassure and empower people not to be alarmed or fearful of spinal flexion.

than any other active exercise in the long term and that any therapeutic influence is related to the exercise effects rather than core stability issues.

One area not explored till recently is the influence that lumbar postural positions have on trunk muscle requirement, strength and neuromuscular efficiency during maximal lifting. Mawston et al (2021) demonstrated that lifting with a flexed spine significantly increased lumbar extensor moment and enhanced neuromuscular efficiency, ultimately improving overall strength and efficiency when lifting.

This contradicts the biological understanding of adaptation – a cadaver with no functioning nervous system to facilitate adaptation to load. There are no high quality in-vivo human studies demonstrating causation around spinal flexion and disc-related injury.

A cross-sectional study that observed 198 Danish blue-collar workers recorded the time spent in forward bending (>30°, >60°, >90°) and found no significant positive associations between forward bending and lower back pain intensity. In fact, higher durations of forward bending of >30° was associated with lower low back pain intensity, again highlighting the adaptive nature of the human body in that we can habituate to our environment and become resilient to physical tasks that we are exposed to over time. continued on Page 48

Furthermore, it was outlined that lifting with a lordotic posture resulted in reduced neuromuscular efficiency. This again questions the traditional approach in many manual handling courses and medical advice to maintain a lordotic lumbar spine when lifting heavy loads.

Contemporary literature Biomechanical cadaver studies generally underpin the traditional understandings of lifting and back pain, whereby animal spines were placed into mechanical jigs and vertebral discs were shown MEDICAL FORUM | PAIN MANAGEMENT

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CLINICAL UPDATE

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CLINICAL UPDATE

Managing the person in chronic back pain

By Dr JP Caneiro (PhD), Specialist Sports Physiotherapist, Shenton Park “Strengthen your core”, “Sit straight”, “Don’t bend your back”, “Pain is your guide…. Rest if you are sore”. These are common recommendations offered by clinicians to people with back pain in conjunction with interventions to fix or correct structural deficits. While commonly implemented in clinical practice, does current evidence support such approach in managing people with chronic back pain?

The short answer is no.

Research trials testing traditional health care interventions such as core stability training, postural retraining, spinal manipulation and ergonomic interventions have provided uninspiring outcomes.

Similarly, the use of strong medications, spinal injections and surgery (e.g. spinal fusion) for people with back pain, had yielded no long-term benefits and was no better than non-operative care.

This data challenges common unhelpful and non-factual beliefs driving current health care practice such as: 1) back pain is caused by poor posture when sitting, standing or lifting 2) having weak core muscles causes back pain, and having a strong core protects against future back pain 3) repeated use of the back results in wear and tear 4) pain related to exercise and movement is always a warning that harm is being done to the spine and a signal to stop or modify activity 5) that pain flare-ups are a sign of damage and require rest, protection, and a scan to identify the source of the pain.

These beliefs inaccurately promote that pain is always associated with a structural or physical problem. In contrast, current evidence supports that a person’s posture during sitting, standing, or lifting does not cause or predict a person’s pain.

Having a weak core does not cause back pain. In fact, people in pain tend to overtense their trunk muscles to protect their backs, often with little benefit. Learning to move and load the back in a relaxed, confident, and graduated manner is not only safe but also necessary for the spine’s health.

While there is a common belief that the intensity of pain is reflected in the degree of tissue damage (i.e., pain = damage), it is well established that the majority of chronic non-traumatic musculoskeletal pain does not have a patho-anatomical diagnosis explaining a person’s pain experience and level of disability.

Back pain flare-ups are often linked to factors such as stress, feeling rundown, carrying too much weight around the belly, sleeping poorly, low mood, inactivity, smoking, poor conditioning, and ‘overdoing it’.

The evidence supports that while biological factors MEDICAL FORUM | PAIN MANAGEMENT

Key messages Management of chronic back pain is often driven by inaccurate and unhelpful beliefs A person’s pain experience is influenced by an interplay of biopsychosocial factors, many of which are modifiable and can be targeted for effective management Best care guidelines recommend a management approach that is centred on the person empowering them to develop skills to manage the condition.

such as radiological findings, physical conditioning and behavioural responses to pain are important to consider; there are other psychological factors (e.g. fear-avoidance behaviour, poor coping behaviours) and social factors (e.g. lack of support, isolation) contributing to a person’s pain experience and level of disability. Importantly, many of these factors are modifiable and can be targeted at an individual level for effective management.

Furthermore, contemporary evidence states that pain shares similar risk factors to other chronic health conditions, and that its management should be personcentred.

Person-centred care Person-centered care is characterised by focusing on the person, taking a biopsychosocial perspective to understand their pain and sharing power and responsibility on the design of a management plan. In practice, we clinicians need to: • Screen for serious pathology, health co-morbidities and psychosocial factors.

• Adopt effective communication, allowing patients to express their agenda (i.e., concerns, expectations, goals) and clinicians to identify key contributing factors (e.g. sleep, stress, coping behaviours), and undertake a targeted clinical examination.

• Design an individualised management plan addressing key contributing factors that is considerate of the patient's context, and that discusses the benefits of high-value care and limitations of low-value care.

• Provide evidence-based and personalised education.

• Coach and support patients towards selfmanagement, equipping them with skills to actively engage in exercise and a healthy lifestyle and take responsibility in the management of their health.

• Facilitate and manage co-care (when needed) through ongoing communication with the patient and other health care professionals.

continued on Page 49

MARCH 2022 | 47

Putting the ‘psych’ in ‘biopsychosocial’ for pain

By Dr Rob Schütze, Clinical Psychologist, RPH Pain Management Centre Most of us experience episodes of bothersome back pain in our lives, usually resolving with minimal intervention. But for a significant minority, back pain becomes a chronic, costly, and debilitating condition. Doctors know the havoc it can wreak on people’s lives, including time off work, social isolation, low mood spiralling into depression, escalating anxiety and desperation for a medical miracle.

So how do these psychological factors predict and fuel the chronic pain cycle? And how can we address these so-called ‘yellow flags’ with and without the help of mental health professionals such as psychologists?

Burgeoning evidence has documented the harms associated with over-imaging, over-prescription of opioids, and the over-use of low-value interventional procedures for back pain. The ‘problem of too much medicine’ is acutely felt in chronic low back pain (CLBP) where the issues are rarely in the tissues – around 85% of cases are ‘non-specific’, with no significant underlying structural pathology.

Longitudinal studies show that psychological factors are better predictors than MRI findings of acute back pain not resolving.

Clinical guidelines encourage

psychologically informed approach and often combining physical and psychological therapies.

Key messages Psychosocial factors such as low mood, activity avoidance and negative pain beliefs predict and maintain chronicity in low back pain

This is documented in clinical guidelines such as NICE guidelines on managing low back pain and sciatica in the UK, and the ACI Musculoskeletal Network guidelines in Australia. What this looks like in clinical practice is less clear. Do you just refer to a psychologist and risk your patient walking away thinking, “so the pain is all in my head”?

Clinical guidelines emphasise the importance of screening for and addressing ‘yellow flags’ We need to break down professional ‘silos’ and better integrate our multidisciplinary treatments to improve patientcentred pain care.

screening tools (e.g. STarT Back, Orebro) to catch yellow flags and inform treatment. These include risk factors such as low mood or emotional dysregulation, activity avoidance, excessive worry (‘catastrophising’), negative recovery expectations or pain beliefs, reliance on passive treatments, work problems and lack of social support. These psychosocial factors increase allostatic load contributing to central sensitisation in the development of ‘nociplastic’ pain, now reflected in ICD-11 pain diagnoses.

Preventing and ameliorating these nociplastic changes in people with higher risk profiles involves taking a

Without patients having a good understanding of the biopsychosocial model, this can easily fuel the invalidation and alienation so commonly experienced by people with chronic pain (the ‘hidden disability’), as shown by extensive qualitative research on the lived experience of pain.

It may be hard to refer to a psychologist with experience in pain. Pain literacy among most psychologists has historically been low but is improving with projects linked to the recently endorsed National Strategic Action Plan for Pain Management.

Stand-alone psychological treatments such as Cognitive Behaviour Therapy and Acceptance and Commitment Therapy for chronic pain are effective according to at least three Cochrane Reviews.

Lifting & back pain: a literature review A 2019 systematic review and meta-analysis found that lumbar spine flexion when lifting was not a risk factor for low back pain onset or the persistence of existing low back pain, and that advising individuals to avoid lumbar flexion when lifting cannot be justified by current evidence.

flexion might actually be largely unavoidable. A study found minimal lumbar kinematic differences between those who actively attempted to stoop during a squat, compared to those who actively attempted to maintain a neutral spine – instead, a compensation occurred higher in the thoracic spine. Therefore, advice to avoid bending may be problematic in that it may not be attainable.

Interestingly, lumbar spinal

Contemporary literature and

continued from Page 46

48 | MARCH 2022

societal beliefs are in conflict. As health professionals, we need to provide evidence-based advice on lifting and manual handling to those experiencing low back pain. This can give people greater confidence in their spines and reduce the disability associated with low back pain.

Author competing interests - nil

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CLINICAL UPDATE However, effect on pain, disability and mood are modest.

Within this landscape, physiotherapists have played a crucial role in bridging the dualistic mind-body divide with the advent of psychologically informed physiotherapy (e.g. Cognitive Functional Therapy).

Meta-analyses show these interventions – using cognitive-behavioural principles and a strong emphasis on therapeutic alliance – have robust effects on pain, function and psychological outcomes such as depression and anxiety.

In more complex cases, a multidisciplinary approach is still indicated, especially in cases of co-morbid psychopathology like major depressive disorder, PTSD, or a substance use disorder.

Multidisciplinary treatment (MDT) has long been the gold standard for chronic pain treatment.

Yet timely access to these services is enduringly elusive, not to mention expensive for health systems.

In the case of CLBP, it’s not even clear that existing models of MDT are superior. Some systematic reviews show only a half-point benefit over usual care or physiotherapy on a 0-10 pain intensity scale, which is of questionable clinical significance.

One explanation for this is that pain care continues to be ‘siloed’ or fragmented, with limited integration between treatment components. This will be familiar to many doctors who see complex cases where a large menagerie of specialists, allied health professionals and complementary practitioners are all treating a patient, with limited coordination or communication.

Reasons for this are multifactorial and systemic. I am often one of the menagerie. But the way forward certainly lies in better integrating our treatments.

Paving that path forward will involve things such as: • emphasising a truly patient-centred approach, • using a common clinical reasoning framework between health disciplines based on cognitive behavioural principles and a biopsychosocial framework • incentivising high-value evidence-based pain rather than fee-forservice models with perverse incentives for low-value care • and investment in health practitioner training that focuses on interdisciplinary collaboration.

Meanwhile, we can we all help our patients with CLBP by, as one person with lived experience recently told researchers, “Listen to me, learn from me”. Empowering people to self-manage their pain starts with validation and flourishes with a good dose of collaboration.

Author competing interests – nil

Managing the person in chronic back pain continued from Page 47 The patient's perspective is central to this process. Recent research reported that health care professionals such as physiotherapists, who have been trained to broaden their skill

set towards a person-centred approach to pain, report positive changes to their clinical practice and outcomes.

Evidently, there are obstacles to this approach both at the system and at the clinician level. Initiatives to change how we care for

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people with chronic pain should involve all stakeholders including clinicians, educators, researchers, funders, policymakers and, most importantly, patients.

– References available on request Author competing interests – nil

MARCH 2022 | 49

Providing specialist anaesthetic services across metropolitan Perth and the wider WA community

Southern Anaesthetics is a well regarded anaesthetic practice, with a 42 year history of providing specialist anaesthetic services across metropolitan Perth and the wider WA community.

We currently consist of 18 professional, highly competent and approachable Specialist Anaesthetists. The practice is supported by an experienced team in the office, utilising the MediTrust anaesthetic management software.

Every aspect of anaesthetic practice is taken care of, including: 2 in office consultation rooms, theatre list management, informed financial consent, billing and fees collection, debt management, transparent fair allocation of incoming work, pre-op patient health questionnaires, pre-op reports acquisition and electronic facilities to support patient surveys, practice evaluation and CPD requirements.

Our fee structure is competitive and is constantly being reviewed to minimize costs.

We welcome enquiries from both part-time and full-time Specialist Anaesthetists to join our practice at our new rooms at 3/2 McCourt St, Subiaco, WA, 6008.

Please contact Dr.Galatis@southerns.com.au. We also welcome offers of permanent and ad-hoc surgical lists to enquiries@southerns.com.au.

3/2 McCourt St, Subiaco, WA, 6008 | Tel: 08 9381 9100 Fax: 08 9388 3019 | Email: enquiries@southerns.com.au

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Acute cervical radiculopathy

By Dr Reza Feizerfan, Pain Medicine Physician Acute cervical radiculopathy (ACR) occurs due to a compressed cervical nerve root with any combination of pain, numbness, weakness, or diminished reflexes in either or both upper extremities.

It is most prevalent in the fourth and fifth decades of life.

Spondylosis, disc herniation and bony hypertrophy of joints (facet, uncovertebral) are common, while trauma and red flags are rare aetiologies.

The clinical presentation is often unilateral, and the most common symptom is radicular pain.

Paraesthesia or neuropathic pain descriptors can be present without a history of pain. Other clinical features can be muscle weakness or diminished reflexes.

The most common physical findings are painful neck movement and muscle spasm, which would be evident by examining the patient’s posture in the upright position, and the range of movement of the neck (including forward and lateral flexions, extension, and rotation).

Radicular pain may be outside the classic dermatomal anatomy (see Table 1) due to the crossover of the innervation. Hence, a combination of symptoms, mapping the pain distribution, examining muscle power, sensory pinprick testing and

reflexes is essential to identify the compressed nerve root.

The most commonly affected nerves are C7 and C6. Spurling’s Test (lateral flexion and extension of head towards the affected side with axial compression of the neck to reproduce the patient’s symptom) is the most commonly used provocative manoeuvre. The other test is relief of symptoms in shoulder abduction with the patient putting the palm of the affected side over the head. I routinely exclude shoulder pathologies, myofascial-related pain, whiplash injury and peripheral nerve entrapments due to similarities in their clinical presentation.

Plain x-ray is useful when looking for trauma, malignancy and red flags.

However, it is non-specific for ACR. MRI evaluates soft tissue-related pathologies but due to the high rate of false-negative and false-positive findings, MRI orders should be done in selected cases. A CT scan is often useful for spondylosis and bony pathologies. EMG and nerve conduction studies can be helpful in selected cases where diagnoses of peripheral neuropathy would alter the course of treatment.

It is crucial to exclude red flags (fever, weight loss, night sweat, nocturnal pain, ataxia, clonus, hyperreflexia, gait abnormality, H/O IV drug

Table 1: Clinical pattern of cervical radicular pain NERVE ROOT

PAIN

MUSCLE FUNCTION*

SENSORY*

REFLEX

C4

Lower neck, trapezius

Nil

Lower neck, shoulder girdle

Nil

C5

Lateral arm, neck, and shoulder

Elbow flexor

Lateral arm

Biceps, Brachioradialis

C6

Posterolateral arm, neck, thumb

Wrist extensor

Lateral forearm, thumb, and index finger

Brachioradialis

C7

Posterolateral forearm, middle finger

Elbow extensors

Middle finger

Triceps

C8

Medial forearm, neck, little and ring fingers

Finger flexors

medial hand, fourth and fifth digits

Nil

T1

Ulnar forearm

Finger abductors

medial forearm

Nil

* Source: American Spinal Injury Association (ASIA) Impairment Scale

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use and immunocompromise) as their management requires urgent surgical strategies.

High quality evidence for treatment modalities in ACR is lacking.

Available recommendations and my approach to ACR are: 1. Most ACR cases are selfresolving. Hence, starting with conservative treatments such as avoiding the triggering cause and a brief period of immobilisation with or without a soft collar (not more than 1-2 weeks) is reasonable. This period should be followed by physical therapy.

2. NSAIDs, muscle relaxants and a short course of oral corticosteroid, (e.g. around five days) have been recommended, but the evidence in the literature is limited. I personally don’t use oral corticosteroids. A short course of anti-neuropathic agents such as gabanoids, SNRIs, or tricyclic antidepressants is reasonable. If it is required, a short course of atypical opioids can be considered, especially to facilitate physical therapy.

3. If there is no improvement in the patient’s symptoms after conservative treatments, a referral to a pain medicine specialist is recommended for psychosocial and biological assessment, where patienttailored comprehensive pain management strategies can be recommended. There are multiple studies supporting epidural (transforaminal via nerve root or interlaminar) steroid injections in ACR. Pain medicine specialists can perform interventional pain procedures such epidural and nerve-root sleeve injections as a diagnostic/therapeutic treatment, as an adjunct to the multifaceted pain management strategies.

4. Referring the patient for surgical assessment is warranted in presence of red flags, myelopathic features, muscle weakness and unresponsive cases to the treatments.

– References available on request Author competing interests - nil MARCH 2022 | 51

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What exactly happens in a rhizotomy?

By Dr Brian Lee, Pain Specialist, Perth Radiofrequency treatments are commonly performed to target painful conditions involving the spine and major joints, but it is often hard to know exactly what the patient has gone through.

Let’s demystify.

Ever since Rene Descartes first came up with the theory of pain pathway in 1664, humans have tried to lessen pain by affecting the transmission of nociception to the brain. The idea of neural destruction and interruption of nociception as a treatment of intractable pain was explored in mid-1900s, including surgical laceration of nerves and chemical denervation using phenol.

While still in use in select circumstances, the inherently invasive nature of these techniques and the unpredictable pattern of injectate spread has limited its uptake.

The first documented use of radiofrequency technology for therapeutic neural destruction occurred in 1973, when Shealy targeted the lumbar facet joints, with Cosman and Sluijter bringing the first commercial radiofrequency kit to market soon after.

Since then, with the embrace of radiographic guidance and development of techniques based on cadaveric research

by Australian pioneer Nikolai Bogduk, radiofrequency ablative techniques have become accepted as an integral part of interventional pain medicine. More recent uptake of non-destructive pulsed radiofrequency techniques, as well as rise of novel technologies, have broadened its application. So, what are they?

Radiofrequency Ablation (RFA) /Radiofrequency Neurotomy, the “rhizotomy” Under fluoroscopy or CT guidance, radiofrequency cannulae (needles) are inserted into the region of interest where the afferent nerve fibres, thought to be transmitting pain, are located. These cannulae

Key messages Therapeutic radiofrequency technology dates to the 1970s Rhizotomy is a generic term used for two different techniques.

Distinction is very important PRF can be considered in situations where RFA is contraindicated.

are electrically insulated except for the exposed tip of 0.5-1cm length.

When the cannulae are connected to an RF generator, continuous AC current is generated, heating the exposed tip in a controlled manner to a temperature that causes tissue coagulation and neural destruction, generally to 80-90 ◦C, for 1-2 minutes. This leads to Wallerian degeneration and interruption of nociceptive transmission, therefore relieving pain.

Studies have shown that application of continuous RF in this manner produces well circumscribed thermal lesions of predictable size, allowing for techniques that can be replicated. This is referred to as Radiofrequency Ablation (RFA)/ Neurotomy (RFN), and traditionally called rhizotomy in WA. Due to its nature, RFA can cause temporary pain flare-ups and is almost exclusively used for nerves without a significant motor component. RFA of medial branch nerves is well validated for treatment of zygopophyseal (facet) joint mediated spinal pain.

Size of thermal lesions and its proximity to target nerves are thought to be vital to the success of RFA. Technologies such as tined RF cannulae and bipolar treatments (generating a contiguous lesion between two cannulae spaced ~1cm apart) have allowed for larger lesion sizes to better capture target nerves, while ongoing refinements in techniques continue, and new potential targets have been identified for pain involving the spine and major joints of the body.

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Pulsed Radiofrequency (PRF), a non-destructive alternative Sluijter and Cosman, brought out this next novel therapy in 1998.

While RF ablation uses continuous uninterrupted AC current (and therefore delivery of energy) to heat the RF cannulae tip, in pulsed RF treatments the same AC current is applied in short burst of milliseconds, 2-5 times per second.

This allows for energy delivered to dissipate between pulses and hence allows for treatment without significant heating of tip and associated tissue destruction. The exact mechanism of action of PRF is unclear but thought to be related to the strong electric field created and altered expression of c-Fos gene that may induce changes in neural activity over short-medium term. Pain relief from PRF appears to last in the vicinity of months, whereas a successful RFA may provide benefits for over a year.

PRF technique can be applied to a wider range of targets where neural destruction is undesirable, including major mixed motor/sensory nerves and nerve roots. Temperature is regulated to a maximum of 42 ◦C during PRF to ensure that unintended thermal damage does not occur. Anecdotally it could also be considered as an alternative to RFA in patients whose risk profile would predict significant potential pain flare-up from such treatment.

While the term rhizotomy is sometimes used interchangeably to refer to both RFA and PRF techniques, no tissue lesion is made in PRF and Bogduk emphasises the importance of distinction between the two to minimise confusion amongst patients and colleagues.

The author acknowledges Drs Marc Russo and Rob Wright, whose article on RF technology history was extensively quoted.

– References available on request Author competing interests – nil

MARCH 2022 | 53

Image-guided lumbar spine injections – what to refer for and when?

By Dr Sven Klinken, Radiologist, Nedlands Lower back pain is a common condition, with most cases settling without intervention. However, for cases refractory to conservative management (oral analgesia and rehabilitation), image-guided spinal injections can be beneficial.

The success of these injections is significantly improved by accurately targeting the likely pain generator by marrying the clinical and radiological findings.

The main spinal pain generators are from the facet joints, intervertebral disc and spinal nerves. Facet joint pain is most commonly secondary to degenerative change. Facet joint arthropathy (Figure 1A) usually presents with localised back pain which can radiate to the buttock and hip region, known as “pseudoradicular” symptoms, without associated neurological deficit.

The intervertebral disc commonly causes back pain due to annular tearing or irritation of a spinal

1C). Irritation is usually due to disc herniations, which can combine with facet joint arthropathy and ligamentum flavum hypertrophy.

Key messages Clinical correlation with imaging findings is critical before requesting lumbar spine pain relief injections FJI’s are best for localised back pain or pseudo radicular symptoms with nerve-root sleeve injections best for single level nerve compression with radicular symptoms Epidural is best for spinal stenosis, subarticular recess nerve compression, multi-level nerve compression and annular tearing. nerve, with radiculopathy / ‘sciatica’ (numbness / pain in a dermatomal distribution – Figure 2) symptoms.

The spinal nerves can be irritated exiting the spinal canal (foraminal or extraforaminal compression – Figure 1B), or as the nerve forms in the subarticular recess (Figure

Nerves can also be compressed centrally, as in spinal stenosis (Figure 1D), which is often due to a combination of factors. In the lumbar spine, symptoms of spinal stenosis depend on the level and degree of stenosis. Patients can present with neurogenic claudication, which can include a combination of lower back pain, lower limb symptoms (pain, numbness, and weakness) and fatigue, often exacerbated by walking, and improved with rest and bending forward.

As imaging findings (including nerve compression) can be asymptomatic, history and clinical examination, in combination with imaging findings, are critical to arranging the most appropriate and beneficial imageguided spinal injection. If there is

Figure 1. MRI images

A. Bilateral facet joint arthritis

C. S1 nerve compression in the subarticular recess at the L5/S1 level

B. L5 foraminal nerve compression at the L5/S1 level

D. Severe spinal stenosis Figure 2.

54 | MARCH 2022

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Figure 4.

A. Facet joint injection

Figure 3.

multilevel pathology and it is difficult to clinically establish the predominant cause for symptoms, a combination of injections may be required. A gap of two weeks between injections can be beneficial from a diagnostic perspective and this can help better target future injections or determine if surgery is needed.

Image-guided spinal injections are generally safe procedures, especially when performed under CT guidance, however, there are several rare potential complications, with the main risks including infection, bleeding, nerve damage and possible dural puncture (post spinal headache).

For epidural injections, all anticoagulants are usually stopped prior to the procedure, with radiologist discretion for facet joint and nerve-root sleeve injections, whereby the risk of stopping the anticoagulants needs to be balanced against the small risk of a bleeding complication.

Injection subtypes Facet joint injection (Figures 3, 4A) Facet joint arthropathy can be detected on x-ray, CT, MRI or bone scan. If pain is multilevel and/ or difficult to localise clinically, a bone scan can help confirm the most ‘active’ joint (and most likely to respond to an injection). Ideally single level injections (particularly initial injections) are performed, to ascertain response and confirm

the pain source. A spinal needle is inserted into the facet joint under CT guidance, with a combination of long-acting local anaesthetic and steroid injected.

B. Epidural (interlaminar) injection

Nerve-root sleeve (transforaminal epidural) injection (Figures 3, 4B) Nerve-root sleeve injections are ideal for single level nerve irritation, especially due to foraminal or extraforaminal nerve compression.

Nerve root compression can be assessed with either a CT or MRI of the lumbar spine, which may identify areas of foraminal stenosis or extraforaminal nerve root compression (e.g. exiting L4 nerve compressed at the L4/5 level).

If there are multiple levels of foraminal compression, both clinically and radiologically, ideally single level injections are performed to assess response and target future injections if required. However, if there are bilateral or multilevel radicular symptoms, an epidural injection (interlaminar epidural) is often a more appropriate option. In nerve root sleeve injections, a spinal needle is inserted adjacent to the exiting nerve root, with a perineural position confirmed with a small volume of contrast prior to injecting.

Lumbar epidural (interlaminar epidural) injection (Figure 3, 4C) A lumbar epidural injection can be used for spinal stenosis, nerve

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C. Nerve root sleeve (transforaminal epidural) injection

compression in the subarticular recess (e.g. traversing L5 nerve compressed in the subarticular recess at the L4/5 level), bilateral or multilevel radiculopathy and pain due to annular tearing or coexistent facet joint arthropathy. Spinal stenosis or subarticular recess compression can be assessed with either a CT or MRI. However, MRI is superior, especially in assessment of the cauda equina in cases of severe central canal stenosis.

During an epidural injection the spinal needle is inserted into the epidural space at the desired level, sometimes angled towards the symptomatic side, with position confirmed with injection of contrast (iodinated or air) prior to injecting.

The author acknowledges the contribution of Dr Matt Prentice and Dr Rahul Lakshmanan Author competing interests – nil

MARCH 2022 | 55

Medicinal cannabis 3.0 – a role in treating IBS?

By A/Prof Alistair Vickery, Cannabinoid Medicine, West Leederville Irritable bowel syndrome (IBS) affects 15-20% of the population worldwide, predominately young professionals in industrialised countries. In the US it is thought to cause $US21b productivity loss.

Plant derived medicinal cannabis is a highly purified extract from hydroponically controlled cannabis plants. The only registered nonintoxicant cannabidiol (CBD) in Australia, Epidyolex® contains less than 0.01% impurities. Other scheduled “CBD-only” products contain up to 2% impurities of the multiple other minor cannabinoids including Δ9-tetrahydrocannabinol (THC). In higher doses this may be significant.

IBS is diagnosed in those with at least six months intermittent abdominal pain, bloating, diarrhoea, constipation and urgency associated with symptoms of nausea, anorexia, anxiety, and sleep disturbance. Restrictive FODMAP diets have demonstrated efficacy but are difficult to sustain and maintain. Current pharmacotherapy (e.g. hyoscine) is largely inadequate or poorly tolerated.

Emyria has commenced an observational ethics-approved trial to collect longitudinal data for specific IBS symptoms and quality of life in those taking cannabidiol (CBD). This was inspired by firsthand insights from our clinical trial registry of over 6000 patients who reported coincident resolution in IBS symptoms when taking CBD for another primary indication.

In pre-clinical studies, cannabinoid agonists decrease gut motility and transit, while antagonism produces the opposite effect. There have also been anti-inflammatory and analgesic effects for visceral pain in vitro and in vivo for both THC and CBD. Multiple case studies show long-term efficacy and safety in the use of CBD for ameliorating symptoms of IBS and reducing reliance on anticholinergic, antidepressant or other medications.

Is cannabis ready for the mainstream?

Cannabis sativa has been used for millennia as a medicine. Botanicals have historically been a rich source of proprietary medication including aspirin (white willow), quinine (cinchona tree), digoxin (foxglove), and statins (oyster mushroom). The conflation of pre-2016 research using the “marijuana plant” (Cannabis 1.0) with plant derived GMP (pharmaceutical grade) 56 | MARCH 2022

TGA compliance ensures scheduled products must contain THC and CBD concentrations within 10% variance of stated levels and less than 2% of the uncontrolled minor cannabinoid, flavonoid, and terpene profiles.

cannabis oil (Cannabis 2.0) has muddied the research regarding clinical efficacy and safety of medicinal cannabis.

Medicinal cannabis has an admirable safety profile and has level 1 evidence for reduction of pain and spasm associated with multiple sclerosis, chemotherapy induced nausea and vomiting, and seizure disorders. Large observational trials and small RCTs have demonstrated significant reductions in chronic non-cancer pain, anxiety, and insomnia. The longitudinal outcomes from our clinical registry show clearly that medicinal cannabis is a safe, welltolerated drug with a place in our pharmacopeia for the management of a number of clinical conditions.

Medicinal cannabis in Australia is generally plant-derived and dispensed in two different forms. a. Oral – suspended in medium chain triglyceride oil, alcoholbased oral spray, dispersible wafers, gel capsules and hard tablets or, b. Inhaled - GMP-grade flower for vaporisation or burning.

There are problems associated with both delivery mechanisms.

Issues of stability, absorption, bioavailability, first pass metabolism, pharmacogenomics, active drug exposure and batchto-batch variability have led to significant inter- and intra-user variability in efficacy and adverse effects, which is exacerbated in inhaled cannabis. Fortunately, the therapeutic index for cannabinoids is wide and the harm risk low.

A 2021, FreshLeaf Analytics’ report showed a rapid sustained increase in prescriptions in Australia. The growth was in the number of approvals, authorised prescribers (>70,000 active patients), different products available (>220), approved clinical indications (>60), and, interestingly, a steep rise in prescription of mixed THC/CBD flower-based product (Cannabis 1.0).

Inhaled or vapourised botanical flower I believe is a retrograde step in the development of pharmaceutical uses for medicinal cannabis. It is consistently and rapidly absorbed via the respiratory epithelium, with peak levels experienced in minutes avoiding first-pass metabolism.

However, control for dose of active cannabinoids is difficult and not possible for minor cannabinoids and other impurities.

Claims of different efficacy of

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GUEST COLUMN

Living with chronic pain Former Olympian Jenn Morris explains the painful reason why she has become involved in the medicinal cannabis industry.

Many of us dream of representing our country at the Olympics but few of us realise the risks that go along with the glory and the toll it can take on our bodies.

I represented Australia in hockey from 1991 to 2000. My team won our first gold medal at the Atlanta Olympics 25 years ago and we did it again at the 2000 Sydney Olympics.

They are moments I wouldn’t trade for anything but achieving them had long-term effects on my wellbeing.

Hockey is a wonderful but notoriously punishing sport. I had two knee reconstructions during my Olympic career that left me living with chronic pain and often unable to get out of bed.

Throughout my life I have also suffered from endometriosis and I reached a point where I just put up with pain. It became a daily part of my life.

For the past six months, however, I have been using prescribed medicinal cannabis from my GP to manage my chronic pain.

It has made an enormous difference for me, which has led to me becoming more interested in the potential benefits for the huge

“strains” of flower have been shown to be wrong and misleading.

Genetic analysis found no distinction between “strains”.

Further, dose accuracy and vaping in Canada showed that inconsistencies in dosing (packing and quantities), concentration (THC +/- 20% between batches) and efficiency of vaping devices varied the dose and concentrations between dosing and batches.

Development of a treatment for IBS, using nature-identical pure cannabinoids that have none of the complexities and impurities of the botanical extracts, are

number of people living with similar conditions.

Despite the anecdotal evidence of the benefits of medicinal cannabis, there is clearly still hesitancy amongst the medical profession on the topic despite the growing demand from the 1.5 million Australians suffering from chronic pain.

I’m living proof that a good discussion with your GP about an approach to chronic pain that can include medicinal cannabis has the potential to be life changing, but I’m also aware that research and evidence are going to be the key to changing minds.

The community is eager for evidence, and that’s why I was inspired to join a sports science start-up that is focused on conducting clinical trials to research its benefits for both managing chronic pain and as a potential alternative for more common medications.

I have got back to doing what I have loved doing, which is exercise, being mobile, being active and living a healthier, happier life.

I realise medicinal cannabis is not a silver bullet or a magic remedy, and maintaining a healthy lifestyle

Key messages IBS is common and current pharmacotherapy is generally inadequate Patients on medicinal cannabis for other indications report improvement in IBS symptoms

also plays a role in helping to keep my body free of aches and pains.

Chronic pain can also affect our mental health. If you wake up at a four out of 10 on the pain scale literally every day, honestly it can get you down.

One in five Australians over the age of 45 suffer from chronic pain.

I am just one of them. I’m now in a position to work with research institutions through clinical trials to advance pharmaceutical expertise and understanding of the positive benefits of medicinal cannabis for treating not only chronic pain, but a range of conditions that have shown positive responses to medicinal cannabis treatments.

I like to be at the start of something. I believe medicinal cannabis is an industry with a huge amount of potential.

Part of my role is an educative one because the more we learn, the more confidence the medical industry will have in exploring these pathways.

ED: Jenn Morris is a board member of sports science start-up Levin Health, one of several companies researching the use of medicinal cannabis to treat chronic pain.

to be better defined and the place for this promising medicine to be included in modern mainstream treatment. (Cannabis 3.0) – References available on request Author competing interests – the author is Medical Director of Emyira (Principal Investigator CALM-Gut study)

A new trial is examining the specific use of medicinal cannabis in treating IBS. more consistently absorbed, bioavailable, and stable, will allow the pharmacokinetics, efficacy and safety of both CBD and THC

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MARCH 2022 | 57

LIFESTYLE

Voila! Time for French films

Open your mind, expand your horizons and enjoy some armchair travel during this year’s Alliance Francaise French Film Festival which kicks off on March 9.

The 2022 festival features more than 40 films and documentaries and its 33rd year celebrates French culture with movies across genres, featuring several Australian and international premieres packed with a collection of rising stars and well-known favourites.

Festival Artistic Director Karine Mauris says there’s truly something for everyone in the festival which last year sold more than 200,000 tickets across Australia and close to 20,000 in Perth.

“From several laugh-out-loud comedies, many beautiful tales of romance and compelling stories,” Mauris says. “You will travel to France, Lebanon, Mali, Russia, Canada, Tibet, the North Pole and many other places, where you will meet fascinating characters that will take you into the whirlwind of life.”

Overseeing the festival here in Perth is Alliance Francaise executive director Thomas Feldstein, who arrived in town 58 | MARCH 2022

late last year after a four-year stint in Fiji. Luckily, he’s a huge cinephile and is looking forward to seeing many of the films he hasn’t yet seen – reliable babysitter pending – after a local diet of Hollywood and Bollywood blockbusters.

“I like the variety of films the festival has – there’s comedy and romance but also a bit of more heavy themes with a social conscience and a few movies about the end of life and the elderly. Some of them are quite tense but very interesting,” says Feldstein.

“You feel so different having that experience but you’re also feeling a lot of the same things with other people at the same moment in a film. You can’t replace that. There’s also something important in making the gesture to spend your time to go and sit and enjoy the big screen with others.”

The 2022 Alliance Francaise French Film Festival runs from March 9 – April 6 at Palace Cinemas Raine Square, Luna Palace Leederville, Windsor and Luna on SX and Camelot. Tickets and screening times: affrenchfilmfestival.org

“The festival offers very different styles of movies for a large audience as well as having movies for a more niche audience. Great for language students too, it’s the largest festival dedicated to contemporary French films outside France.”

While streaming has changed the film watching landscape, Feldstein says there’s still nothing like seeing one on the big screen and going into a room with other people.

Win...

We have five double passes to the film festival to give away – valid for all sessions except special events. To enter, go to the competitions tab at www.medicalforum.com.au or enter via our weekly e-newsletter.

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The French Film Festival is back on big screens this month and the program offers plenty of laughter, drama and a chance to work on your language skills, as Ara Jansen details.

LIFESTYLE

Sculptural feast for all the senses

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Sand, sea and art mix it up again for the 18th annual Sculpture by the Sea exhibition, as Ara Jansen explains.

It’s one of the places where artists have free range to have fun. Welcome to Sculpture by the Sea, the annual art show which takes place on Cottesloe Beach.

It welcomes artists from all over the world, the country and our backyard, to create sculptures of all shapes, sizes, colours and materials.

The results are often fun, larger than life, can be thoughtful or make a statement, touch-friendly and allow you to get up close or walk through them. It’s one of the most accessible exhibitions around where people of all ages can talk about the whats and whys of it all – or just love the colour.

Sculpture by the Sea is one of the city’s largest free public events, where 70 artists from 12 countries will showcase their work, including sculptors from Japan, the Czech Republic, France, Singapore, India, Mexico, Norway and Taiwan. Thirty-two are from Western Australia.

“I love that it’s not a controlled space and is totally open,” he says. “It’s also a totally tactile experience. I love that people are more playful in this space, can be more themselves and take the chance to connect with the work.

“From an artist’s perspective it can be daunting because who can compete with the beach, but that’s also the great and fun challenge.

You also have to take into account the weather.”

Flavel says one of the tricks to having a successful work in the beach collection is making a piece which obviously attracts people but also has a more subtle purpose.

Most famously, Flavel created a piece called Bulk Carrier, more fondly dubbed the giant goon bag. This year his work blends the figurative and the abstract in a series of brushed aluminium columns with figures moving in and out of the pieces.

For local artist and Sculpture by the Sea veteran Norton Flavel, he loves the way people interact with the sculptures scattered across the beach.

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“For visitors to the exhibition, as well as those of us who work on the exhibition, it is fascinating to see what artists like Norton Flavel – who does such different artwork – create,” says Handley.

“Norton’s creativity is really quite extraordinary, from Bulk Carrier through to his ball and chain, the large metal drop of water in the tree and this new work.

“The outdoor beach setting is where Australians are uninhibited, so this predisposes people to be open to wander the sculptures and think and say what they enjoy and what they might not enjoy. This doesn’t happen in a gallery. Some artists intentionally sit next to their artworks incognito and listen to the comments people make – both positive and negative.”

Sculpture by the Sea is a free event at Cottesloe Beach and runs from March 4 – 21.

Sculpture by the Sea founding director David Handley loves the event because of the wonderful interaction between the beach, people and sculptures.

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MUSIC

ThornBird flies solo You’ll recognise Vikki Thorn as one part of the much-loved globetrotting WA band The Waifs. With her first solo album, it’s time to meet ThornBird.

By Ara Jansen When you’ve always shared the stage with your sister and bandmates, a solo project can be thoroughly daunting.

of liberation and freedom in making this album. Ultimately I wanted to make music that I enjoyed and that was fun for me on stage.”

For Vikki Thorn, one third of WA folk rock band The Waifs, it was an opportunity to find her voice away from her part in a band she’s been playing with for decades.

Thorn says standing in the crowd and watching Donna play a solo gig recently was a wonderful opportunity to see her sister as a musician and their musical differences, as opposed to the person always across the stage from her.

Calling herself ThornBird, she’s taken that as the title for her debut solo album. The result is a joyful folk-based collection which is soulful, thoughtful and sometimes rocky while always retaining that distinctive and familiar voice and songwriting style.

After more than a decade living in the American state of Utah, Thorn returned home to Western Australia ahead of the pandemic and is currently living in the Great Southern with her husband and three boys.

“In Utah I thought a lot about recording and was doing a lot of writing, but I didn’t have a musical community around me,” Thorn says. “Musically I was a bit isolated which turned out to be a good thing because I was able to sit and experiment, sitting with my guitar playing and writing.”

One of her musical explorations was considering who was she outside The Waifs, the band she started with her elder sister Donna in the early ’90s.

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“It was a different collection of songs.

I lived in a small town with a strong cowboy culture, so the songs were influenced a bit by that. It forced me to question who I was as an artist.

Am I writing for me or an audience?

What do I want to sound like?”

The project was shelved when her family moved back to WA and the band was touring. When COVID hit and touring halted, it provided a perfect opening for a new project.

Back in the company of local musical friends, she was inspired to return to those songs. A few had gone to a Waifs album but the rest allowed Thorn to explore her solo sound.

“I still wanted it loosely to be folk but I wanted to be adventurous and stretch myself a little more – but not too far away. There’s been a sense

“I got a chance to see the essence of who she is, which I can’t always see in The Waifs. And after all this time, I felt like it was really important to be able to see each other that way. It also showed what we both bring to the band, which also explains some of the frustrations we have with each other when it comes to how we want to do things. She said the same thing. That has been really beautiful.”

Thorn feels these solo experiences will prove a strength for the band the next time they come together. Now she, Donna and singer/guitarist Josh Cunningham have done projects outside the band, there will be a chance for them to write in the same room, which hasn’t been possible for a while.

ThornBird is out now through Jarrah Records and she is due to play a show in Kings Park on April 22.

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WINE REVIEW

Fermoy ‘reserved’ strength Last month, Master of Wine Dr Craig Drummond reviewed five wines from Margaret River’s Fermoy Estate, which has gone from strength to strength in recent years. This month, he explores two of the winery’s premium reserve wines, perfect for those looking for something special.

The Fermoy Estate Reserve wines are of the highest possible quality. I have often been asked what makes a reserve wine. It comes down to fruit quality – selecting the finest parcels of fruit, hand-picked (verses mechanically picked) and often from the oldest vines.

Then the most detailed attention in the winery, using the finest oak, careful monitoring of all production stages and often selecting of the best barrels before blending.

Review by Dr Craig Drummond Master of Wine

Fermoy Estate Margaret River Reserve 2018 Chardonnay (RRP $65)

Fermoy Estate Margaret River Reserve 2017 Cabernet Sauvignon (RRP $95)

This is Margaret River Chardonnay at its finest. It displays a wonderful bouquet, which leaps out of the glass.

Rich aromas of ripe peach, nashi pear, with nutty oak to the fore. Palate is mouth filling with weight and texture, concentrated and intense by way of quality fruit selection. Lingering flavours of stone fruit, green melon and cashew. Clean fresh acid, and fine integrating oak. Displays all the hallmarks of quality – balance, intensity, complexity, length and varietal expression. Drink now to 2026.

It is of no surprise that this wine has won gold medals at wine shows, including a gold at the 2021 Decanter World Wine Awards held in London.

It is a beauty. The colour is a youthful deep red/black. The nose has loads of varietal blackcurrant/cassis, with fresh herbs, and cedar and spice from oak. It is enticing and leads on to an equally exciting palate that displays power and concentration. Flavours of blackcurrant abound, supported by nuances of green capsicum, menthol and mint. I love the tannins, fine grained from quality oak, long on the palate. Fruit and oak are in balance.

High acidity from this cooler vintage adds to the structural integrity. A Margaret River classic. Love it now, but will cellar and reward over at least 20 years.

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MARCH 2022 | 61

LIFESTYLE

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Lighten up with a summer declutter Decluttering will not only have you living in a tidier home but it might ease some stress in your life, as Ara Jansen explains.

Can you find the sticky tape when you need it? Do you know where your favourite shirt is? Are mornings a mad scramble trying to find phones, matching socks or kids’ homework?

space and a desire to lighten up, it’s amazing what you can achieve in a few hours.

“A lot of what we share with people is common sense, but sometimes it takes fresh eyes to stand back and see the bigger picture and what makes sense.”

You might simply feel like there’s just too much stuff and your home could benefit from some tidying and decluttering.

Kirrilee Lehman didn’t ever plan to become a decluttering expert. As a pharmacist, she just fell into it when she cleaned up her own home and started helping her friends over a glass of wine. Word spread and alongside her sister Taryn, they set up Queens of Clutter. Five years later there are almost 10 Queens are working busily all over Perth, helping others tidy up their spaces.

While some people have extreme problems with hoarding and are prime candidates for a TV show, Kirrilee says many of us just feel like we’ve got too much stuff and life is messier and more stressful than we’d like. Lightening the load, make things easier to find and living in tidier spaces can positively influence mental health.

Once you pick a space to declutter, everything gets pulled out, sorted and then put back in a way which is functional and suits your lifestyle.

Kirrilee says the benefit of having someone to help offers another perspective and someone to cheer you on.

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Kirrilee Lehman (right) with sister Taryn

“People can sometimes just get overwhelmed by their stuff,” says Kirrilee. “They could probably do it themselves but they don’t. So, decluttering with someone else and getting helpful guidance gives them great results. Kind of like a personal trainer for your house!”

Best of all, everything you decide to give away, they’ll take away and deliver to various charities.

And in the spirit of generosity and recycling, there’s also the opportunity to share. A recent client parted with a new toaster, which a Queen was able to give to another client who didn’t have one.

She suggests if you’re going to embark on decluttering your space, start small, rather than up-ending the whole house. Pick a few drawers – the junk one or a cupboard in the bathroom – then you’ll be heartened by a few wins.

Marie Kondo and Australian organisation king Peter Walsh are the Queens’ heroes and they team that knowledge with their own experiences. They also pride themselves on understanding different needs and life stages, whether it’s a house with kids, a couple in an apartment or someone living with disability.

“At the moment, all our Queens are mums and we definitely bring that experience, but we also bring kindness and empathy for people who are just feeling overwhelmed.

The work we do helps people breathe because it takes some of the stress out of their lives.

“After decluttering, people tell us their anxiety is better and they don’t feel so suffocated by their stuff. Everyone’s level of too much stuff is different but when they have less or it’s just more organised, they have more time for other things because they can find things easily. When I start losing things, I know it’s time to get into the cupboards.”

Kirrilee says with a plan, targeted MEDICAL FORUM | PAIN MANAGEMENT

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