Search

Polymyalgia rheumatica and giant cell arteritis are closely related conditions, considered by many to represent opposite poles of a single disease spectrum. They can occur together or separately. Polymyalgia rheumatica is characterized by pain and morning stiffness in the shoulder girdle and sometimes the pelvic girdle. The symptoms are felt to be related to synovitis of proximal joints and extra-articular synovial structures. Giant cell arteritis displays a frank vasculitis affecting the regions supplied by the temporal artery to give visual loss and scalp tenderness but is increasingly recognized to also affect the aorta and its extra-cranial branches. For this reason the term 'giant cell arteritis', which is descriptive of the pathology, is used instead of the alternative term 'temporal arteritis', which gives a misleading impression of localization but which was the term used in previous reviews for this journal, the most recent in 2003. [ABSTRACT FROM AUTHOR]

1 Six healthy male volunteers received a total of 2500 mg of a new cephalosporin antibiotic Ro13-9904 by intramuscular injection in five divided doses at intervals of 12 h. 2 No significant systemic side- effects were observed and this was confirmed haematologically and biochemically. 3 The drug was distributed following intramuscular injection reaching a mean peak plasma concentration of 55 micrograms ml- 1 (range 46-66) 1 to 2 h after the first injection. 4 Monoexponential elimination of drug was demonstrated. No significant difference was recorded in the plasma half-life after the initial dose (mean 6.7 h) and at steady state (mean 6.7 h). The half-life is long compared with other cephalosporin antibiotics. 5 On the basis of the observed half- life, steady state should be reached within 48 h. A mean peak plasma concentration of 74 micrograms ml-1 (range 65-87) was recorded at steady state. Steady state plasma concentrations of Ro13-9904 with a dose of 500 mg every 13 h may be predicted from the pharmacokinetics of a single dose. [ABSTRACT FROM AUTHOR]

The effect of 5 days treatment with allopurinol (300 mg) on the pharmacokinetics of indomethacin at steady-state was investigated in eight patients. Allopurinol produced no significant effect on the indomethacin serum concentration-time curve. Allopurinol did not alter significantly the amounts of indomethacin excreted in the urine within 8 h. However, the urinary ratio of N-deschlorobenzoylindomethacin to indomethacin was reduced significantly by allopurinol administration (P less than 0.05). [ABSTRACT FROM AUTHOR]

Background: Ergonomically, the flute is especially complex among wind instruments, and flautists may therefore be at particular risk of performance-related musculoskeletal disorders. Yet little is known about injury prevalence among flute players, and even less in those flautists who are also hypermobile. Recent research has found hand and wrist pain to be common complaints among flautists. Understanding of the predictors of injury and pain is therefore crucial as the presence of pain decreases performance quality and causes unnecessary time loss. There is a strong relationship between hypermobility and impaired proprioception, although many musicians may acquire greater proprioception than the average population. We have compared flexibility and proprioception of the hand in a study of flautists., Methods: Twenty flautists took part in the study. General hypermobility, the passive range of motion of the 3 specific joints most involved in flute playing, and proprioception acuity were all measured accurately for the first time in this awkward instrument that needs high levels of dexterity., Results: Flautists' finger joints have a greater range of movement than in the general population. This group of flute players had especially large ranges of movement in the finger joints, which take the weight of the instrument. Although flautists have hypermobile finger joints, they are not generally hypermobile elsewhere as measured by the Beighton Scale. Flautists, even with very mobile finger joints, have very accurate proprioception, which may be acquired through training., Conclusions: The study of instrumentalists may provide an ideal model for study of the interaction between localized joint flexibility and joint proprioception, both inherited and acquired.

Objective: To compare the effectiveness of a physiotherapy programme with a control treatment of advice and education in patients with neurogenic claudication symptoms., Design: Pragmatic randomised controlled clinical trial., Setting: Primary care-based musculoskeletal service., Patients: Adults aged 50 or over with neurogenic claudication symptoms causing limitation of walking., Interventions: Condition-specific home exercises combined with advice and education, or advice and education alone., Main Outcome Measures: The primary outcome was the difference in improvement of symptom severity scores on the Swiss Spinal Stenosis Scale at eight weeks. Secondary outcomes included measures of physical function, pain and general well-being at eight weeks and 12 months., Results: There was no significant difference between groups in the Swiss Spinal Stenosis symptom severity scale at eight weeks (t = 0.47, p = 0.643): mean change (SD) control group -0.18 (0.47), treatment group -0.10 (0.66), difference (95% CI) 0.08 (-0.19, 0.35); baseline-adjusted difference 0.06 (-0.19, 0.31)]. An unplanned subgroup analysis suggested that for patients with the top 25% of baseline symptom severity scores, the physiotherapy exercise programme resulted in an improvement in the primary outcome, and modest but consistently better secondary outcomes at both time-points compared to the control group. The effectiveness in different subgroups requires further direct evaluation., Conclusions: In the treatment of patients with neurogenic claudication symptoms, a physiotherapist-prescribed home exercise programme is no more effective than advice and education., Ethical Approval: The study was approved by Leeds Central Ethics Committee and informed consent was given by all participating patients., Copyright: The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all forms, formats and media (whether known now or created in the future), to i) publish, reproduce, distribute, display and store the Contribution, ii) translate the Contribution into other languages, create adaptations, reprints, include within collections and create summaries, extracts and/or, abstracts of the Contribution, iii) create any other derivative work(s) based on the Contribution, iv) to exploit all subsidiary rights in the Contribution, v) the inclusion of electronic links from the Contribution to third party material where-ever it may be located; and, vi) licence any third party to do any or all of the above., Trial Registration: ISRCTN 78288224 - doi10.1186/ISRCTN35836727; UKCRN 4814.

A case report of a professional contemporary dancer who successfully returned to the stage after bilateral total hip replacements (THR) for osteoarthritis is presented, together with her own commentary and a retrospective cohort study of total hip replacements in dancers. In the presented cohort, there were no post-operative dislocations or infections, the original pain had been relieved, rehabilitation was objectively normal and all resumed their dance (teaching) activities. Nevertheless, they were disappointed about the prolonged rehabilitation. Due to their high demands as professional dancers, post-operative expectations were too optimistic in view of the usual quick and favourable results of THR in the older and less physically active, general population. In all dancers with unilateral osteoarthritis, the left hip was involved, which may reflect the tendency to use the left leg as standing leg and be suggestive that strenuous physical activity may lead to osteoarthritis. Better rehabilitation guidelines are needed for dancer patients undergoing THR, especially drawing their attention to realistic post-operative expectations.

Proprioception is important to many musicians and all dancers. Methods of measuring proprioception in the hands of musicians and globally in dancers are reviewed. Their uses in defining proprioception in performers and thereby reducing the risk of injury as well as enhancing performance are discussed.

Overuse syndromes of the upper limb are common in musicians. This reflects the long hours spent playing. Possible pathological causes are discussed as well as the ergonomic patterns of playing required of some instruments and other anatomical factors that predispose.

The interface between sports medicine and performing arts medicine is closest for "tariff" sports, where the sportsperson can select their own programme of varying difficulty with the more complex skills carrying potential for higher marks. Inevitably, some performers over-reach themselves. Examples of injuries and prevention strategies to avoid such injuries are discussed in a preliminary analysis of four sports: diving, cheerleading, gymnastics, and figure skating.

A case study is presented in which a student dancer who developed rheumatoid arthritis during her degree course was able to complete her course with meticulous treatment including the use of biologics. She describes her own reactions to the disease occurring at this crucial phase in her career.

Opinions vary on whether joint hypermobility is an asset or liability in dance. This paper argues that it is an asset, the arguments for its being a liability often confounded by inadequate scoring systems inappropriately applied. The ambiguity and distress this presents to dancers, the several different causes of joint hypermobility and the separate needs of the many different diverse styles of dance are all discussed. A strategy for the future care and training of hypermobile dancers is proposed.

An association has been demonstrated between haemorrhoids and joint hypermobility. Reasons for this are discussed. Many performing artists are hypermobile and the extra-articular features of joint hypermobility should not be forgotten or underestimated as a potential constraint upon performance.

Scoliosis, although often considered a condition of athletes, is very common as a cause of symptoms in performing artists. Three typical case histories are presented with a physiotherapy review. Surprisingly, scoliosis is often more of a problem in musicians than in dancers.

Objectives: To explore possible mechanisms underpinning symptom relief and improved walking tolerance in patients with neurogenic claudication (NC) when pushing a shopping trolley by evaluating the effects of a shopping trolley on spinal posture and loading patterns., Design: An exploratory study of kinematic and kinetic changes in walking with and without pushing a shopping trolley in persons with NC symptoms and a comparison with asymptomatic control subjects., Setting: A primary care-based musculoskeletal service., Participants: Participants (n=8) with NC symptoms who have anecdotally reported symptomatic improvement when walking with a shopping trolley and a control group of asymptomatic persons (n=8)., Interventions: Shopping trolley., Main Outcome Measures: Changes in lumbar spinal sagittal posture and ground reaction force., Results: Subjects with NC and asymptomatic controls walked with significantly more flexed spinal posture (increase in flexion, 3.40°; z=3.516; P<.001) and reduced mean ground reaction forces (-6.9% of body weight; z=-3.46; P=.001) when walking with a shopping trolley. However, at the midstance point of the gait cycle, controls showed minimal reliance on the trolley, whereas, people with NC showed continued offloading., Conclusions: Both posture and loading are affected by pushing a shopping trolley; however, patients with NC were found to offload the spine throughout the stance phase of gait, whereas asymptomatic controls did not., (Copyright © 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Comer CM, Johnson MI, Marchant PR, Redmond AC, Bird HA, Conaghan PG. The effectiveness of walking stick use for neurogenic claudication: results from a randomized trial and the effects on walking tolerance and posture., Objectives: To determine the immediate effects of using a stick on walking tolerance and on the potential explanatory variable of posture, and to provide a preliminary evaluation of the effects of daily walking stick use on symptoms and function for people with neurogenic claudication., Design: A 2-phase study of neurogenic claudication patients comprising a randomized trial of 2 weeks of home use of a walking stick and a crossover study comparing walking tolerance and posture with and without a walking stick., Setting: A primary care-based musculoskeletal service., Participants: Patients aged 50 years or older with neurogenic claudication symptoms (N=46; 24 women, 22 men, mean age=71.26y) were recruited., Intervention: Walking stick., Main Outcome Measures: Phase 1 of the trial used the Zurich Claudication Questionnaire symptom severity and physical function scores to measure outcome. The total walking distance during a shuttle walking test and the mean lumbar spinal posture (measured by using electronic goniometry) were used as the primary outcome measurements in the second phase., Results: Forty of the participants completed phase 1 of the trial, and 40 completed phase 2. No significant differences in symptom severity or physical function were shown in score improvements for walking stick users (stick user scores - control scores) in the 2-week trial (95% confidence interval [CI], -.24 to .28 and -.10 to .26, respectively). In the second phase of the trial, the ratio of the shuttle walking distance with a stick to without a stick showed no significance (95% CI, .959-1.096) between the groups. Furthermore, the use of a walking stick did not systematically promote spinal flexion; no significant difference was shown for mean lumbar spinal flexion for stick use versus no stick (95% CI, .351 degrees -.836 degrees )., Conclusions: The prescription of a walking stick does not improve walking tolerance or systematically alter the postural mechanisms associated with symptoms in neurogenic claudication., (Copyright (c) 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Neurogenic claudication (NC) is the clinical syndrome commonly associated with lumbar spinal stenosis (LSS). Non-surgical management is recommended as initial treatment, but little is known about current practice in relation to the assessment and management of these patients in the non-surgical setting., Methods: We conducted a questionnaire survey of physiotherapists in a large UK primary care musculoskeletal service which provides a city-wide multidisciplinary assessment and treatment facility for patients with spinal and other musculoskeletal problems. Data on therapists' recognition and management of patients with NC and LSS were collected., Results: Fifty out of 54 therapists completed questionnaires, and all but one of these identified a clearly recognised posture-related clinical syndrome of NC. Almost all respondents (48: 96%) reported the routine use of physiotherapy treatments. In particular, advice and education (49: 98%) along with an exercise programme (47: 94%) incorporating flexion-based exercises (41: 82%) and trunk muscle stabilising exercises (35: 70%) were favoured., Conclusion: Musculoskeletal physiotherapy clinicians in this survey recognised a clear clinical syndrome of NC, based on the findings of posture-dependent symptoms. Most therapists reported the routine use of flexion-based exercise, reflecting recommendations in the literature which are based on theoretical benefits, but for which trial evidence is lacking. There is a need for research evidence to guide the choice of physiotherapy treatments.

Objectives: This study investigated the clinical impression that there was an increased prevalence of respiratory disorders in both the Hypermobility Syndrome (HMS)/Benign Joint Hypermobility Syndrome (BJHS) and Ehlers-Danlos Syndrome (EDS), compared with the normal population., Methods: A questionnaire was distributed to 509 subjects (221 healthy controls, 126 HMS, 162 EDS) who documented respiratory symptoms and previously diagnosed respiratory and atopic disorders. A subgroup of 157 responders underwent full clinical and serological assessments, and 57 subjects were assessed physiologically., Results: A significant increase in the frequency of a wide range of respiratory symptoms and reduced exercise tolerance was observed in subjects with both HMS and EDS compared with controls. In particular, there was an increased prevalence of asthmatic symptoms (HMS: OR 2.4, 95% CI 1.4-4.1, p = 0.002; EDS: OR 3.1, 95% CI 1.8-5.2, p<0.001) and atopy (HMS: OR 2.7, 95% CI 1.6-4.5, p<0.001; EDS: OR 2.6, 95% CI 1.6-4.4, p<0.001), which was subsequently confirmed by clinical assessment. Pulmonary physiological studies revealed increased lung volumes, impaired gas exchange and an increased tendency of both the lower and upper airways to collapse., Conclusions: We have demonstrated, for the first time, that individuals with HMS/BJHS and EDS have respiratory symptoms in association with various pulmonary physiological abnormalities. The increased prevalence of asthma may be due to linkage disequilibrium between the genes causing these conditions or a function of the connective tissue defect itself. In the non-asthmatic population, changes in the mechanical properties of the bronchial airways and lung parenchyma may underlie the observed increased tendency of the airways to collapse.

Work-related upper limb disorder is a non-specific diagnosis for pain in the hand, wrist or, in particular, forearm once more discrete clinical conditions such as epicondylitis, tenosynovitis and carpal tunnel syndrome have been excluded. The pathophysiology of the condition is uncertain, although it is normally held to be related to an ergonomic incident. Ergonomic factors either at work or at home remain important and are discussed. Initial management is based on modification of ergonomics with appropriate periods of rest and job rotation. Treatment, however, remains somewhat unfocused and unsatisfactory. Much can be learnt from the ergonomic study of musicians, where the condition is perhaps at its most refined. Medico-legal aspects and recent thoughts on pathogenesis are also discussed.

Patients with joint hypermobility, perhaps the mildest of the various inherited abnormalities of connective tissue, may present to a rheumatologist or general practitioner although a large proportion are recognized by health professionals, particularly physiotherapists. Hypermobility may be generalized or extreme at a small number of joints. Sometimes it is associated with involvement of other organs because of abnormal inherited collagen structure elsewhere. A small proportion of patients will have one of the more serious conditions such as Ehlers-Danlos syndrome, Marfan's syndrome or osteogenesis imperfecta. Management is multidisciplinary requiring a team including physicians, physiotherapists, occupational therapists and podiatrists, among others. Patients often wait a long time before receiving their definitive diagnosis and are sometimes dismissed as malingerers. Patients often have a lot of queries about their condition unrelated to their joints. Among these are whether there will be problems in pregnancy, whether the condition will be passed on to their children, whether symptoms arising from organs other than the joints are related and whether they might have been incorrectly accused of battering their children.

Background: Together with visual information, awareness of limb position and movement is essential for limb coordination. A proprioceptive deficit has been demonstrated in a number of rheumatological disorders. There is a lack of a portable device for measuring hand proprioception in the field., Methods: A compact portable device for measuring joint position sense in the metacarpophalangeal joint of the index finger of either hand was constructed. This device was manually operated and required the subject to match the position of the hidden finger with a surface-mounted silhouette. Reliability studies were performed over three consecutive days in 12 normal volunteers., Results: Intrasubject variability [95% confidence interval (CI)] was 0.86 degrees (0.04-1.76) between days 1 and 2, and 1.23 degrees (1.04-3.50) between days 2 and 3. The intraclass correlation coefficient (95% CI) between all 3 days was 0.92 (0.85-0.96). Average proprioceptive error (95% CI) in the sample population was 5.72 degrees (1.23-10.2) over the 3 days. This value was 5.94 degrees , 5.79 degrees and 5.42 degrees on days 1, 2 and 3, respectively. No difference was found between sexes but dominant hands gave smaller errors (mean dominant error 5.11 degrees , mean non-dominant error 6.35 degrees ; t = -3.4, P = 0.002)., Conclusions: This report describes a new portable device for measuring proprioception in the hand. Reproducibility was shown to be good on an individual and group basis. These results are promising and warrant larger age- and sex-related studies. The ease and portability of the device make it ideal for use in epidemiological studies of rheumatological disorders involving the hands, including joint hypermobility.

Objective: To compare the performance of the several different diagnostic criteria sets currently in use for polymyalgia rheumatica (PMR)., Methods: 213 patients attending eight rheumatological centres in eight different European countries were studied. All had recently been referred and were considered by the senior investigator at each centre, selected because of their experience in treatment of PMR, to have this condition. By use of a standard international proforma, the requisite diagnostic points in each criteria set were sought. Sensitivity for each criterion from each set was then calculated, as well as the sensitivity of each criteria set as a whole., Results: Of four criteria sets compared, the Bird (1979) criteria performed best with a sensitivity of 99.5%, and the Hunder (1982) criteria second best, with sensitivity of 93.3%. These both performed significantly better than the two other criteria sets, though each of these was admittedly developed for rather specialised reasons., Conclusions: Although this study compares homogeneity, we suggest the Bird 1979 or Hunder 1982 criteria should be used whenever possible. Studies that have used alternative criteria may have less sensitivity in diagnosis.