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Providing information to patients regarding appropriate management of LBP is a crucial component of primary care and treatment of low back pain (LBP). Limited knowledge is available, however, about the information delivered by physicians to patients with low back pain. Hence, this study aimed at evaluating (1) the self-reported practices of French physicians concerning information about patients with acute LBP (2) the consistency of these practices with the COST B13 guidelines, and (3) the effects of the delivery of a leaflet summarizing the COST B13 recommendations on the management of patient information, using the following study design: 528 French physicians [319 general practitioners (GP) and 209 rheumatologists (RH)] were asked to provide demographic information, responses to a Fear Avoidance Beliefs questionnaire adapted for physicians and responses to a questionnaire investigating the consistency of their practice with the COST B13 guidelines. Half of the participants (163 GP and 105 RH) were randomized to receive a summary of the COST B13 guidelines concerning information delivery to patient with low back pain and half (156 GP and 104 RH) were not given this information. The mean age of physicians was 52.1±7.6 years, 25.2% were females, 75% work in private practice, 63.1% reported to treat 10-50 patients with LBP per month and 18.2%<10 per month. The majority of the physicians (71.0%) reported personal LBP episode (7.1% with a duration superior to 3 months). Among the 18.4% (97) of the physicians that knew the COST B13 guidelines, 85.6% (83/97) reported that they totally or partially applied these recommendations in their practice. The average work (0-24) and physical activity (0-24) FABQ scores were 21.2±8.4 and 10.1±6.0, respectively. The consistency scores (11 questions scored 0 to 6, total score was standardized from 0 to 100) were significantly higher in the RH group (75.6±11.6) than in GP group (67.2±12.6; p<0.001). The delivery of a summary of the COST B13 guidelines significantly improved the consistency score (p=0.018). However, a multivariate analysis indicated that only GP consistency was improved by recommendations' delivery.The results indicated that GP were less consistent with the European COST B13 guidelines on the information of patients with acute LBP than RH. Interestingly, delivery of a summary of these guidelines to GP improved their consistency score, but not that of the RH. This suggests that GP information campaign can modify the message that they deliver to LBP, and subsequently could change patient's beliefs on LBP. [ABSTRACT FROM AUTHOR]

Objectives: Despite the availability of practice guidelines for the management of knee osteoarthritis, inadequacies in practices of clinicians and patients have been found, leading to suboptimal outcomes. Literature has shown that simply disseminating management recommendations does not lead to adherence. Research suggests that barriers to use should be identified and addressed to improve adherence. The objective of this study was to identify barriers to use of conservative management recommendations for knee osteoarthritis by patients, general practitioners and physiotherapists., Methods: Following systematic reviews of evidence and guidelines, 12 key management recommendations were elaborated on four themes: medication, exercise, self-management and occupation. Focus groups were separately done with patients with knee osteoarthritis, general practitioners and physiotherapists to assess barriers to the use of recommendations., Results: Patients and general practitioners appeared generally fatalistic with regards to knee osteoarthritis, with physiotherapists being more positive regarding long-term improvement of knee osteoarthritis. For medication, discrepancies were found between recommendations and views of clinicians. Both patients and general practitioners appeared ambivalent towards exercise and activity, recognizing its usefulness but identifying it at the same time as a cause of knee osteoarthritis. Patients and general practitioners appeared to consider weight loss particularly difficult., Discussion/conclusions: Barriers specific to each knee osteoarthritis management recommendation and stakeholder group were identified. Recommendations to address these barriers were elaborated. Results of this study can be used to develop implementation strategies to overcome identified barriers, with the goal of facilitating the use of guideline recommendations and improving outcomes., (Copyright © 2010 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)

Infliximab is a chimeric monoclonal antibody that binds to human tumor necrosis factor alpha and is approved for refractory rheumatoid arthritis. We studied the association between infliximab concentration and long-term control of disease activity in patients with rheumatoid arthritis treated on a routine basis both in cross-sectional analysis and over the long term. Trough serum infliximab concentrations were measured in patients with rheumatoid arthritis receiving infliximab infusions during the period August to October 2006. Disease activity was assessed by the Disease Activity Score for 28 Joints (DAS28) and usual biologic markers. During a 42-week follow-up period, patients were classified into two groups: those continuing with the same or lower doses of infliximab (Group A = treatment success) and those who switched to another biopharmaceutical or required an increase in infliximab dose (Group B = treatment failure). Treatment maintenance for Group A was analyzed by categories of infliximab concentration at baseline and compared by the log rank test. In 28 patients, C-reactive protein and infliximab concentrations were inversely related. Infliximab concentration in patients with low disease activity (DAS28 3.2 or less) was higher than in those with persistent active disease (DAS28 greater than 3.2); median values were 3.26 and 0.16 mg/L, respectively (P < 0.01). Analysis after 42 weeks showed that patients in Group A had higher infliximab concentrations at baseline than those with treatment failure (P < 0.01). In rheumatoid arthritis, infliximab concentration is predictive of sustained efficacy with the same infliximab regimen and should be considered on a routine basis.

Sciatica is a symptom rather than a specific diagnosis. Available evidence from basic science and clinical research indicates that both inflammation and compression are important in order for the nerve root to be symptomatic. Tumour necrosis factor-alpha (TNF-alpha) is a key mediator in animal models, but its exact contribution in human radiculopathy is still a matter of debate. Sciatica is mainly diagnosed by history taking and physical examination. In general, the clinical course of acute sciatica is considered to be favourable. In the first 6-8 weeks, there is consensus that treatment of sciatica should be conservative. We review and comment on the levels of evidence of the efficacy of patient information, advice to stay active, physical therapy analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), epidural corticosteroid injections and transforaminal peri-radicular injections of corticosteroid. There is good evidence that discectomy is effective in the short term. but, in the long term, it is not more effective than prolonged conservative care. Shared decision making with regard to surgery is necessary in the absence of severe progressive neurological symptoms. Although the term sciatica is simple and easy to use, it is, in fact, an archaic and confusing term. For most researchers and clinicians, it refers to a radiculopathy, involving one of the lower extremities, and related to disc herniation (DH). As such, the term 'sciatica' is too restrictive as nerve roots from L1 to L4 may also be involved in the same process. However, even more confusing is the fact that patients, and many clinicians alike, use sciatica to describe any pain arising from the lower back and radiating down to the leg. The majority of the time, this painful sensation is referred pain from the lower back and is neither related to DH nor does it result from nerve-root compression. Although differentiating the radicular pain from the referred pain may be challenging for the clinician, it is of primary importance. This is because the epidemiology, clinical course and, most importantly, therapeutic interventions are different for these two conditions. It should, however, be emphasised that the quality of the available evidence is rather limited due to a considerable heterogeneity in the study populations included in the trials. This makes generalisation of findings across studies, and to routine clinical practice, a challenge. Prevalence estimates of radicular pain related to DH also vary considerably between studies, which is, in part, due to differences in the definitions used. A recent review showed that the prevalence of sciatic symptoms is rather variable, with values ranging from 1.6% to 43%. If stricter definitions of sciatica were used, for example, in terms of pain distribution and/or pain duration, lower prevalence rates were reported. Studies in working populations with physically demanding jobs consistently report higher rates of sciatica compared with studies in the general population., (Copyright 2009. Published by Elsevier Ltd.)

Objective: To develop a diagnostic score for knee osteoarthritis flare-ups and to evaluate its sensitivity and specificity., Methods: We used two epidemiological databases built using the same methodology. One database was from a general-practice study and served to develop the score, whereas the other was from a rheumatology study and served to validate the score. Physicians determined the flare-up status of each patient. The rheumatologist diagnosis was the reference standard. Logistic regression was performed to identify factors significantly associated with having a flare-up., Results: Of the 6085 patients in the general-practice database, 52.3% had a knee osteoarthritis flare-up. The score was built by assigning points to features that were present, with a weighting system based on the odds ratio of each feature for having a flare-up (0, feature absent; 1, morning stiffness for longer than 20 min; 2, pain causing nocturnal awakenings and knee effusion; 3, limping, joint swelling, and increased warmth over the knee). The score could range from 0 to 14. The receiver-operating characteristic curve showed that 7 was the best cutoff for diagnosing a flare-up. In the rheumatologist database, the numbers of patients having a flare-up were 274 (46.4%) based on the score and 270 (45.7%) based on the rheumatologist diagnosis. Sensitivity of the score was 87.0%, specificity 87.9%, positive predictive value 85.8%, and negative predictive value 89.0%. The Youden index was 0.75., Conclusion: A score equal to or greater than 7 points correlated well with a rheumatologist diagnosis of flare-up. Our score may constitute a valid objective criterion for standardizing the diagnosis of knee osteoarthritis flare-up, most notably when screening patients for inclusion in therapeutic trials.

Unlabelled: The advent of TNF antagonists has had a revolutionary impact on the treatment of ankylosing spondylitis (AS). However, whether the benefits recorded in controlled trials are replicated in everyday practice has not been extensively evaluated., Objectives: To evaluate the effectiveness of infliximab in patients with axial spondyloarthropathies, to identify factors associated with the treatment response, and to assess fulfillment of modified New York criteria and compliance with guidelines about using TNF antagonists., Methods: Retrospective review of patients given infliximab for axial spondyloarthropathy between 2001 and 2003. Disease activity, motion limitation, laboratory tests, and the 6-week response rate were recorded., Results: Of the 86 included patients (48 women and 38 men, mean age, 44+/-11 years), 37% responded to infliximab therapy. Uveitis and C-reactive protein elevation at baseline predicted a response. Only 53% of patients met modified New York criteria and only 23% met ASAS criteria for starting TNF antagonist therapy., Conclusion: Infliximab was less effective in our patients with axial spondyloarthropathy than expected based on the results of controlled trials. However, many patients did not meet New York criteria for AS and/or ASAS criteria for TNF antagonist therapy. Therefore, our results do not challenge the usefulness of TNF antagonists in axial AS. Our patients were treated before the development of guidelines for TNF antagonist therapy and before the introduction of magnetic resonance imaging as an evaluation tool in AS. Strict criteria should be used to decide when TNF antagonist therapy is appropriate in patients with spondyloarthropathies.

Introduction: Adjustment of infliximab dosage for individuals may be useful in improving therapeutic response in rheumatoid arthritis (RA). Herein, we aimed to determine whether measurement of infliximab serum concentration modifies the therapeutic decision and improves the control of disease activity., Methods: RA patients routinely treated with infliximab were included in an observational open-label study. On visit 1 (V1), according to the disease activity, a preliminary therapeutic decision was selected among four therapeutic options and a blood sample was collected to measure trough serum infliximab concentration. The final therapeutic decision, based on both disease activity and serum infliximab concentration assessed at V1, was applied at the following infusion (V2). Clinical and biological evaluations were performed at V3 and V4 and compared with those at V1., Results: We included 24 patients. The final therapeutic decision differed from the preliminary decision for 12 patients (50%). For patients with increased infliximab dosage at V2, mean disease activity score for 28 joints (DAS28) decreased by about 20% at V3 or V4 as compared with V1 (P < 0.05). Decreased DAS28 was correlated with increased serum infliximab concentration (P < 0.02)., Conclusions: The measurement of infliximab trough concentration modifies the therapeutic decision for RA patients and helps improve control of disease activity. Therapeutic drug monitoring of infliximab in RA may be useful for individual dosage adjustment.

In patients with symptoms caused by intervertebral disk displacement, studies of epidural corticosteroid injections have produced compelling evidence of a short-term analgesic effect (lasting about 3 weeks), despite a number of discrepancies. In contrast, no reductions were noted in the time off work or need for surgery. Strong evidence supports a short-term symptomatic effect of guided transforaminal corticosteroid injections, and there is also some evidence of a long-term effect. Further work is needed to assess the potential of this treatment modality for decreasing surgical requirements in patients who fail conventional nonsurgical treatment. Facet-joint injections may produce pain relief in some patients with common low back pain. This modality can be offered to selected patients who fail to respond to first-line treatment. Epidural injections are not appropriate in patients with acute low back pain. They may offer short-term symptom relief to patients experiencing acute exacerbations of chronic low back pain, in whom they are used as an ancillary method. Intradural injections should not be performed, as they may induce adverse effects and have not been proved effective. Interspinous injections and iliolumbar ligament injections can be considered in selected patients. Although published data have led to controversy about the effectiveness of local corticosteroid injections, a short-term analgesic effect is usually obtained, making this modality useful for the second-line treatment of patients with disk-related sciatica, as well as in selected patients with chronic low back pain.

During last years knowledge about assessment and management of non specific low back pain and their assumption of responsibility developed much. The hazardous anatomoclinic physiopathology is not any more setting. In at least 50% of the cases the precise cause of pain cannot be established. Acute non specific low back pain, in the very large majority of the cases, is a banal incident of the life. Its management rests on precise and reassuring information, withdrawal of the useless and harmful imaging techniques, optimal use of analgesic treatment, and on the early resumption of the activities. When, after sixth week, the favourable outcome did not clearly take shape, the management should be reinforced to avoid disability. In such a case, the principal problem is not any more the back pain itself, but the prolonged incapacity generated by the back pain, which requires a global and multidisciplinary management. One cannot recommend the surgery in low back pain without radicular involvement, except in some very particular and exceptional cases. The recent recommendations for the management of non specific low back pain appear to have involved a reduction of back pain disability.

Disk-related sciatica is a common disorder that resolves without surgery in 95% of patients within 1 to 12months. Several treatment strategies designed to hasten recovery, enable a return to previous social and occupational activities, and prevent chronicization have been evaluated. Available efficacy data support the use of analgesics, nonsteroidal anti-inflammatory drugs, and epidural steroid injections, which probably relieve the pain and improve the quality of life without radically changing the midterm outcome. After a specialized evaluation of physical, psychological, social, and occupational factors, surgery may be offered to patients with persistent nerve root pain (as opposed to low back pain). The complication rate ranges from 1% to 3%. Surgery is clearly effective, shortening the time to recovery by about 50% compared to nonsurgical treatment. Whether one specific surgical procedure is better than others remains unclear. Methodological weaknesses of studies evaluating the efficacy of percutaneous methods preclude definitive conclusions. Bed rest, systemic glucocorticoid therapy, spinal manipulation, bracing, spinal traction, and physical therapy have no proven effects on the outcome of sciatica.

Background: Discontinuation of the marketing of chymodactin has reawakened interest in other percutaneous techniques for treating lumbar disc herniation. Developed in the 1980s, the concept of laser disc decompression is based on the percutaneous introduction of an optical fiber into the intervertebral disc and administering laser energy. The procedure allows for the vaporization of a small amount of the nucleus pulposus and hence a reduction in the intradisc pressure and relief of radicular pain., Objectives: To review of the literature and summarize the technical modalities, mechanism, indications for, and results of percutaneous laser disc decompression for treating lumbar disc herniation., Methods: We identified studies of percutaneous laser disc decompression published between January 1980 and June 2006 in the MEDLINE, EMBASE, and Cochrane Library databases. The search terms used were percutaneous laser disc decompression, laser, and spine or lumbar, disc or disk. The articles underwent a stepwise selection process on the basis of their title, abstract, and full text., Results: Experimental and clinical studies have investigated the modality of percutaneous laser disc decompression, but no consensus exists on the type of laser to use, the wavelength, duration of application, or appropriate energy applied. Studies have evaluated the impact of different techniques on the amount of disc removed, intradisc pressure, and damage to neighboring tissue. Several open studies have been published, but their methodology and conclusions are questionable, and no controlled study has been performed., Conclusions: Although the concept of laser disc nucleotomy is appealing, this treatment cannot be considered validated for disc herniation-associated radiculopathy resistant to medical treatment.

Introduction: In 2008 the national ranking examination (NRE) will include a test on critical reading of scientific articles. This decision has provoked controversy about whether reproducible correction is possible. The aim of our study was to assess the consistency of grading between this two-part test (critical analysis and summarizing, analyzed separately), and the more classic tests., Methods: Eight graders, all instructors at the Tours Medical School, corrected papers for each of the 3 tests. Papers for the critical reading test came from medical school final examinations and for the standard test from a practice examination. The instructors worked in pairs: each pair read 30 papers for each test, and both members separately graded each paper. The final grade was the mean of the two grades. The consistency of grading between the 4 pairs was estimated by Kendall's coefficient of concordance., Results: Kendall's coefficients of concordance were estimated at 0.94 (95% CI=[0.86; 0.97]) for the standard test, at 0.92 (95% CI=[0.81;0.97]) for the critical analysis test, and at 0.75 (95% CI=[0.62; 0.84]) for the summaries. Pairwise comparisons estimated the difference in concordance between the standard test and the summary at 0.18 (95% CI=[0.08; 0.32]) and that between the standard and critical reading test at 0.01 (95% CI= [-0.07; 0.12]). Finally the difference in concordance between the 2 new tests - summary and critical reading - was estimated at -0.17 (95% CI=[-0.32; -0.04])., Conclusion: The focus should be on the difficulty of reproducible correction of the summaries, to set up methods for appropriate correction and adequate grading. The elaboration of detailed scoring templates, including numerous items and specifying in which part of the summary each item must be placed, should help to improve the reproducibility of this test's correction.

Clinical practice guidelines have been elaborated to summarize evidence related to the management of knee osteoarthritis and to facilitate uptake of evidence-based knowledge by clinicians. The objectives of the present review were summarizing the recommendations of existing guidelines on knee osteoarthritis, and assessing the quality of the guidelines using a standardized and validated instrument--the Appraisal of Guidelines Research and Evaluation (AGREE) tool. Internet medical literature databases from 2001 to 2006 were searched for guidelines, with six guidelines being identified. Thirteen clinician researchers participated in the review. Each reviewer was trained in the AGREE instrument. The guidelines were distributed to four groups of three or four reviewers, each group reviewing one guideline with the exception of one group that reviewed two guidelines. One independent evaluator reviewed all guidelines. All guidelines effectively addressed only a minority of AGREE domains. Clarity/presentation was effectively addressed in three out of six guidelines, scope/purpose and rigour of development in two guidelines, editorial independence in one guideline, and stakeholder involvement and applicability in none. The clinical management recommendation tended to be similar among guidelines, although interventions addressed varied. Acetaminophen was recommended for initial pain treatment, combined with exercise and education. Nonsteroidal anti-inflammatory drugs were recommended if acetaminophen failed to control pain, but cautiously because of gastrointestinal risks. Surgery was recommended in the presence of persistent pain and disability. Education and activity management interventions were superficially addressed in most guidelines. Guideline creators should use the AGREE criteria when developing guidelines. Innovative and effective methods of knowledge translation to health professionals are needed.

Three placebo-controlled studies have demonstrated deleterious cardiovascular (CV) effects of rofecoxib, celecoxib, and pare/valdecoxib. It remains to be determined whether this CV toxicity is specific to coxibs, or shared with all non-steroidal anti-inflammatory drugs (NSAIDs). Seven meta-analyses show that, in comparison with non-specific NSAIDs, the risk of thrombotic CV accident is increased with rofecoxib and celecoxib, but not with valdecoxib or lumiracoxib. Concerning the risk of thrombotic CV accident, seven of the ten observational studies which have evaluated the risk have found an increased risk for the non-specific NSAIDs in comparison with non-exposed subjects. The seven observational studies, which evaluated the risk of coxibs, have all found an increased risk with rofecoxib, and two with celecoxib. Three studies out of six have shown on increase of risk with rofecoxib and one study out of five with celecoxib. Two of the three studies, which have compared rofecoxib with celecoxib, have found on increased risk with rofecoxib. Concerning the risk of arterial hypertension, aedemas or congestive cardiac insufficiency, a meta-analysis and a randomised trial have shown a deleterious effect of rofecoxib in comparison with celecoxib and non-specific NSAIDs. Two studies have shown a deleterious effect of the non-selective NSAIDs and three a deleterious effect of rofecoxib in comparison with non-exposed subjects. Three studies have demonstrated a deleterious effect of rofecoxib in comparison with non-specific NSAIDs. No study has shown any deleterious effect of celecoxib in comparison with subjects non-exposed or exposed to non-specific NSAIDs. These studies suggest that all the NSAIDs, specific or not, increase the CV and renal risk. This risk seems variable from a compound to another one and must be evaluated, for each patient, according to the susceptibility and associated risk factors. While waiting for other long-term controlled studies, the available data show the existence of a risk of CV secondary effect linked to the class of NSAIDs, specific (coxibs) or not.

Unlabelled: The goal of this study was to determine which activities in four domains, daily life, exercises, sports and occupational activities, should be recommended, in favor or against, for the patient suffering from knee or hip OA., Methods: Scientific literature was searched in Medline, Embase and Cochrane databases for articles in French or English, reporting original data. The articles were evaluated with standardized epidemiological criteria. Seventy-two articles were retained. Recommendations were graded according to the level of scientific evidence (A high, B moderate, C clinical consensus) and were formulated for primary care., Conclusions and Recommendations: For activity of daily life (ADL), the OASIS group states with a moderate level of scientific evidence, that ADL are a risk factor for knee OA and that risk increases with intensity and duration of activity. The group concludes that healthy subjects as well as OA patients in general can pursue a high level of physical activity, provided the activity is not painful and does not predispose to trauma (grade B). Radiographic or clinical OA is not a contraindication to promoting activity in patients who have a sedentary lifestyle (grade C). For exercises and other structured activities pursued with a goal of health improvement, the group states with a high level of scientific evidence that they have a favourable effect on pain and function in the sedentary knee OA patient. The OASIS group recommends the practice of exercises and other structured activities for the sedentary patient with knee OA (grade A). Static exercises are not favored over dynamic exercises, availability, preference and tolerance being the criteria for the choice of an exercise (grade A). As results deteriorate when exercises are stopped, they should be performed at a frequency of between one and three times per week (grade B). Professional assistance can be useful in improving initial compliance and perseverance (grade B). There is no scientific argument to support halting exercise in case of an OA flare-up (grade C). For sports and recreational activity, the group states with a high degree of scientific evidence, that these activities are a risk factor for knee and hip OA and that the risk correlates with intensity and duration of exposure. The group also states, with a high degree of scientific evidence, that the risk of OA associated with sport is lesser than that associated with a history of trauma and overweight. No firm conclusion could be drawn about the possible protective role of sports such as cycling, swimming or golf. The OASIS group recommends that athletes should be informed that joint trauma is a greater risk factor than the practice of sport (Grade A). The high level athlete should be informed that the risk of OA is associated with the duration and intensity of exposure (Grade B). The OA patient can continue to engage regularly in recreational sports as long as the activity does not cause pain (Grade C). The OA patient who practices a sport at risk for joint trauma should be encouraged to change sport (Grade C). For occupational activity, the OASIS group states with a high level of scientific evidence that there is a relationship between occupational activity and OA of the knee and hip. The precise nature of biomechanical stresses leading to OA remains unclear but factors such as high loads on the joint, unnatural body position, heavy lifting, climbing and jumping may contribute to knee and hip OA. The group recommends that taking an occupational history should always be part of managing the OA patient (Grade B). In the knee or hip OA patient, work-related activity that produces or maintains pain should be avoided (Grade B). Physicians should be alerted by the early knee and hip signs and symptoms in workers exposed to stresses that are known or supposed to favour knee or hip OA (Grade C).

Objective: To investigate the characteristics of patients managed for spinal tuberculosis at the rheumatology department of the Tours Teaching Hospital, France, between 1986 and 2003., Methods: Retrospective chart review. The incidence, epidemiology, clinical features, imaging study findings, and diagnostic procedures were recorded., Results: The annual incidence of spinal tuberculosis was stable throughout the study period. There were 24 patients, 15 women and nine men with a mean age of 61 years; 15 patients were of French descent, three were of Portuguese descent, two were Asian, and four were North-African. Risk factors consisted of alcohol abuse in one patient, diabetes in two patients, glucocorticoid therapy in two patients, and a history of tuberculosis in six patients; none of the patients had AIDS. The cervical spine was involved in two patients, the thoracic spine in 11 patients, and the lumbar spine in 12 patients. Mean time from symptom onset to diagnosis was 4.3 months (range, 1-12 months). Percutaneous vertebral biopsy established the diagnosis in 16 of the 20 patients who underwent this procedure., Conclusion: The annual incidence of spinal tuberculosis remained unchanged throughout the study period and was not influenced by immigration or the AIDS epidemic. The typical patient was an elderly Caucasian woman of French descent. Reactivation of untreated or inadequately treated tuberculosis was probably the main mechanism.

Case Report: To report a case of epidural lipomatosis in a patient with abnormal adipose tissue distribution, glucose intolerance and mixed hyperlipidemia. A 63-year-old male patient presented with low back pain radiating to the left calf on standing and walking (walking distance <100 m). He weighed 97.5 kg, was 1.73 m tall (BMI 32.6 kg/m2) and had a waist circumference of 113 cm. He had a glucose intolerance after a 75-g glucose oral load test. CT-Myelography revealed voluminous epidural lipomatosis around L4-L5 and L5-S1. Low calorie diet and reduction in alcohol intake achieved a weight loss of 17.5 kg in 7 months (80 kg, BMI 25.8 kg/m2, waist circumference 94 cm) and dramatic improvement in low back pain, walking distance (>500 m) and reduction of lipomatosis on CT-scan. Our case suggests a relationship between central obesity phenotype and epidural lipomatosis. Specific insulin resistance treatment might be proposed for these patients if this hypothesis is confirmed in further studies.

Purpose: In clinical guidelines for acute and subacute low-back pain, pharmacological treatment is recommended for short-term symptomatic relief. The objective was to study the effect of the guidelines' advise to remain active, alone and with the addition of the drug adenosine tri-phosphate (ATP), in patients with subacute low-back pain., Methods: A drug-guidelines effectiveness trial was undertaken simultaneously to an experimental drug efficacy placebo controlled trial in subacute (4-12 weeks) non-specific low-back pain patients. The 132 participating primary care physicians across France were randomised to participate to either trial. In the drug-guidelines trial, all physicians received a quick consultation card containing the key elements of the clinical guidelines and a brochure that gave their patients practical tips to remain active. Patients were then randomised to receive Atepadene, containing 90 mg of ATP by mouth daily for 30 days (guidelines plus ATP group), or nothing beside the rescue drug that was made available to all patients (guidelines alone group). The principal outcome was functional improvement on the Roland-Morris Disability Questionnaire (RDQ) at 90 days., Results: In the drug-guidelines effectiveness trial, 157 patients were randomised. The rate of improvement in the RDQ over the 90 days of follow-up was superior in the group guidelines plus ATP (8.3 points, 95% confidence interval (CI): 7.3-9.3) than in the group guidelines alone (6.5 points, 95%CI: 5.3-7.7) (p = 0.02). In terms of probability of improving between two to five points on the RDQ at 90 days this difference translated in a 2 to 13 times higher probability compared to the group guidelines alone (odds ratios ranging from 2.1, 95%CI: 0.9-5.0 to 12.9, 95%CI: 1.6-103.4). Patients in the group guidelines plus ATP were also three times less likely to report a condition that had worsened or remained unimproved at 90 days (p = 0.02)., Conclusion: This drug-guidelines effectiveness trial showed a modest advantage of combined specific pharmacologic and non-pharmacological treatments on absolute improvement on the RDQ. A threefold reduction in the risk of chronicity was observed, an important goal in low-back pain guidelines., (Copyright (c) 2005 John Wiley & Sons, Ltd.)

Aim: To identify occupations with excess prevalence of osteoarthritis of the knee, hip, and hand in a nationwide survey and to compare occupations with and without excess prevalence with regard to biomechanical stresses and severity of osteoarthritis., Methods: Patients presenting with osteoarthritis of the knee, hip, or hand were recruited throughout France by their treating physician who collected information on history, including age at onset, occupation, and occupational stresses to joints. Severity was assessed using joint specific functional status questionnaires: Lequesne for the hip and knee and Dreiser for the hand. The distribution of osteoarthritis patients by occupation was compared with the distribution of occupations in all workers in France to obtain prevalence rate ratios., Results: Occupations with the greatest prevalence rate ratio were female cleaners (6.2; 95% CI 4.6 to 8.0), women in the clothing industry (5.0; 95% CI 3.9 to 6.3), male masons and other construction workers (2.9; 95% CI 2.6 to 3.3), and agriculture male and female workers (2.8; 95% CI 2.5 to 3.2). A twofold greater prevalence rate was observed within certain occupations between self-employed and salaried workers. Early onset of osteoarthritis was seen in the more heavy labour jobs with almost 40% of patients reporting their first symptoms before the age of 50., Conclusion: The early onset and severity of osteoarthritis in certain occupations warrants an urgent need for occupation specific studies for the development and evaluation of preventive strategies in this leading cause of disability in Western countries.

We describe a case of cervical cord compression due to ossification of the posterior longitudinal ligament of the spine (OPLLS) in a 43-year-old Vietnamese patient with SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis). Idiopathic OPLLS is mainly reported in 50- to 60-year-old men, particularly in Japanese, with a prevalence of 2%. Cervical myelopathy may occur. In addition to OPLLS in patients of Asian origin, the condition has also been described in association with ossifying diseases, including ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) but not previously, to our knowledge, with SAPHO syndrome.

Objective: To assess the efficacy and safety of oral adenosine triphosphate (ATP) in subacute low back pain., Methods: This was a randomized, double-blind, parallel group, placebo controlled clinical trial. The patients were given either ATP 90 mg once daily (n=81) or placebo (n=80) for one month. The patients were assessed 3 times during the study period, at days 0, 7, and 30. The primary outcome measure was the Roland-Morris Disability Questionnaire (RDQ) at day 30. Secondary measures of efficacy included visual analog scale (VAS) pain, overall assessments of efficacy by both patient and investigator, and number of dextropropoxyphene and acetaminophen combination tablets used as rescue analgesic., Results: Regarding the RDQ, the mean values dropped from 10.3 +/-2.8 at baseline to 7.5 +/-3.8 (day 7) and 5.2 +/-5.2 (day 30) in the ATP group, and from 11.0 +/- 3.5 to 9.1 +/- 4.2 (day 7) and 6.1 +/- 4.3 (day 30) in the placebo group. The difference between the 2 groups was statistically significant at day 7 (p= 0.02) but not at day 30 (p=0.2). In other words, the mean changes from baseline were 2.8 +/- 3.1 and 2.0 +/- 2.6 at day 7 (p=0.06), and 5.1 +/- 3.9 and 5.0 +/- 4.2 at day 30 (p=0.78) in the ATP group and the placebo group, respectively. There were no statistically significant differences in the VAS pain and overall assessments of efficacy between groups at any time point during the study. Conversely, there was a significant difference in the use of the rescue analgesic between groups, in favor of ATP (p=0.04). Oral ATP was well tolerated., Conclusion: Oral ATP might have an early acting effect in subacute low back pain.

Unlabelled: Acute low back pain is a very common reason for general practitioner visits., Objective: To evaluate practices among French general practitioners regarding the prescription of bed rest in patients with low back pain., Methods: 2000 general practitioners were to include the first three patients presenting within the first 3 d of onset of acute low back pain without nerve root pain. The characteristics of the pain, social and demographic characteristics of the patients, and treatments prescribed by the physicians were recorded., Results: 5355 patients were included, of whom more than half had a history of one or more episodes of low back pain. The mean pain severity score on a 100-mm visual analog scale was 57.2 +/- 22.7 mm. Bed rest was recommended to 27.6% of the patients, for a mean duration of 4.4 d. Patients to whom bed rest was recommended were significantly more likely than the other patients to have chronic low back pain (32.1% vs. 26.5%) and received a greater number of medications. Bed rest was associated with significantly poorer outcomes in the multivariable analysis adjusting for confounding factors., Conclusion: Recommendations to avoid bed rest in patients with acute low back pain are widely followed in France. Furthermore, our results confirm that bed rest is associated with poorer outcomes.

Epidemiological Studies: Most often case-control studies, based on serious GI complications reported in hospitalization statistics are available to compare the gastro-intestinal (GI) safety and tolerability of the various NSAIDs currently on the market. Based on pooled data regarding 5 medicinal products among the most widely used and best documented (ibuprofen, diclofenac, naproxen, indomethacin and piroxicam), the relative result consistency of these studies is striking, thus these 5 NSAIDs may be legitimately classified from the least gastro-toxic (ibuprofen) to the most gastrotoxic (piroxicam). MISSING DATA: But epidemiological survey results may be questioned. Indeed, the volume of prescriptions written, individual dosages and the route of administration are not well documented. Above all, the disease justifying the prescription of an NSAID is never specified. Yet, it is likely that some major anti-inflammatory agents are prescribed more often, at higher doses in patients more seriously and chronically affected, and thus more likely to develop serious gastro-intestinal adverse effects. Data for recently marketed NSAIDs are less comprehensive, with the number of subjects exposed to these new NSAIDs being low, and the validity of the results reported, limited. Regarding currently marketed specific cyclo-oxygenase 2 inhibitors, recent cohort studies demonstrating that the relative risk of ulcer is about half compared to subjects treated with traditional NSAIDs are available., In Summary: The epidemiological survey results can only be extrapolated to individual clinical practice with great caution.

Aims: To describe the age standardised prevalence of symptomatic osteoarthritis (OA) in a nationwide cross sectional survey of 10 412 patients in France, and their functional and work limitations., Methods: Cases in the survey were compared with their expected counterpart by age, gender, and occupational groupings using data from the 1998 French National Survey on Health Impairment and Disability., Results: Women represented 66.2% of the sample; mean age was 66.2 years. One third of patients had OA of the knee, 16% of the hip, and 12% of the hand; a third had multiple joint OA. Peak prevalence of symptomatic OA was in the 60-69 year category in women and in the 70-79 year category in men. Agricultural workers showed a significant excess prevalence of OA, with an observed to expected (O/E) ratio of 1.7 in women and 2.3 in men. Linear trends in prevalences between white collar, "mixed" collar, and blue collar workers were also significant, with odds ratios respectively of 1.0, 2.9, and 2.6 in women and 1.0, 1.2, and 1.7 in men. Specific excess prevalence was found in women among housekeepers (O/E 4.4), and in men among unskilled labour workers (O/E 10.3) and truck drivers (O/E 6.7). Total work disability was highest among blue collar workers and partial disability among agricultural workers., Conclusion: Results contribute to the mounting evidence that OA is potentially aetiologically linked to occupation in a sizeable segment of the population and that OA can no longer be considered an inevitable disease of ageing.

In this paper we propose guidelines for clinical trials aimed at assessing the efficacy of drugs for acute non-specific low back pain (LBP) with or without radicular pain, preliminary to their approval and registration. To this end, consensus statements were obtained from a group of experts in the fields of rheumatology, clinical medicine, public health and epidemiology. EBM resources were systematically used as references. Four diagnostic categories were defined: type 1--LBP with no radiation; type 2--LBP radiating no further than the knee; type 3--LBP radiating beyond the knee, but with no neurologic signs; and type 4--LBP radiating to a specific and entire leg dermatome, with or without neurologic signs. Studies should be designed on the basis of the claimed indications for the drug, but must be double-blinded whatever the indication. The duration of the study may be shorter for LBP type 1 or 2 (one week) than for LBP types 3 and 4 (up to one month), depending on the aim of the study and the indications for the drug. The comparator may be inactive (placebo) or active (for a superiority trial, e.g., versus paracetamol). Specific inclusion and exclusion criteria have been defined here for each category. An appropriate wash-out period for any drugs that could affect the pain status should be planned. Paracetamol may be allowed as rescue medication. The primary endpoint should be based on a validated pain assessment tool that may be either generic (type 1 or 2) or oriented (back and knee for types 3 and 4). Secondary endpoints could include the assessment of functional performance; the duration of any period of bed-rest; work limitation; a global assessment comprising pain at rest, standing and walking; the time elapsed before epidural injection, the prescription of other therapeutic agents, or surgery; and the use of rescue medication. Adverse events (AE) should be monitored systematically using a methodology that reflects the mode of action of the tested drug. With the application of these guidelines, LBP could serve as an appropriate disease for testing analgesic drugs. Rigorous evaluation may also help to improve the management of acute LBP.

Objective: To determine the efficacy of epidural corticosteroid injections for sciatica., Methods: Three epidural injections (two day intervals) of 2 ml prednisolone acetate (50 mg) or 2 ml isotonic saline were administered to patients with sciatica presumably due to a disk herniation lasting 15-180 days. Self evaluation was the main judgment criterion at day 20. Patients who recovered or showed marked improvement were considered as success. Pain measured by VAS, the SLR test, Schober's test, Dallas pain questionnaire, and the Roland-Morris index were evaluated at days 0, 5, 20, and 35. Only analgesics were authorised, patients requiring non-steroidal anti-inflammatory drugs (NSAIDs) before day 20 were considered as failure., Results: 42 patients were included in the control group (CG), 43 in the steroid group (SG). On an intention to treat analysis 15/42 (36%) in the CG and 22/43 (51%) in the SG (p=0.15) were considered as success (difference 15.5%, 95% CI (-5.4 to 36.3)). Among the 48 failures, 14 patients (6 CG, 8 SG) required NSAIDs, 3 (2 CG, 1 SG) required surgery, and 7 (3 CG, 4 SG) other treatments. On analysis according to protocol, in 74 remaining patients 12/35 (34%) in the CG and 22/39 (56%) in the SG (p=0.057) were considered as success (difference 22.1%, 95% CI (0.0 to 44.2)). For all secondary end points intragroup improvement with time was significant, but intergroup differences were not., Conclusion: The efficacy of isotonic saline administered epidurally for sciatica cannot be excluded, but epidural steroid injections provide no additional improvement.

Background: The management of common low back pain has two principal objectives: to relieve acute pain and to attempt prevention of transition to chronicity. Several studies have shown the ineffectiveness of prolonged periods of bed rest., Objective: To compare 4 days of bed rest with continued normal daily activity in acute low back pain, taking into account the type of work (physical or sedentary labor)., Methods: This open, comparative multicenter study enrolled 281 ambulatory patients, ages 18 to 65 years, with low back pain (onset < 72 hours). The subjects did not have pain radiating below the buttocks and did not have work-related injuries. They were randomized into two treatment groups: one instructed to continue normal activity (insofar as the pain allowed), and the other prescribed 4 days of bed rest. After inclusion, patients were seen at three visits: on day 6 or 7, after 1 month, and after 3 months., Results: On day 6 or 7, pain intensity was similar for both groups, as was the overall judgment of the treatment by patients and physicians. At 1 and 3 months, the groups again had equivalent intensity of back pain, functional disability, and vertebral stiffness. A higher proportion of patients in the bed rest group than in the normal activity group had an initial sick leave (86% vs 52%; P < 0.0001). This difference was greater for the patients whose work was sedentary., Conclusions: For patients with acute low back pain, normal activity is at least equivalent to bed rest. The findings of this study indicate that prescriptions for bed rest, and thus for sick leaves, should be limited when the physical demands of the job are similar to those for daily life activities.

Background: Although the existence of a motor defect in discogenic sciatica is a sign of severity, the literature does not provide evidence for an immediate requirement for surgery., Objective: To assess the course of sciatica with discogenic paresis and to determine possible prognostic factors for recovery or improvement., Study Design: This open prospective multicenter study included patients with discogenic sciatica with paresis that had been developing for less than 1 month and was rated < or =3 on a 5-grade scale. Pain, the strength of 11 muscles, return to work, and analgesic intake were assessed at 1, 3, and 6 months. Recovery and improvement were defined by pain not exceeding 20 mm or < or =50% of the initial pain score and a score of either 5 (recovery) or 4 (improvement) for the weakest muscle at inclusion., Results: Sixty-seven patients were enrolled; 39 (58%) patients were treated surgically and 28 (42%) medically. Surgically treated patients differed from medically treated patients by a higher rate of extruded herniation, a higher number of paretic muscles (6.3 vs. 5; P = 0.051), and a longer course of sciatica (31.4 vs. 17.3 days; P = 0.034). At 6 months, 7 (10.4%) patients were lost to follow-up; 32 (53.3%) had improved, including 18 (30%) recovered, 33 (85%) back to work and having a professional activity, and 22 (39%) still taking analgesics. The only significant difference between recovered and not recovered patients was mean age at inclusion (43 vs. 51 years, P = 0.034). There were no significant differences between improved and not improved patients. Moreover, the outcome was not different in the two treatment groups: there were 17 (53%) improvements in surgically treated patients, including 8 (25%) recoveries, and 14 (56%) improvements in medically treated patients, including 8 (40%) recoveries., Conclusion: This pilot study showed no difference between surgical or medical management for recovery or improvement in patients with discogenic paresis. These results need confirmation by a randomized study.

Objective: The aim of this study was to evaluate the efficacy and tolerability of meloxicam compared with diclofenac in patients with osteoarthritis of the lumbar spine., Subjects: 229 patients with radiologically confirmed osteoarthritis of the lumbar spine., Treatment and Methods: Once-daily meloxicam 7.5 mg tablet or diclofenac 100 mg slow release tablet. Efficacy and tolerability parameters were assessed at baseline and after 3, 7 and 14 days of treatment., Results: The two drugs had equal short-term efficacy, with pain on motion of lumbar spine significantly (p<0.05) decreased at Day 3. Secondary efficacy variables were also significantly improved at Days 3, 7 and 14. There were no statistically significant differences between the two drugs, although the global tolerability of meloxicam was significantly better than for diclofenac, as assessed by the investigators (p = 0.0072) and the patients (p = 0.049)., Conclusions: Meloxicam and diclofenac were equivalent in relieving the acute pain associated with osteoarthritis of the lumbar spine. However, meloxicam was much better tolerated.

Objective: Clinical assessment of rheumatoid arthritis (RA) based on pain and swelling and physical examination is limited by observer error and interpretation. We compared magnetic resonance imaging (MRI) and clinical examination to detect synovitis in RA., Methods: Twelve patients with active RA were assessed according to Ritchie index, swollen joint count and score, swollen joint count of hands and wrists [2 wrists, 10 metacarpophalangeal (MCP), 10 proximal interphalangeal (PIP)], morning stiffness, pain intensity, Disease Activity Score (DAS), erythrocyte sedimentation rate, and C-reactive protein. MR images of hands and wrists were obtained with an adapted device, on T1 weighted (T1W) spin echo (SE) coronal images before and after gadolinium DTPA, TIW SE axial images with gadolinium DTPA, T2* gradient echo recall coronal and axial sequences, and assessed by 2 radiologists (O = no synovitis, 1 = synovitis)., Results: The swollen joint count on hands and wrists was 59 on clinical examination (mean 5.08 +/- 3.15 per patient; 20/24 wrists, 7/120 MCP, 32/120 PIP) and 162 on MRI (mean 13.50+/- 5.65; 22/24 wrists, 70/120 MCP, 70/120 PIP). Statistically significant correlations were found between MRI synovitis count and swollen joint count (p = 0.015) and score (p = 0.019), Ritchie Index (p = 0.035), DAS (p = 0.02) and morning stiffness (p = 0.07). MRI revealed synovitis significantly more often than clinical examination (162 vs 59; p = 0.00002) [2-fold in PIP (70/32) and 10-fold in MCP (70/7)]. Clinical examination and MRI were concordant for 157/264 joints (59.5%). The association of normal MRI with synovitis on clinical examination was observed in 2 cases, the opposite in 105., Conclusion: MRI is more sensitive than clinical examination to detect synovitis of hands and wrists in RA, especially for MCP and PIP joints, and is valuable for assessment of inflammation in hands and wrists in RA.