Hypermobility and proprioception in the finger joints of flautists.

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.

Effects of walking with a shopping trolley on spinal posture and loading in subjects with neurogenic claudication.

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.

The effectiveness of walking stick use for neurogenic claudication: results from a randomized trial and the effects on walking tolerance and posture.

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.

Assessment and management of neurogenic claudication associated with lumbar spinal stenosis in a UK primary care musculoskeletal service: a survey of current practice among physiotherapists.

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.

Occupational disorders: non-specific forearm pain.

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.

Haemorrhoids and joint hypermobility: a new extra-articular association.

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.

A home exercise programme is no more beneficial than advice and education for people with neurogenic claudication: results from a randomised controlled trial.

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.

Joint hypermobility.

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.

The polymyalgia rheumatica activity score in daily use: proposal for a definition of remission.

OBJECTIVE: To confirm the reliability and applicability of the Polymyalgia Rheumatica Disease Activity Score (PMR-AS), and to establish a threshold for remission. METHODS: First, 78 patients with PMR (50 women/28 men, mean age 65.97 years) were enrolled in a cross-sectional evaluation. The PMR-AS, patient's satisfaction with disease status (PATSAT; range 1-5), erythrocyte sedimentation rate (ESR; first hour), and a visual analog scale of patients' general health assessment (VAS patient global; range 0-100) were recorded. Subsequently, another 39 PMR patients (24 women/15 men, mean age 68.12 years) were followed longitudinally. Relationships between the PMR-AS, PATSAT, ESR, and VAS patient global were analyzed by the Kruskal-Wallis test, Spearman's rank correlation, and kappa statistics. PMR-AS values in patients with a PATSAT score of 1 and a VAS patient global <10 formed the basis to establish a remission threshold. RESULTS: PMR-AS values were significantly related to PATSAT (P < 0.001), VAS patient global (P < 0.001), and ESR (P < 0.01). PATSAT and VAS patient global were reasonably different (kappa = 0.226). The median PMR-AS score in patients with PATSAT score 1 and VAS patient global <10 was 0.7 (range 0-3.3), and the respective 75th percentile was 1.3. To enhance applicability, a range from 0 to 1.5 was proposed to define remission in PMR. The median ESR in these patients was 10 mm/hour (range 3-28), indicating external validity. CONCLUSION: We demonstrated the reliability, validity, and applicability of the PMR-AS in daily routine. Moreover, we proposed a remission threshold (0-1.5) founded on patient-dependent parameters.

Drug treatment for fibromyalgia.

The term 'fibromyalgia' probably covers a variety of diagnoses for which we have no formal diagnostic tests. Nevertheless, it remains a cause of discomfort and disability, often amenable to non-drug treatment that should always be tried first. This article reviews the different drug treatments available that are of interest to the rheumatology community because the drugs that often procure pain relief are not always the same as those that are conventionally used for degenerative or inflammatory polyarthritis. This, in turn, may provide a clue to causation.