Mechanisms of strength gain in a handgrip exercise programme in rheumatoid arthritis.

In a progressive resistive strengthening programme, healthy individuals gain strength initially through neural adaptation followed by increases in muscle mass. Programmes are designed to maximise these responses. The physiological mechanisms of strength gain in RA are unknown, but their identification will help to develop more effective exercise programmes. The aim of this study was to investigate the responses to a 12-week isometric handgrip strengthening programme in female subjects with RA. Fourteen right-handed female subjects with RA and 14 age-matched female controls participated in a 12-week right handgrip strengthening programme. Maximum grip strength (MGS) and disease activity were measured serially over 12 weeks. Forearm muscle volume was measured using MRI at baseline and 12 weeks. Significant gains in right handgrip strength were noted in both groups, the gains being most marked in those with RA: mean (SD; range) MGS (mmHg) in RA group at baseline 105.1 (48.1; 34-108) and 174.8 (76.4; 50-340) at 12 weeks. Mean (SD; range) MGS in control group at baseline 311.7 (49.6; 220-370) and 357.0 (67.1; 250-540) at 12 weeks. Significant increases in forearm muscle volume occurred in the controls, correlating with gains in strength. No such changes were noted in the RA group, indicating that improvements were solely related to neural adaptation. Response to strength training in RA differs from those of healthy individuals. Significant gains in strength in individuals with RA can occur due to neural adaptation without gains in muscle mass during a strengthening programme. This has implications for the design of rehabilitation programmes for such subjects.

Extracorporeal shock wave therapy for plantar fasciitis. A double blind randomised controlled trial.

BACKGROUND: Extracorporeal shock wave therapy (ESWT) is an increasingly popular therapeutic approach in the management of a number of tendinopathies. Benefit has been shown in calcific tendinitis of the rotator cuff, but evidence for its use in non-calcific disorders is limited. AIMS: To perform a double blind randomised controlled trial of moderate dose shock wave therapy in plantar fasciitis. METHODS: Adults with plantar fasciitis for at least 3 months were randomised to receive either active treatment (0.12 mJ/mm(2)) or sham therapy, monthly for 3 months. Pain in the day, nocturnal pain and morning start-up pain were assessed at baseline, before each treatment and 1 and 3 months after completion of therapy. RESULTS: Eighty-eight subjects participated and no differences existed between the groups at baseline. At 3 months, 37% of the subjects in the ESWT group and 24% in the sham group showed a positive response (50% improvement from baseline) with respect to pain. Positive responses in night pain occurred in 41% and 31% in the ESWT and sham groups, respectively. Positive responses in start-up pain occurred in 37% and 36% in the ESWT and sham groups, respectively. Both groups showed significant improvement over the course of the study, but no statistically significant difference existed between the groups with respect to the changes were seen in any of the outcome measures over the 6-month period. CONCLUSIONS: There appears to be no treatment effect of moderate dose ESWT in subjects with plantar fasciitis. Efficacy may be highly dependent upon machine types and treatment protocols. Further research is needed to develop evidence based recommendation for the use ESWT in musculoskeletal complaints.

Extracorporeal shock wave therapy for lateral epicondylitis--a double blind randomised controlled trial.

UNLABELLED: Extracorporeal shock wave therapy (ESWT) is an increasingly popular therapeutic approach to the treatment of a number of soft tissue complaints. Whilst benefit has been demonstrated in calcific tendinitis, evidence is lacking for benefit in the management of non-calcific rotator cuff disorders. AIMS: To perform a double-blind placebo controlled trial of moderate dose ESWT in chronic lateral epicondylitis. METHODS: Adults with lateral epicondylitis were randomised to receive either active treatment (1500 pulses ESWT at 0.12 mJ/ mm2) or sham therapy, monthly for three months. All were assessed before each treatment and one month after completion of therapy. Outcome measures consisted of visual analogue scores for pain in the day and at night. RESULTS: Seventy-five subjects participated and there were no significant differences between the two groups at baseline. The mean duration of symptoms was 15.9 and 12 months in the ESWT and sham groups, respectively. Both groups showed significant improvements from two months. No significant difference existed between the groups with respect to the degrees of change in pain scores over the study period. In the ESWT group the mean (SD, range) pain score was 73.4 (14.5, 38-99) at baseline and 47.9 (31.4, 3-100) at three months. In the sham group the mean (SD, range) pain score was 67.2 (21.7, 12-100) at baseline and 51.5 (32.5, 3-100) at three months. At three months, 50% improvement from baseline was noted in 35% of the ESWT group and 34% of the sham group with respect to pain. CONCLUSIONS: There appears to be a significant placebo effect of moderate dose ESWT in subjects with lateral epicondylitis but there is no evidence of added benefit of treatment when compared to sham therapy.

Injection therapies for soft-tissue disorders.

Local injection therapies are used in the management of a variety of musculoskeletal pain syndromes and include the local infiltration of substances such as corticosteroid and/or anaesthetic, dry needling and neural blockade. Although commonly used, the rationale for their use in many conditions is arguable and evidence of efficacy is often lacking. In this chapter, a number of common injection therapies for soft-tissue-mediated pain are described. The reasoning for their use, potential mechanisms of action and unwanted effects are discussed. The literature relating to their documented effects is critically reviewed. Practical suggestions for their utilization in the management of soft-tissue conditions are given and proposals are made for future research in this important area.

Ultrasound velocity and attenuation at different skeletal sites compared with bone mineral density measured using dual energy X-ray absorptiometry.

Measurements of ultrasound velocity were performed in the tibia in a group of 89 female subjects (mean age 50.6 years). Velocity and broadband ultrasound attenuation (BUA) measurements were performed in the os-calcis in a group of 100 male and female subjects (mean age 55.8 years). Dual energy X-ray absorptiometry (DEXA) scans were also performed on all of these subjects enabling measurements of lumbar spine and femoral neck bone mineral density (BMD) to be obtained. In two small subgroups of the above groups, each comprising 20 subjects, measurements of tibial BMD and os-calcis BMD were also performed. Tibial BMD and ultrasound velocity were found to be well correlated (r = 0.71), although both spine and femoral neck BMD were poorly correlated with ultrasound velocity in the tibia (r = 0.299 and 0.072, respectively). BUA of the os-calcis was moderately correlated with BMD at the same site (r = 0.44) and showed similar or slightly better correlations with BMD measurements of the lumbar spine and femoral neck (r = 0.410 and 0.537, respectively). Ultrasound velocity in the os-calcis was well correlated with os-calcis BMD (r = 0.729) but only moderately correlated with spine and femoral neck BMD (r = 0.470 and 0.498, respectively). This study suggests that BUA and ultrasound velocity measurements of the os-calcis are better predictors of BMD at the critical skeletal sites of the lumbar spine and femoral neck than ultrasound velocity in the tibia. Ultrasound velocity in the tibia and the os-calcis was found to be a good predictor of the BMD in the measured bone.

Extracorporeal shock-wave therapy for tendonitis of the rotator cuff. A double-blind, randomised, controlled trial.

We have performed a double-blind placebo-controlled trial of moderate doses of extracorporeal shock-wave therapy (ESWT) for non-calcific tendonitis of the rotator cuff. Adults (74) with chronic tendonitis of the rotator cuff were randomised to receive either active (1500 pulses ESWT at 0.12 mJ/mm2) or sham treatment, monthly for three months. All were assessed before each treatment, and at one and three months after the completion of treatment. The outcome was measured with regard to pain in the shoulder, including a visual analogue score for night pain, and a disability index. There were no significant differences between the two groups before treatment. The mean duration of symptoms in both groups was 23.3 months. Both showed significant and sustained improvements from two months onwards. There was no significant difference between them with respect to change in the Shoulder Pain and Disability Index (SPADI) scores or night pain over the six-month period. A mean (+/-SD; range) change in SPADI of 16.1 +/- 27.2 (0 to 82) in the treatment group and 24.3 +/- 24.8 (-11 to 83) in the sham group was noted at three months. At six months the mean changes were 28.4 +/- 25.9 (-24 to 69) and 30.4 +/- 31.2 (-12 to 88), respectively. Similar results were noted for night pain. We conclude that there is a significant and sustained placebo effect after moderate doses of ESWT in patients with non-calcific tendonitis of the rotator cuff, but there is no evidence of added benefit when compared with sham treatment.

Stress fractures.

Stress fractures are being increasingly reported as a common cause of morbidity in both healthy populations and those with underlying diseases involving abnormal bone. An insight into the types and pathogenesis of stress fractures is necessary to considering the diagnosis, management and prevention of such conditions. The classification, aetiology and aspects of management are discussed.

Coincident seronegative spondarthritis: a case report.

A patient is described in whom ankylosing spondylitis (AS) and reactive arthritis (ReA) coincided. Follow-up five years later showed no progression of his AS. He demonstrates that some individuals do have the capacity to express seronegative spondarthritides in different ways, possibly dependent on the infective trigger. The lack of long term effect of the second disease is both clinically reassuring and theoretically intriguing.

Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial.

OBJECTIVES: Pulsed low-intensity ultrasound therapy (LIUS) has been found to be beneficial in accelerating fracture healing and has produced positive results in animal tendon repair. In the light of this we undertook a randomized, double-blind, placebo controlled trial to assess the effectiveness of LIUS vs placebo therapy daily for 12 weeks in patients with chronic lateral epicondylitis (LE). METHODS: Patients with LE of at least 6 weeks' duration were recruited from general practice, physiotherapy and rheumatology clinics, and had to have failed at least one first-line treatment including non steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injection. Participants were assigned either active LIUS or placebo. Treatment was self-administered daily for 20 min over a 12-week period. The primary end-point was a 50% improvement from baseline in elbow pain measured at 12 weeks using a patient-completed visual analogue scale. RESULTS: Fifty-five subjects aged 18-80 were recruited over a 9-month period. In the active group 64% (16/25) achieved at least 50% improvement from baseline in elbow pain at 12 weeks compared with 57% (13/23) in the placebo group (difference of 7%; 95% confidence interval -20 to 35%). However, this was not statistically significant (chi(2) = 0.28, P = 0.60). CONCLUSION: In this study LIUS was no more effective for a large treatment effect than placebo for recalcitrant LE. This is in keeping with other interventional studies for the condition.

Referrals to hospital-based rheumatology and orthopaedic services: seeking direction.

OBJECTIVES: While both community and hospital-based services strive to cope with the considerable burden posed by musculoskeletal disorders, multidisciplinary-led, integrated approaches are frequently lacking. It has been suggested that referrals to musculoskeletal services are frequently misdirected to an orthopaedic surgeon when non-surgical advice/intervention is warranted, reducing the efficiency of hospital-based services and potentially affecting quality of care. Triage of referrals may help to prevent this, but this system is dependent upon accurate and thorough information being provided in the referral letter. Our aim was to assess the feasibility of triage of musculoskeletal referrals to rheumatology and orthopaedic services at a large teaching hospital. METHODS: One thousand and eighty-seven consecutive referral letters to orthopaedic and rheumatology services were reviewed by a consultant rheumatologist. Letters were assessed for both basic content and the appropriate destination for that referral. In order to evaluate the accuracy of the assessor's prediction of the most appropriate destination of the referrals, the number of patients who were ultimately listed for surgical intervention was calculated in a random sample of orthopaedic referrals, 1 yr after the initial hospital appointment was requested. RESULTS: Six hundred and eighty-two referrals were to orthopaedics and 393 to rheumatology. Referrals relating to spinal pain were excluded. The content of letters was scant and no diagnosis was volunteered in 63.4% of referrals. Fifty-eight per cent of referrals to orthopaedics were considered appropriate; 27% of referrals to orthopaedics were defined as 'should definitely see a rheumatologist' (12%) or 'should probably see a rheumatologist' (15%). Fifteen per cent of referrals to orthopaedics were defined as 'could see either a surgeon or a rheumatologist'. Ninety-four per cent of referrals to rheumatology were defined as appropriate, 2% were not and 4% were defined as 'could see either a surgeon or a rheumatologist'. One year later, in a random sample of 373 of the orthopaedic referrals, 42.2% of those who were categorized as 'should see surgeon' and 9.7% of the 'should see a physician' group were listed for surgical intervention. CONCLUSIONS: Many referrals to hospital-based musculoskeletal services are likely to be misdirected. Integrated referral and care pathways are required for efficient and optimal care of patients with musculoskeletal diseases. The development of such pathways will require significant support, education and training for general practitioners.

Diagnosis and relation to general health of shoulder disorders presenting to primary care.

OBJECTIVES: To prospectively evaluate the incidence, spectrum of disease and relation to general health of shoulder disorders in primary care. METHODS: Patients presenting with shoulder pain to two large general practices in the Cambridge area over a 1-month period were invited to participate. After consulting their general practitioner, patients were administered a demographic information questionnaire, a shoulder pain and disability index (SPADI) and a short form 36 (SF-36) health survey. Subsequent review in a clinic held by a rheumatology registrar every 2 weeks was undertaken. RESULTS: The sex- and age-standardized incidence of shoulder pain was 9.5 per 1000 (95% confidence interval 7.9 to 11.2 per 1000). Rotator cuff tendinopathy was found in 85%, signs of impingement in 74%, acromioclavicular joint disease in 24%, adhesive capsulitis in 15% and referred pain in 7%. On the SPADI the mean disability subscale score was 45 (95% confidence interval 41 to 50) and the mean pain score was 58 (95% confidence interval 53 to 62) (range 0 to 100). Evaluation of general health status using the SF-36 showed the difference between population norms and those with shoulder pain was significant in six of the eight domains, being especially marked (greater than 20 point reduction) for emotional role, physical function and physical role. CONCLUSION: Shoulder pain, most commonly due to rotator cuff tendinopathy, is associated with significantly reduced health when measured by both specific and generic means. Effort towards prevention and early intervention in these complaints is warranted.

Therapeutic ultrasound in soft tissue lesions.

Therapeutic ultrasound is one of the most common treatments used in the management of soft tissue lesions, which constitute the majority of rheumatic complaints. Although many laboratory-based research studies have demonstrated a number of physiological effects of ultrasound upon living tissue, there is remarkably little evidence for benefit in the treatment of soft tissue injuries. This may be related to several confounding factors, including technical variables, the complexity and variety of underlying pathologies in soft tissue lesions, methodological limitations of clinical studies, or true lack of effect. In this review the scientific basis for the use of therapeutic ultrasound in soft tissue lesions and the existing evidence relating to its clinical effect are detailed.

Polymyalgia rheumatica, temporal arteritis and malignancy.

The use of steroid therapy in polymyalgia rheumatica and temporal arteritis is necessary and usually effective, but may mask coexisting disease. The importance of early consideration of other disorders in such patients is illustrated by three case histories.

Simultaneous bilateral tibial stress fractures in a 15-year-old milkman--a case report.

Although stress fractures are well recognized, their frequency, sequelae and complex aetiology are often under-rated. In this case report, we describe an unusual case of simultaneous bilateral stress fractures of the proximal tibial shaft in a young man, exposed to a sudden increase in unaccustomed joint loading due to his part-time occupation. The pathogenesis is discussed.