Short-term Efficiency and Tolerance of Ketoprofen and Methylprednisolone in Acute Sciatica: A Randomized Trial.

OBJECTIVE: Although anti-inflammatory drugs are commonly used in acute discogenic sciatica, data regarding their efficacy are scarce and controversial. We compared the efficacy and safety of intravenous ketoprofen and methylprednisolone with placebo in sciatica. DESIGN: Multicenter, double-blinded randomized controlled trial. SUBJECTS: Patients with confirmed discogenic acute sciatica, without neurologic deficit, were randomized into three arms. METHODS: Besides standard-of-care analgesic therapy, they received intravenous injections of methylprednisolone (60 mg/d) or ketoprofen (200 mg/d) or placebo for five days. The primary outcome was leg pain over five days. Secondary outcomes were clinical responses at days 3 and 5, lumbar pain, Straight Leg Raise Test and lumbar flexion index, analgesic consumption, realization of lumbar spine injections, and surgery during the study period. RESULTS: Fifty-four patients were randomized, and 50 completed the study. In patients admitted to the hospital for pain control with acute lumbar radicular pain due to intervertebral disc herniation and receiving an oral analgesic protocol including paracetamol, nefopam, tramadol, and morphine, there was no additional analgesic effect seen between groups. There was no significant difference in leg pain between the three groups over the study period. In the methylprednisolone group, however, we observed a higher rate of clinically relevant responses at day 3. No difference was observed on other secondary efficacy outcomes and safety. CONCLUSION: No significant difference in leg pain was observed between groups. However, there was a higher proportion of patients relieved with intravenous methylprednisolone at day 3, compared with ketoprofen or placebo.

Gait as predictor of physical function in axial spondyloarthritis: the prospective longitudinal FOLOMI (Function, Locomotion, Measurement, Inflammation) study protocol.

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease affecting predominantly sacroiliac joints and axial skeleton. axSpA progression being irregular and hardly predictable, identifying functional decline is particularly important in patient with axSpA to allow delivery of timely and targeted interventions. Pain, reduced range of motion or altered posture can have adverse consequences on gait. Although gait has previously been used as a sensitive measure of physical outcomes in elderly and pathological populations, to the best of our knowledge, no study has used gait as a predictor of physical function in patients with axSpA. The objective of our study is hence to determine if gait parameters measured in patients with axSpA could predict the evaluation at 18 months of physical function as assessed by the Bath Ankylosing Spondylitis Functional Index (BASFI). This is a prospective and longitudinal study. Sixty patients with axSpA and 30 healthy age- and sex-matched controls will be included. Patients should be aged 18-65 years at time of their first evaluation, followed at Grenoble Alpes University Hospital for axSpA or ankylosing spondylitis, able to walk 180 m without technical help and with stable treatment for at least 12 months. Clinical characteristics, BASFI, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), clinical and laboratory measurements of gait will be assessed during four visits (at baseline and at months 6, 12, and 18). Similar assessments will be performed once for the healthy control group. A linear mixed model at 6, 12 and 18 months will be constructed to answer to the first objective, with the BASFI as dependent variable and gait parameters as explanatory variables. The data collection started in August 2018 and will be completed with the inclusion and follow-up of all the participants. We believe that the combination of clinical and laboratory measurements of gait in patients with axSpA could strengthen the capacity to monitor disease's evolution and to predict changes in patients' physical function. Results of the present study could ultimately allow delivering targeted, timely, personalized interventions and treatment in patients with axSpA.Trial registration: The study was approved by local ethic committee (CPP Ile De France 1, RCB: 2017-A03468-45, date of agreement: July 17th, last version: V4.0, 2018, March 5th, 2019) and is retrospectively registered in Clinical trials (NCT03761212).

Efficacy of resistance exercises in rheumatoid arthritis: meta-analysis of randomized controlled trials.

OBJECTIVE: To evaluate the efficacy of resistance exercises in RA patients. METHODS: A systematic literature search was done using Pubmed, Embase and Cochrane databases through November 2009 and in abstracts presented at rheumatology scientific meetings over the past 3 years. Randomized controlled trials (RCTs) comparing resistance exercise based therapy with interventions without resistance exercise for the treatment of RA patients were included. Outcomes studied were post-intervention disability on the HAQ, functional capacity assessed by walking speed, pain on the visual analogue scale (VAS), joint count, isometric, isokinetic and grip strength. Efficacy was assessed by weighted mean differences (WMDs) and tolerance was assessed by relative risk (RR). Data were pooled using the inverse of variance model, and heterogeneity was tested. RESULTS: Ten RCTs, including 547 patients, met the study inclusion criteria. The mean (S.D.) Jadad score was 2.3 (0.6). Resistance exercises significantly improved isokinetic strength (WMD = 23.7%, P < 0.001), isometric strength (WMD = 35.8%, P < 0.001), grip strength (WMD = 26.4%, P < 0.001) and HAQ (WMD = -0.22, P < 0.001). Exercise also had a positive impact on the 50-foot walking test (WMD = -1.90 s, P < 0.001) and ESR (WMD = -5.17, P = 0.005). Withdrawals [RR = 0.95, 95% confidence interval (CI) 0.61, 1.48] and adverse events (RR = 1.08, 95% CI 0.72, 1.63) were well balanced in both groups. Patient and exercise characteristics did not influence the results. Subgroup analysis revealed a trend towards higher efficacy associated with high-intensity programmes. CONCLUSION: Resistance exercise in RA is safe, and the improvement in most outcomes was statistically significant and possibly clinically relevant for RA disability.

Efficacy and tolerance of systemic steroids in sciatica: a systematic review and meta-analysis.

OBJECTIVES: The efficacy of pharmacological interventions in sciatica is limited and the use of systemic steroids is still controversial. We aimed at evaluating the efficacy and tolerance of systemic steroids in sciatica. METHODS: A systematic literature search was performed in the Medline, Embase and Cochrane databases until February 2010. Randomized placebo-controlled trials evaluating the efficacy and the tolerance of systemic steroids in sciatica were included. Efficacy and tolerance were assessed using the relative risk (RR) and 95% CI with the inverse variance method (RR > 1 means that the event is more likely to occur in the steroid group). We explored the heterogeneity between the studies using subgroup analysis. RESULTS: Seven studies (383 patients) were included. The difference in the rate of responders between both groups was not statistically significant (RR = 1.22, 95% CI 0.96, 1.56). The rate of adverse events was 13.3% for the patients in the steroid group and 6.6% for the placebo group (RR = 2.01, 95% CI 1.06, 3.80). The number needed to harm was 20 (95% CI 10, ∞). Twenty (15.3%) patients in the steroid group and seven (5.7%) patients in the placebo group underwent surgery. A trend towards a higher requirement for spinal surgery was observed in the steroid group (RR = 1.14, 95% CI 0.74, 1.75). The methodological quality slightly influenced the results. We did not find any publication bias. CONCLUSION: Steroid efficacy is not superior to the placebo in sciatica, but it has more side effects. The tolerance : efficacy ratio indicates against the use of systemic steroids in sciatica.

The interest of gait markers in the identification of subgroups among fibromyalgia patients.

BACKGROUND: Fibromyalgia (FM) is a heterogeneous syndrome and its classification into subgroups calls for broad-based discussion. FM subgrouping, which aims to adapt treatment according to different subgroups, relies in part, on psychological and cognitive dysfunctions. Since motor control of gait is closely related to cognitive function, we hypothesized that gait markers could be of interest in the identification of FM patients' subgroups. This controlled study aimed at characterizing gait disorders in FM, and subgrouping FM patients according to gait markers such as stride frequency (SF), stride regularity (SR), and cranio-caudal power (CCP) which measures kinesia. METHODS: A multicentre, observational open trial enrolled patients with primary FM (44.1 ± 8.1 y), and matched controls (44.1 ± 7.3 y). Outcome measurements and gait analyses were available for 52 pairs. A 3-step statistical analysis was carried out. A preliminary single blind analysis using k-means cluster was performed as an initial validation of gait markers. Then in order to quantify FM patients according to psychometric and gait variables an open descriptive analysis comparing patients and controls were made, and correlations between gait variables and main outcomes were calculated. Finally using cluster analysis, we described subgroups for each gait variable and looked for significant differences in self-reported assessments. RESULTS: SF was the most discriminating gait variable (73% of patients and controls). SF, SR, and CCP were different between patients and controls. There was a non-significant association between SF, FIQ and physical components from Short-Form 36 (p = 0.06). SR was correlated to FIQ (p = 0.01) and catastrophizing (p = 0.05) while CCP was correlated to pain (p = 0.01). The SF cluster identified 3 subgroups with a particular one characterized by normal SF, low pain, high activity and hyperkinesia. The SR cluster identified 2 distinct subgroups: the one with a reduced SR was distinguished by high FIQ, poor coping and altered affective status. CONCLUSION: Gait analysis may provide additional information in the identification of subgroups among fibromyalgia patients. Gait analysis provided relevant information about physical and cognitive status, and pain behavior. Further studies are needed to better understand gait analysis implications in FM.

Synovial fluid proteomic fingerprint: S100A8, S100A9 and S100A12 proteins discriminate rheumatoid arthritis from other inflammatory joint diseases.

OBJECTIVE: We investigated SF and serum proteomic fingerprints of patients suffering from RA, OA and other miscellaneous inflammatory arthritides (MIAs) in order to identify RA-specific biomarkers. METHODS: SF profiles of 65 patients and serum profiles of 31 patients were studied by surface-enhanced laser desorption and ionization-time-of-flight-mass spectrometry technology. The most discriminating RA biomarkers were identified by matrix-assisted laser desorption ionization-time of flight and their overexpression was confirmed by western blotting and ELISA. RESULTS: Three biomarkers of 10 839, 10 445 and 13 338 Da, characterized as S100A8, S100A12 and S100A9 proteins, were the most up-regulated proteins in RA SF. Their expression was about 10-fold higher in RA SF vs OA SF. S100A8 exhibited a sensitivity of 82% and a specificity of 69% in discriminating RA from other MIAs, whereas S100A12 displayed a sensitivity of 79% and a specificity of 64%. Three peptides of 3351, 3423 and 3465 Da, corresponding to the alpha-defensins-1, -2 and -3, were also shown to differentiate RA from other MIAs with weaker sensitivity and specificity. Levels of S100A12, S100A8 and S100A9 were statistically correlated with the neutrophil count in MIA SF but not in the SF of RA patients. S100A8, S100A9, S100A12 and alpha-defensin expression in serum was not different in the three populations. CONCLUSION: The most enhanced proteins in RA SF, the S100A8, S100A9 and S00A12 proteins, distinguished RA from MIA with high accuracy. Possible implication of resident cells in this increase may play a role in RA physiopathology.

A dynamic exercise programme to improve patients' disability in rheumatoid arthritis: a prospective randomized controlled trial.

OBJECTIVE: To evaluate the functional, clinical, radiological and quality of life outcomes of a 4-week dynamic exercise programme (DEP) in RA. METHODS: Patients matched on the principal medico-social parameters were randomly assigned to either the DEP or the conventional joint rehabilitation group. Primary end point for judging effectiveness was functional status assessed by HAQ. Secondary outcomes included Nottingham Health Profile (NHP), Arthritis Impact Measurement Scale 2-Short Form (AIMS2-SF) and radiological worsening measured by Simple Narrowing Erosion Score (SENS). Clinical evaluation consisted of disease activity score (DAS 28), cycling aerobic fitness and dexterity. Dexterity was measured using Sequential Occupational Dexterity Assessment (SODA) and Duruoz Hand Index (DHI). Data were collected at baseline 1, 6 and 12 months. RESULTS: Fifty patients were enrolled. HAQ improved throughout the length of the trial in the DEP group. This improvement was greater in DEP than in the standard joint rehabilitation group at 1 month (-0.2 vs no variation from baseline, P = 0.04), but not at 6 months (-0.2 vs -0.1 in control group, P = 0.25) or 12 months (-0.1 vs no variation in control group, P = 0.51). DEP improved NHP (-23 vs + 7% in control group, P = 0.01) and aerobic fitness (+0.3 vs + 0.1 km per 5 min in control group, P = 0.02) at 1 month but the progress was not statistically significant thereafter. DEP also improved DHI, SODA, DAS 28 and AIMS2-SF, although not significantly. CONCLUSION: DEP was effective on functional status assessed by HAQ, quality of life and aerobic fitness at 1 month.

Effect of manipulation of the feet and ankles on postural control in elderly adults.

The purpose of the present experiment was to investigate the effect of a therapeutic manipulation of the feet and ankles on postural control during quiet standing in elderly adults. Seventeen elderly adults stood barefeet on a force platform and were asked to sway as little as possible. Within a trial, vision was suppressed by eyes closure. The task was executed in two experimental sessions: before and after a therapeutic manipulation of the feet and ankles. Centre of feet pressure (COP) displacements along the mediolateral (ML) and anteroposterior (AP) axes were recorded. For the two experimental sessions, subjects exhibited comparable COP displacements when vision was available and were similarly affected by the suppression of vision. However, when subjects had to adapt to the absence of vision within a 10s temporal frame, postural behaviour became different in the two experimental sessions: the sum of the ML and AP COP displacements increased within the 10s temporal frame before the therapeutic manipulation of the feet and ankles, whereas it remained unchanged after it. These results suggested that the therapeutic manipulation of the feet and ankles allows the elderly adults to partially compensate for the destabilising effect induced by the suppression of vision.

Bisphosphonates for treatment of Complex Regional Pain Syndrome type 1: A systematic literature review and meta-analysis of randomized controlled trials versus placebo.

OBJECTIVES: Complex Regional Pain Syndrome Type 1 is a severely disabling pain syndrome with no definite established treatment. We have performed a systematic literature review and meta-analysis of all randomized controlled trials to assess the benefit of bisphosphonates on pain and function in patients with Complex Regional Pain Syndrome Type 1. METHODS: A systematic literature search was performed in the Medline, Embase and Cochrane databases. Two authors selected independently blinded randomized trials comparing bisphosphonates to placebo on short-term (J30 to J40) and medium term pain (M2-M3), safety and function in patients with CRPS 1. The methodological quality of the studies was analyzed. Data were aggregated using the method of the inverse of the variance. RESULTS: 258 articles were identified. Four trials of moderate to good quality comprising 181 patients (90 in the bisphosphonate group and 91 in the placebo group) were included in this meta-analysis. Short-term pain Visual Analog Scale was significantly lower in the bisphosphonate group versus the placebo group (SMD=-2.6, 95%CI [-1.8, -3.4], P<0.001), as well as the medium term Visual Analog Scale pain (SMD=-2.5, 95%CI [-1.4, -3.6], P<0.001). There were more adverse events in the bisphosphonate group (35.5%) than in the placebo group (16.4%) with a relative risk of 2.1 (95%CI [1.3, 3.5], P=0.004) and a number needed to harm of 4.6, (95%CI [2.4, 168.0]) but no serious side effects. CONCLUSIONS: Our results suggest that bisphosphonates reduce pain in patients with Complex Regional Pain Syndrome type 1. Other studies are needed to determine their effectiveness.

Balance, aging, and osteoporosis: effects of cognitive exercises combined with physiotherapy.

OBJECTIVE: To evaluate whether performing cognitive tasks while exercising influenced the effects of an exercise program designed to reduce the risk of falling in elderly women with osteoporosis. METHODS: We included 68 osteoporotic women older than 70 years of age (mean age, 73.5 years+/-1.6) who followed a program of 12 sessions of balance, coordination, and ambulation exercises designed to lessen the risk of falling. The patients were divided into two groups based on proximity to the study centers. The groups were randomly allocated to the exercise program alone (N=31, single-task group) or to the same program combined with cognitive tasks performed while exercising (N=37, dual-task group). Timed up-and-go tests and one-leg balance (OLB) tests were done at baseline, at the end of the exercise program, and 3 months after the end of the exercise program. RESULTS: In both groups, the exercise program produced significant improvements in up-and-go and OLB times. Additional improvements occurred over the first 3 months following the program. Adding cognitive exercises did not provide added efficacy. CONCLUSIONS: Balance was improved after the exercise sessions. The improvements were clinically significant and increased over time.

Pyogenic discitis revealing infrarenal aortic prosthetic graft infection impinging on the left ureter.

Coexistence of aortic lesions and discitis is uncommon but potentially fatal if the diagnosis is not made promptly. We report the case of a 71-year-old patient with an infected prosthetic graft of the abdominal aorta impinging on the left ureter and accompanied with lumbar discitis. This triad has not been reported previously. Other unusual features in this patient were the circumstances of onset and the development of the infection in a vascular prosthetic graft. The medical and surgical treatment is discussed.

Acute pseudoseptic arthritis after intraarticular sodium hyaluronan.

A 70-year-old woman with a history of knee osteoarthritis was admitted for acute arthritis 9 days after a second intraarticular injection of sodium hyaluronan (Ostenil). The joint fluid was purulent, with no crystals, and laboratory tests showed marked inflammation, leading to antibiotic treatment for suspected septic arthritis. Incapacitating symptoms persisted, prompting surgical lavage of the knee, which failed to relieve the severe pain. The persistent symptoms and negative results of joint fluid and blood cultures led to discontinuation of the antibiotic therapy after 10 days. Antiinflammatory therapy relieved the symptoms, and the patient was discharged home 1 month after her admission. Nevertheless, the pain persisted, requiring rehabilitation therapy of the knee. Aseptic arthritis induced by repeated sodium hyaluronan injection is the most likely diagnosis. Physicians should be aware of this extremely severe complication.

Extensive primary epidural abscess. Report of a case.

We report a case of Staphylococcus aureus epidural infection extending from the cervical to the lumbar spine. Findings from the first magnetic resonance imaging study were misleading. The symptoms resolved fully under medical treatment, with no recurrence after 1 year.

Agreement between rheumatologist visit and lay interviewer telephone survey for screening for rheumatoid arthritis and spondyloarthropathy.

OBJECTIVE: To evaluate agreement between a rheumatologist visit and a telephone interview by a patient organization member, regarding the diagnosis of rheumatoid arthritis (RA) or spondyloarthropathy (SpA) and the classification criteria for these two conditions. METHOD: Patients underwent a standardized interview and physical examination by hospital-based rheumatologists, who diagnosed RA in 230 cases, SpA in 175, and other conditions (controls) in 195. Members of patient organizations then used a standardized questionnaire to interview the patients by telephone about their diagnosis and about 1987 ACR classification criteria for RA and the ESSG criteria for SpA. RESULTS: Agreement between the two sources of data was poor for the classification criteria but satisfactory for the diagnosis (kappa, 0.84 (0.81-0.87) for RA and 0.78 (0.75-0.81) for SpA). CONCLUSION: Standardized telephone interviews conducted by patient organization members accurately identify the diagnosis made by rheumatologists based on a physical examination and medical record review, whereas agreement is poor regarding classification criteria for RA and SpA.

Efficacy of cardiorespiratory aerobic exercise in rheumatoid arthritis: meta-analysis of randomized controlled trials.

OBJECTIVE: Several lines of evidence have emphasized an improvement in aerobic capacity and muscle strength after physical exercise programs in rheumatoid arthritis (RA) patients. Our objective was to evaluate the efficacy of aerobic exercises in RA on quality of life, function, and clinical and radiologic outcomes by a systematic literature review and a meta-analysis. METHODS: A systematic literature search was performed in the Medline, EMBase, and Cochrane databases up to July 2009 and in the abstracts presented at rheumatology scientific meetings during the last 5 years. Randomized controlled trials (RCTs) comparing aerobic exercises with non-aerobic interventions in RA patients were included. Outcomes studied were postintervention quality of life, function assessed by the Health Assessment Questionnaire (HAQ), a pain visual analog scale (VAS), joint count, the Disease Activity Score in 28 joints (DAS28), and radiologic damage. Efficacy was assessed by standardized mean differences (SMDs; difference between groups of mean outcome variation from baseline/SD at baseline) of aerobic exercises versus non-aerobic rehabilitation. Heterogeneity was tested. SMDs were pooled by a meta-analysis using the inverse of variance model. RESULTS: Fourteen RCTs, including 1,040 patients, met the inclusion criteria. Exercise improved the postintervention quality of life (SMD 0.39, P < 0.0001), HAQ score (SMD 0.24, P = 0.0009), and pain VAS (SMD 0.31, P = 0.02). Exercise in this RA population appeared safe, since global compliance, DAS28, and joint count were similar in both groups. CONCLUSION: Cardiorespiratory aerobic conditioning in stable RA appears to be safe and improves some of the most important outcome measures. However, the degree of the effect of aerobic exercise on the abovementioned parameters is small.

Massage and mobilization of the feet and ankles in elderly adults: effect on clinical balance performance.

The aim of this study was to evaluate the effects of a session of plantar massage and joint mobilization of the feet and ankles on clinical balance performance in elderly people. A randomized, placebo-controlled, cross-over trial was used to examine the immediate effects of manual massage and mobilization of the feet and ankles. Twenty-eight subjects, aged from 65 to 95 years (78.8+/-8.5 years - mean+/-SD) were recruited from community nursing homes. Main outcome measures were the performances in three tests: One Leg Balance (OLB) test, Timed Up and Go (TUG) test and Lateral Reach (LR) test. Results demonstrated a significant improvement after massage and mobilization compared with placebo for the OLB test (1.1+/-1.7s versus 0.4+/-1.2s, p<0.01) and the TUG test (0.9+/-2.6s versus 0.2+/-1.2s, p<0.05). Conversely, performances in the LR test did not improve significantly. These results emphasise the positive impact of a single session of manual therapy applied to the feet and ankles on balance in elderly subjects.

Is dynamic exercise beneficial in patients with rheumatoid arthritis?

INTRODUCTION: Dynamic exercise therapy as defined by the American College of Sports Medicine for healthy individuals is of unclear relevance to patients with rheumatoid arthritis (RA). No recommendations on this issue are available. Few studies have evaluated the optimal program, frequency, or target population; furthermore, there is no consensus about the best assessment tools for monitoring clinical, functional, and structural parameters during dynamic exercise therapy in patients with RA. METHODS: We conducted an extensive review of the literature published between 1964 and 2005. We identified nine randomized controlled studies that provided a high level of proof regarding the effects of dynamic exercise therapy in RA patients older than 18 years of age. RESULTS: Dynamic exercise programs improve aerobic capacity and muscle strength in patients with RA. Their effects on functional capacity are unclear, and many sources of bias influenced the study results. The clinical and laboratory safety profiles were good. The structural impact of dynamic exercise remains to be determined.

Radiculopathy as a manifestation of Langerhans' cell histiocytosis.

Langerhans' cell histiocytosis (LCH) is a rare condition of children and young adults in which Langerhans' cells proliferate. The clinical spectrum ranges from solitary or few focal lesions to multisystem involvement mimicking vasculitis or hematological malignancy. Focal bone lesions, known as eosinophilic granulomas, are the most common manifestations. Eosinophilic granuloma usually presents with a variable combination of pain, swelling, fracture, and fever. Facial bone involvement may manifest as an ear discharge, hearing loss, or exophthalmos. Nerve root pain is rarely reported, even in patients with lesions in the axial skeleton. We report four cases of nerve root pain caused by LCH. Two male patients aged 25 and 34 years, respectively, presented with truncated femoral neuralgia related to acetabular granulomas. A 25-year-old woman with involvement of the L5 vertebral body and a 41-year-old man with a sacral lesion presented with sciatica.

Mirror versus stationary cross feedback in controlling the center of foot pressure displacement in quiet standing in elderly subjects.

OBJECTIVE: To investigate the effect of mirror feedback on postural control during quiet standing in elderly adults. DESIGN: Before and after intervention trials. SETTING: Pneumology center in France. PARTICIPANTS: Eleven elderly adults (mean age, 70.7+/-4.6 y; mean body weight, 64.5+/-15.0 kg; mean height, 161.4+/-12.0 cm). INTERVENTIONS: Participants were asked to stand upright, as immobile as possible, in 2 eyes-open and mirror-feedback conditions. The latter experimental condition consisted of supplying the subjects with their frontal reflection by positioning a mirror in front of them. MAIN OUTCOME MEASURES: Foot center of pressure (COP) displacements in the mediolateral (ML) and anteroposterior (AP) directions were recorded using a force platform. RESULTS: The mirror-feedback condition had different effects on postural sway, depending on the direction: range, variability, and maximal instantaneous speed of the COP displacements decreased in the ML direction, whereas these effects remained unchanged in the AP direction. CONCLUSIONS: This study provided evidence that mirror feedback may put elderly adults at lower risk of falling.