Cervico-cephalalgiaphobia: a subtype of phobia in patients with cervicogenic headache and neck pain? A pilot study.

OBJECTIVES: The term 'cephalalgiaphobia' was introduced in the mid-1980s and defined as fear of migraine (attacks). We hypothesized that a specific subtype of cephalalgiaphobia affects patients with cervicogenic headache (CEH). This study aimed to: (1) define the term 'cervico-cephalalgiaphobia'; (2) develop a set of indicators for phobia relevant to patients with CEH; and (3) apply this set to a practice test in order to estimate the frequency of cervico-cephalalgiaphobia in the Dutch primary care practice of manual physical therapy. METHODS: A systematic approach was used to develop a definition and potential indicators for cervico-cephalalgiaphobia. An expert group appraised the definition and the set of indicators (score per indicator: never; sometimes; often/always). An invitation to participate in the practice test was sent to Dutch manual physical therapy practices (n = 56) representing 134 manual physical therapists (MPTs). The cut-off point for percentages of scores for coverage of the indicators was set at ≥ 60%. RESULTS: The expert group agreed with the proposed definition of cervico-cephalalgiaphobia. A set of eight indicators for cervico-cephalalgiaphobia was selected from 10 initial indicators. Thirty-six MPTs provided data from 46 patients diagnosed with CEH. The coverage of 'often/always' was substantial for the indicators, 'Short-term positive results in previous manual physical therapeutic treatment', 'Shorter interval between treatment sessions', 'Fear of "locked facet joints" of the neck', 'More frequent manipulation', and 'Fear of increase in headaches'. Coverage was also substantial for 'never' regarding 'Long-term positive results in previous manual physical therapeutic treatment'. 'Confirmation of "locked facet joints" of the cervical spine by MPT as a cause for increase of CEH' scored 'often/always' in all patients. Coverage for 'Increased use of medication with insufficient effect' was substantial, scoring as 'sometimes' in 39 (84.8%) patients. DISCUSSION: Cervico-cephalalgiaphobia was defined and a set of eight indicators formulated based on the literature and clinical expertise. The practice test provides valuable information on the frequency of indicators for cervico-cephalalgiaphobia in the Dutch manual physical therapy practice, suggesting that cervico-cephalalgiaphobia is common in patients with CEH.

Manual physical therapists' use of biopsychosocial history taking in the management of patients with back or neck pain in clinical practice.

OBJECTIVE: To develop and evaluate process indicators relevant to biopsychosocial history taking in patients with chronic back and neck pain. METHODS: The SCEBS method, covering the Somatic, Psychological (Cognition, Emotion, and Behavior), and Social dimensions of chronic pain, was used to evaluate biopsychosocial history taking by manual physical therapists (MPTs). In Phase I, process indicators were developed while in Phase II indicators were tested in practice. RESULTS: Literature-based recommendations were transformed into 51 process indicators. Twenty MTPs contributed 108 patient audio recordings. History taking was excellent (98.3%) for the Somatic dimension, very inadequate for Cognition (43.1%) and Behavior (38.3%), weak (27.8%) for Emotion, and low (18.2%) for the Social dimension. MTPs estimated their coverage of the Somatic dimension as excellent (100%), as adequate for Cognition, Emotion, and Behavior (60.1%), and as very inadequate for the Social dimension (39.8%). CONCLUSION: MTPs perform screening for musculoskeletal pain mainly through the use of somatic dimension of (chronic) pain. Psychological and social dimensions of chronic pain were inadequately covered by MPTs. Furthermore, a substantial discrepancy between actual and self-estimated use of biopsychosocial history taking was noted. We strongly recommend full implementation of the SCEBS method in educational programs in manual physical therapy.

Preliminary results, methodological considerations and recruitment difficulties of a randomised clinical trial comparing two treatment regimens for patients with headache and neck pain.

BACKGROUND: Headache is a highly prevalent disorder. Irrespective of the headache diagnosis it is often accompanied with neck pain and -stiffness. Due to this common combination of headache and neck pain, physical treatments of the cervical spine are often considered. The additional value of these treatments to standard medical care or usual care (UC) is insufficiently documented.We therefore wanted to compare the treatment effects of UC alone and in combination with manual therapy (MT) in patients with a combination of headache and neck pain. UC consisted of a stepped treatment approach according to the Dutch General Practitioners Guideline for headache, the additional MT consisted of articular mobilisations and low load exercises.Due to insufficient enrolment the study was terminated prematurely. We aim to report not only our preliminary clinical findings but also to discuss the encountered difficulties and to formulate recommendations for future research. METHODS: A randomised clinical trial was conducted. Thirty-seven patients were included and randomly allocated to one of both treatment groups. The treatment period was 6 weeks, with follow-up measurements at weeks 7, 12 and 26. Primary outcome measures were global perceived effect (GPE) and the impact of the headache using the Headache Impact Test (HIT-6). Reduction in headache frequency, pain intensity, medication intake, absenteeism and the use of additional professional help were secondary outcome measures RESULTS: Significant improvements on primary and secondary outcome measures were recorded in both treatment groups. No significant differences between both treatment groups were found. The number of recruited patients remained low despite various strategies. CONCLUSION: It appears that both treatment strategies can have equivalent positive influences on headache complaints. Additional studies with larger study populations are needed to draw firm conclusions. Recommendations to increase patient inflow in primary care trials, such as the use of an extended network of participating physicians and of clinical alert software applications, are discussed. TRIAL REGISTRATION NUMBER: NCT00298142.

The dynamic postural control is impaired in patients with chronic ankle instability: reliability and validity of the multiple hop test.

OBJECTIVE: To investigate the reliability and validity of a clinical evaluation method for the assessment of the dynamic postural control in patients with chronic ankle instability (CAI). DESIGN: Cross-sectional study. SETTING: All tests were conducted at the practice room of the Physical Therapy Department. PARTICIPANTS: Twenty-nine healthy subjects and 29 patients with CAI were selected. INTERVENTIONS: Participants performed twice a multiple hop test within a 1-week time interval. Subjects hopped on 10 different tape markers while trying to avoid any postural correction. MAIN OUTCOME MEASURES: The number and type of balance errors were documented by analyzing the digital video images. RESULTS: Test-retest reliability of the number of balance errors was excellent in patients (intraclass correlation coefficient, ICC = 0.83; standard errors of measurement = 2.6) and moderate in healthy subjects (ICC = 0.64; standard errors of measurement = 2.8). The intra-observer and inter-observer reliability was excellent (ICC > 0.90). Both for the test (P = 0.000) and for the retest (P = 0.000), the number of balance errors in patients was significantly higher (17.9 +/- 6.6) when compared with healthy subjects (10.9 +/- 4.6). On both test occasions, patients with CAI used significantly more a change-in-support strategy (test: P = 0.000; retest: P = 0.000). The number of balance errors was significantly correlated with the time needed to perform the test (r = 0.60; P = 0.000) and the perceived difficulty of the hop test as rated on a visual analogue scale (r = 0.44; P = 0.014). CONCLUSIONS: The multiple hop test is a reliable and valid test for detecting an impaired dynamic postural control in patients with CAI.

Changes of skin characteristics during and after local Parafango therapy as used in physiotherapy.

BACKGROUND/AIMS: In physiotherapy, fango (mud) application is a frequently used heat therapy. The main therapeutic effects are due to the elevated temperature of the different tissues with a significant redistribution of blood towards the heated area. This may influence several cardiovascular parameters. There is only limited information on the effect of fango application on skin characteristics. It was the aim of the present study to evaluate the effects of fango application on skin temperature, perfusion of the microcirculation and skin colour. At the same time, cardiovascular parameters such as heart rate, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded. METHOD: Eighteen healthy subjects (age 23.7+/-3.8 years) entered the study. The skin characteristics and cardiovascular parameters were measured before, during and after a 21-min fango application at 44.5 degrees C. RESULTS: Skin temperature and perfusion of the microcirculation increased significantly during fango application: from 35.5+/-0.4 degrees C to 44.3+/-1.2 degrees C for skin temperature and from 23.2+/-8.8 to 197+/-41 p.u. for the skin microcirculation. These two parameters remained elevated during the fango application and decreased slowly to baseline values within 21 min after fango removal. Skin colour (CIELAB, a(*) parameter) increased from 11.0+/-2.5 to 17.9+/-1.9 when comparing pre- with post-treatment values. At the end of the measuring period, the a(*) parameter did not return to baseline values (15.8+/-2.1). Heart rate increased with 8 bpm during the fango therapy and returned to baseline within 3 min after removal of the fango. SBP and DBP varied slightly during the fango application. They returned to baseline values within 21 min after fango removal. CONCLUSION: The skin parameters indicate a transient temperature effect with an increased perfusion of the microcirculation and a flooding of the superficial capacitance system. The cardiovascular parameters were only slightly influenced and remained in the physiological range. Fango application seems not to be too demanding for the cardiovascular system in healthy subjects.

Endogenous sex hormone levels in postmenopausal women undergoing carotid artery endarterectomy.

OBJECTIVE: To study the endogenous sex hormone levels in natural postmenopausal women and their association with the presence of internal carotid artery (ICA) atherosclerosis. DESIGN: Case-control study METHODS: We compared 56 patients with severe ICA atherosclerosis referred for carotid artery endarterectomy (CEA) with 56 age-matched control subjects free of severe atherosclerotic disease. The presence of atherosclerosis was determined by high-resolution B-mode ultrasound. Metabolic parameters and sex hormones were measured or calculated: total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, glucose, insulin, quantitative insulin sensitivity check index, insulin resistance index, IGF-I, DHEA, DHEA sulfate (DHEA-S), free testosterone, total testosterone, estrone, estradiol, androstenedione, and sex hormone-binding globulin. RESULTS: The cases had statistically significant lower levels of both total testosterone (0.23 +/- 0.12 vs 0.31 +/- 0.20 microg/l, P = 0.043) and free testosterone (3.42 +/- 1.94 vs 4.59 +/- 2.97 ng/l, P = 0.009) and significantly lower levels of androstenedione (625.3 +/- 168.7 vs 697.0 +/- 211.9 ng/l, P = 0.017) when compared with controls. Multivariate linear regression analysis, adjusted for traditional cardiovascular risk factors, baseline and physiologic characteristics, showed a significant inverse relationship between both serum free testosterone (beta = -0.234, P = 0.028) and androstenedione (beta = -0.241, P = 0.028) levels with the presence of severe atherosclerosis of ICA. CONCLUSIONS: The study provides evidence of a positive association between low serum androgen levels and severe ICA atherosclerosis in postmenopausal women. It suggests that higher, but physiological, levels of androgens in postmenopausal women have a protective role in the development of atherosclerosis of ICA.

Muscular strength, aerobic fitness, and metabolic syndrome risk in Flemish adults.

PURPOSE: To investigate the association of muscular strength and aerobic fitness with a continuous metabolic syndrome risk score in male and female adults. METHODS: This cross-sectional study included 1019 (571 men) Flemish adults, aged 18-75. Muscular strength was evaluated by measuring isometric knee extension and flexion peak torque, using a Biodex System Pro 3 dynamometer. Aerobic fitness was quantified as VO2peak and was determined during a maximal cycle ergometer exercise test. Both strength and aerobic fitness were scaled for differences in FFM, using allometric analyses. A validated metabolic syndrome risk score that was based on waist circumference, triglycerides, blood pressure, fasting plasma glucose, and HDL cholesterol was used. Metabolic syndrome risk score, strength, and aerobic fitness were analyzed as continuous variables using multiple linear regression. RESULTS: Metabolic syndrome risk was inversely associated with strength, independently of aerobic fitness, and after adjustment for age, height, education level, smoking status, and dietary intake in women (beta = -0.172, P < 0.001). In men, however, adjustment for aerobic fitness attenuated the inverse association between strength and metabolic syndrome risk (beta = -0.044, P > 0.05). Independently of strength, aerobic fitness was inversely associated with metabolic syndrome risk (men: beta = -0.309, P < 0.001; women: beta = -0.208, P < 0.001). Furthermore, independent associations were found for strength and aerobic fitness with several individual metabolic syndrome risk factors in women, and most of these associations were only partially mediated by central and general adiposity indicators. CONCLUSION: Although cross-sectional, the present results support inclusion of strength training in addition to aerobic exercise in physical activity recommendations for women, because both types of activity might show additional effects in reducing the risk of the metabolic syndrome.

Measuring activity patterns using actigraphy in multiple sclerosis.

Multiple sclerosis (MS) is a demyelinating disease resulting in impairments in motor and mental performance and restrictions in activities. Self-report instruments are commonly used to measure activity patterns; alternatively, actigraphs can be placed on several parts of the body. The aims of this study were to evaluate the superiority and specificity of actigraph placement (wrist vs. ankle) in subjects with MS and healthy controls and explore the relationship between self-report and objective activity patterns. A total of 19 subjects with definite MS and 10 healthy volunteers wore actigraphs on the non-dominant wrist and ankle for three days while they kept a log to register performed activities every .5 h. Wrist and ankle actigraphs produced similar activity patterns during the most active hours (09:00-20:30 h) (ANOVA, timexlocation interaction: F=.901, df=23, p=.597) in individuals with MS and healthy controls (between subjects factor F=3.275, p=.083). Wrist placement of the actigraphs was better tolerated than ankle placement. Wrist actigraph data corresponded to a higher degree with self-reported activities of the upper limbs in the early afternoon, whereas ankle data seem to reflect better whole body movements in the later afternoon/early evening. Overall, actigraph data correlated moderately with self-reported activity (r=.57 for ankle and r=.59 for wrist). The regression model revealed that self-reported activities explained 44% of the variance in ankle and 50% of wrist data. Wrist and ankle actigraphs produce similar activity patterns in subjects with MS and in healthy controls; however, the placement of actigraphs on the wrist is better tolerated. Ankle actigraphs reflect general movement but underestimate upper body activity. Subjective registration of activity level partly matches with objective actigraph measurement. A combination of both objective and subjective activity registration is recommended to evaluate the physical activity pattern of subjects with MS.

Dietary factors associated with obesity indicators and level of sports participation in Flemish adults: a cross-sectional study.

BACKGROUND: Obesity develops when energy intake continuously exceeds energy expenditure, causing a fundamental chronic energy imbalance. Societal and behavioural changes over the last decades are held responsible for the considerable increase in sedentary lifestyles and inappropriate dietary patterns. The role of dietary fat and other dietary factors in the aetiology and maintenance of excess weight is controversial. The purposes of the present study were to investigate the dietary factors associated with body mass index (BMI) and waist circumference (WC), and to analyse whether dietary intake varies between subjects with different levels of sports participation. METHODS: Data for this cross-sectional study, including anthropometric measurements, 3-day diet diary and physical activity questionnaire, were collected by the Flemish Policy Research Centre Sport, Physical Activity and Health (SPAH) between October 2002 and April 2004. Results of 485 adult men and 362 women with plausible dietary records were analysed. Analyses of covariance were performed to determine the differences in dietary intake between normal weight, overweight and obese subjects, and between subjects with different levels of sports participation. RESULTS: Total energy intake, protein and fat intake (kcal/day) were significantly higher in obese subjects compared to their lean counterparts in both genders. Percentage of energy intake from fat was significantly higher in obese men compared to men with normal weight or WC. Energy percentages from carbohydrates and fibres were negatively related to BMI and WC in men, whereas in women a higher carbohydrate and fibre intake was positively associated with obesity. Alcohol intake was positively associated with WC in men. Subjects participating in health related sports reported higher intake of carbohydrates, but lower intake of fat compared to subjects not participating in sports. CONCLUSION: This study supports the evidence that carbohydrate, fat, protein and fibre intake are closely related to BMI and WC. The sex differences for dietary intake between obese men and women might reflect the generally higher health consciousness of women. Alcohol intake was only associated with WC, emphasizing the importance of WC as an additional indicator in epidemiological studies. Besides enhancing sports and physical activity, it is necessary to improve the knowledge about nutrition and to promote the well-balanced consumption of wholesome food.

Socio-economic and lifestyle factors associated with overweight in Flemish adult men and women.

BACKGROUND: Changes in lifestyles and in the environment over the last decades are probably the most important cause of the overweight epidemic, but the findings are inconsistent among studies. The purpose of this study was to investigate the association of several socio-economic and lifestyle factors with overweight in Flemish adults, using BMI > or = 25 kg/m2, waist circumference (WC) > or = 94 cm (men) or > or = 80 cm (women) and the combination of BMI and WC for identifying overweight. METHODS: This cross-sectional epidemiological study was conducted by the Flemish Policy Research Centre Sport, Physical Activity and Health between October 2002 and February 2004 in 46 Flemish communities. A total of 4903 Flemish adults (2595 men and 2308 women), aged 18 to 75 years, from a population-based random sample were included in the analysis. Body weight, height and WC were measured, and socio-economic and lifestyle factors were reported by means of validated questionnaires. RESULTS: The results of the logistic regressions revealed that age is positively associated with overweight in both genders. Alcohol consumption is associated with overweight only in men. Men smoking in the past and watching TV >11 h/week have significantly higher OR's for overweight, while men who participate in health related sports >4 h/week have significantly lower OR's for overweight. In women, watching TV >9 h/week was positively associated with overweight. Women who are current smokers or participate in health related sports >2.5 h/week or with a higher educational level have significantly lower odds for overweight. Different results are observed between the first (BMI) and the second model (WC) in both genders. In men, the models differ for education and health related sports, while in women they differ for smoking status and leisure time physical activity. CONCLUSION: The present study confirms the contention that overweight is a multifactorial problem. Age and TV viewing are positively associated with overweight, while educational level and health related sports are negatively related to overweight in both genders. In men, alcohol consumption and smoking in the past are also among the lifestyle factors associated with overweight. This study also indicates that BMI and WC do not have the same discriminative function regarding different lifestyle factors.

The clinimetric qualities of patient-assessed instruments for measuring chronic ankle instability: a systematic review.

BACKGROUND: The assessment of outcomes from the patient's perspective becomes more recognized in health care. Also in patients with chronic ankle instability, the degree of present impairments, disabilities and participation problems should be documented from the perspective of the patient. The decision about which patient-assessed instrument is most appropriate for clinical practice should be based upon systematic reviews. Only rating scales constructed for patients with acute ligament injuries were systematically reviewed in the past. The aim of this study was to review systematically the clinimetric qualities of patient-assessed instruments designed for patients with chronic ankle instability. METHODS: A computerized literature search of Medline, Embase, Cinahl, Web of Science, Sport Discus and the Cochrane Controlled Trial Register was performed to identify eligible instruments. Two reviewers independently evaluated the clinimetric qualities of the selected instruments using a criteria list. The inter-observer reliability of both the selection procedure and the clinimetric evaluation was calculated using modified kappa coefficients. RESULTS: The inter-observer reliability of the selection procedure was excellent (k = .86). Four instruments met the eligibility criteria: the Ankle Joint Functional Assessment Tool (AJFAT), the Functional Ankle Outcome Score (FAOS), the Foot and Ankle Disability Index (FADI) and the Functional Ankle Ability Measure (FAAM). The inter-observer reliability of the quality assessment was substantial to excellent (k between .64 and .88). Test-retest reliability was demonstrated for the FAOS, the FADI and the FAAM but not for the AJFAT. The FAOS and the FAAM met the criteria for content validity and construct validity. For none of the studied instruments, the internal consistency was sufficiently demonstrated. The presence of floor- and ceiling effects was assessed for the FAOS but ceiling effects were present for all subscales. Responsiveness was demonstrated for the AJFAT, FADI and the FAAM. Only for the FAAM, a minimal clinical important difference (MCID) was presented. CONCLUSION: The FADI and the FAAM can be considered as the most appropriate, patient-assessed tools to quantify functional disabilities in patients with chronic ankle instability. The clinimetric qualities of the FAAM need to be further demonstrated in a specific population of patients with chronic ankle instability.

Reproducibility of postural control measurement during unstable sitting in low back pain patients.

BACKGROUND: Postural control tests like standing and sitting stabilometry are widely used to evaluate neuromuscular control related to trunk balance in low back pain patients. Chronic low back pain patients have lesser postural control compared to healthy subjects. Few studies have assessed the reproducibility of the centre of pressure deviations and to our knowledge no studies have investigated the reproducibility of three-dimensional kinematics of postural control tests in a low back pain population. Therefore the aim of this study was to assess the test-retest reproducibility of a seated postural control test in low back pain patients. METHODS: Postural control in low back pain patients was registered by a three dimensional motion analysis system combined with a force plate. Sixteen chronic low back pain patients having complaints for at least six months, were included based on specific clinical criteria. Every subject performed 4 postural control tests. Every test was repeated 4 times and lasted 40 seconds. The force plate registered the deviations of the centre of pressure. A Vicon-612-datastation, equipped with 7 infra-red M1 camera's, was used to track 13 markers attached to the torso and pelvis in order to estimate their angular displacement in the 3 cardinal planes. RESULTS: All Intraclass Correlation Coefficients (ICC) calculated for the force plate variables did not exceed 0.73 (ranging between 0.11 and 0.73). As for the torso, ICC's of the mean flexion-extension and rotation angles ranged from 0.65 to 0.93 and of the mean lateral flexion angle from 0.50 to 0.67. For the pelvis the ICC of the mean flexion-extension angle varied between 0.66 and 0.83, the mean lateral flexion angle between 0.16 and 0.81 and the mean rotation angle between 0.40 and 0.62. Consecutive data suggest that the low test-retest reproducibility is probably due to a learning effect. CONCLUSION: The test-retest reproducibility of these postural control tests in an unstable sitting position can globally be considered as rather moderate. In order to improve the test-retest reproducibility, a learning period may be advisable at the beginning of the test.

Management of headache disorders: design of a randomised clinical trial screening for prognostic patient characteristics.

BACKGROUND: Treatment of headache disorders is not always optimal. Patients are treated in multiple ways, and the lack of scientific arguments for referral and the insufficient implementation of guidelines result in unclear treatment strategies. The coexistence of headache and neck pain can lead to the referral to a musculoskeletal physiotherapist. This treatment can only be successful if an underlying cervical segmental dysfunction is present. In such cases a physical treatment can be a valuable option that should be considered. The aim of this study is to identify prognostic therapeutic patient characteristics and to increase the number of correct physiotherapy referrals. METHODS/DESIGN: This trial is designed to identify patient characteristics which can influence the prognosis of the patient. Patients with recurrent headache and co-existent neck pain are recruited via a multicenter setup. After screening for eligibility, subjects are tested at baseline and randomly allocated to one of two treatment groups. Testing includes the administering of questionnaires (a Headache Diagnosis Questionnaire, Headache Inventory List and the Headache Impact Test (HIT-6)) and physical tests (Thermal Stimuli, Manual Cervical Spine Examination and Pressure Algometry). Treatment groups are a usual care group (UC) administered by the General Practitioner (GP) and a usual care plus musculoskeletal physiotherapy treatment group (UCMT). UC is based on the Dutch GP Guideline for Headache. UCMT consists of the UC plus a combination of exercises and spinal cervical mobilisations. Follow-up measurements consist of the completion of the Headache Inventory List, the HIT-6 and scoring of the global perceived effect (GPE). The latter allowing the distinction between responders (positive effect) and non-responders (no effect or worse). Logistic regression analysis will be used to identify the specific patient characteristics of the responders and the non-responders. The additional value of the musculoskeletal physiotherapy will be examined. Follow-up measurements up to 52 weeks are scheduled. DISCUSSION: This trial aims to identify prognostic patient characteristics, in order to supply a useful diagnostic tool for all health care workers, dealing with headache sufferers.

The benefit of fibrates in the treatment of 'bad HDL-C responders to statins'.

BACKGROUND: Lowering high levels of low-density lipoprotein cholesterol (LDL-C) is the primary aim in the prevention of cardiac events. However, low levels of high-density lipoprotein cholesterol (HDL-C) are also associated with an increased risk of ischemic heart disease. Some patients have lower HDL-C during statin treatment than before the treatment. These patients were first described in 2002 as 'bad HDL-C responders to statins'. The aim of this study was to describe the benefit of fibrates in monotherapy for these patients. METHODS: A cross-sectional survey of lipid levels, cardiovascular disease and risk factors in outpatients treated for dyslipidemia. For this study we analyzed the lipid levels, drug treatment and medical history for 14 patients with low HDL-C (<40 mg/dl) during statin treatment and ever treated with fibrates. RESULTS: Total cholesterol (TC) and LDL-C were respectively 8% and 6% higher with fibrates compared to statins. Mean HDL-C was 49% higher during fibrate treatment and TC to HDL-C and LDL-C to HDL-C were respectively 26% and 27% lower with fibrates. CONCLUSIONS: Patients with low levels of HDL-C during statin treatment had far better levels for HDL-C, TC to HDL-C and LDL-C to HDL-C with fibrates in monotherapy. For bad HDL-C responders to statins with low or normal LDL-C treatment with fibrates instead of statins should be considered. For those with high LDL-C fibrates should be added to statins. A randomized double-blind crossover trial with simvastatin and fenofibrate has been initiated to corroborate these findings.

Soluble HLA-DR levels in serum are associated with therapy and genetic factors in rheumatoid arthritis.

As rheumatoid arthritis (RA) is an HLA-DR associated autoimmune disease and soluble HLA-DR (sHLA-DR) molecules have the capacity to regulate the immune response, we studied the sHLA-DR levels in RA patients in view of therapy modalities and clinical and biologic parameters of disease activity. For this sHLA-DR concentrations from 87 RA patients were determined by a sensitive enzyme-linked immunoabsorbent assay (ELISA) format. There was a weak but significant correlation between sHLA-DR levels and disease activity (r 0.186 to 0.287, p < 0.004 to < 0.001). The mean serum sHLA were not significantly different between groups with or without corticosteroids, or undergoing therapy with different disease modifying antirheumatic drugs. However, patients treated with a combination of methotrexate and prednisolone have lower sHLA-DR (206 +/- 21 ng/ml, n = 34) compared with the mean value for all other samples (306 +/- 16, n = 217, p < 0.001). This corresponded with significantly lower EULAR pain and swelling scores, ESR and rheumatoid factor (RF) by latex fixation (p < 0.02 to 0.001) in the former, compared with the latter group. Furthermore, sHLA-DR was, respectively, 267 +/- 15 ng/ml (n = 182) in samples from patients treated with nonsteroidal anti-inflammatory drugs (NSAIDs), and 358 +/- 31 (n = 72) without NSAIDs (p < 0.01). Lower sHLA-DR with NSAIDs contrasted with significantly higher scores for pain, swelling, CRP, and RF by latex fixation and by Waaler-Rose test (p < 0.05 to 0.001). Comparison of subgroups with or without the shared epitope of RA disease (Q)R/KRAA within the HLA-DR beta1-chain confirmed significantly higher parameters of disease activity and sHLA-DR in the presence of this disease associated epitope in our patients. Different mechanisms appear to be involved in sHLA-DR production or release, as their level correlates positively with disease activity under combined therapy with corticosteroids and methotrexate, but decreases with higher disease activity in patients treated with NSAIDs.

Stability of somatotypes: A longitudinal study of Belgian children age 6 to 17 years.

The purpose of this study was to investigate the stability of somatotypes in Belgian children and adolescents, 52 boys and 30 girls, followed longitudinally from 6 to 17 years of age. The anthropometric Heath-Carter somatotypes, with a stature correction for endomorphy, were estimated at 1-year intervals. Mean somatotypes were most different between the earliest and oldest ages in both boys and girls. For boys, the means from 9 to 13 years and from 14 to 17 years did not differ. Means were 2-4-2½, 2½-4-4, and 2-4-4 at 6, 12, and 17 years, respectively. The scatter of somatotypes about their means was smallest at 6-8 years and greatest at 11-13 years in both boys and girls (P <0.05). For girls, the mean somatotypes from 8 or 9 years through adolescence were not different, although they tended to become more meso-endomorphic. Means were 2-4½-2½, 3-4-3½, and 3½-3½-3 at 6, 12, and 17 years, respectively. The average migratory distance for boys was 6.4 (range = 3.7-12.9) and 7.8 (3.9-21.8) for girls. Many subjects had changes that were three to four times greater than others. Boys were lower in ectomorphy at 6-8 years than at older ages, while girls were higher in mesomorphy at 6 than at 12-17 years (P <.05). Interage partial correlations for each component were highest (r2 ⩾ .49) between adjacent years, but were poor to moderate as time intervals increased. The findings of this longitudinal study confirm and further define the instability of somatotypes previously observed in cross-sectional studies of Belgian children and adolescents. © 1995 Wiley-Liss, Inc.

Chronic fatigue syndrome: lack of association between pain-related fear of movement and exercise capacity and disability.

BACKGROUND AND PURPOSE: Patients who experience pain, a symptom of chronic fatigue syndrome (CFS), often exhibit kinesiophobia (irrational fear of movement). The purpose of this study was to examine whether pain-related fear of movement is associated with exercise capacity, activity limitations, or participation restrictions in patients with CFS who experience widespread pain. SUBJECTS AND METHODS: Sixty-four subjects met the inclusion criteria. All subjects fulfilled the 1994 Centers for Disease Control and Prevention case definition for CFS and experienced widespread myalgias or arthralgias. The subjects completed the Tampa Scale for Kinesiophobia-Dutch Version (TSK-DV) and the Dutch Chronic Fatigue Syndrome-Activities and Participation Questionnaire (CFS-APQ). They then performed a maximal exercise test on a bicycle ergometer. Heart rate was monitored continuously by use of an electrocardiograph. Ventilatory factors were measured through spirometry. Correlations between the TSK-DV scores and both the exercise capacity data and the CFS-APQ scores were assessed using the Spearman rank correlation coefficient. Using the Mann-Whitney U test, the TSK-DV scores were compared between subjects who performed a maximal exercise stress test and those who did not perform the test. RESULTS: Forty-seven subjects (73.4%) attained a total score of greater than 37 on the TSK-DV, indicating high fear of movement. Neither the exercise capacity data nor the CFS-APQ scores indicated a correlation with the TSK-DV scores (n=64). Subjects who did not perform a maximal exercise capacity test had more fear of movement (median TSK-DV score=43.0, interquartile range=10.3) compared with those who did perform a maximal exercise capacity test (median TSK-DV score=38.0, interquartile range=13.2; Mann-Whitney U-test score=322.5, z=-1.974, P=.048), but the correlation analysis was unable to reveal an association between exercise capacity and kinesiophobia in either subgroup. DISCUSSION AND CONCLUSION: These results indicate a lack of correlation between kinesiophobia and exercise capacity, activity limitations, or participation restrictions, at least in patients with CFS who are experiencing widespread muscle or joint pain.

Assessing fatigue in multiple sclerosis: Dutch modified fatigue impact scale.

The aim of this study is to evaluate the reliability, validity and responsiveness of the Dutch version of the Modified Fatigue Impact Scale. Fifty-one randomly selected subjects with definite multiple sclerosis (MS) (mean age 51.9 +/- 10.5 years, 25 women) and 20 healthy controls (mean age 50.6 +/- 14.0 years, 13 women) filled in the Modified Fatigue Impact Scale (MFIS), the Fatigue Severity Scale (FSS) and the fatigue subscale of Guy's Neurological Disability Scale (GNDS). All tests were repeated with an interval of maximum three days. The hospitalised individuals with MS (n = 20) were assessed at intake and discharge. No significant difference was found between first and second administration of MFIS (z = -.519, p = .603, Wilcoxon signed ranks test), with a good correlation (.729). MFIS was able to distinguish individuals with MS from controls, and subjects with fatigue from the non-fatigued group. MFIS showed no floor or ceiling effect. MFIS correlated moderately with Fatigue Severity Scale (.447) and the fatigue subscale of GNDS (.487). The 20 hospitalised subjects had significant lower MFIS scores (z = -3.401, p = .001) after a four-week rehabilitation programme, whereas the FSS did not change. This study indicates that the Dutch version of the MFIS is a reliable, valid and responsive tool to assess the impact of MS-related fatigue on daily life.

Serum lipid comparison in patients treated by statins or fibrates: existence of bad HDL-C responders to statins.

INTRODUCTION: Major cardiac events are strongly associated with high levels of low-density lipoprotein cholesterol (LDL-C) and low levels of high-density lipoprotein cholesterol (HDL-C). The HDL-C target level (40 mg/dl) is often not achieved with statins. The aim of this study was to compare the proportions of patients achieving the HDL-C target levels after one year of treatment with statins or fibrates. Furthermore, a subgroup with low HDL-C levels during statin treatment was investigated and suggestions are made for a better management of these patients. METHODS: A survey of lipid levels, cardiovascular disease and risk factors in 120 outpatients treated with a statin or a fibrate for hyperlipidaemia (total cholesterol (TC) > 250 mg/dl or triglycerides (TG) > 200 mg/dl after diet). After one year of treatment the proportions of patients achieving the target levels for TC, LDL-C, HDL-C,TG,TC/HDL-C and LDL-C/HDL-C are compared for statins and fibrates. RESULTS: The proportions of patients achieving the target lipid levels with statins or fibrates are comparable except for HDL-C. Compared to the baseline, the proportion of patients achieving the HDL-C target level of 40 mg/dl increases only by 8.3% for statins and by 42.9% for fibrates. In total, 38.5% of the statin group had low HDL-C-levels after one year of treatment. Among these patients, eight were treated with a fibrate before the statin and six were treated with a fibrate afterwards. In those 14 patients, mean HDL-C increased during fibrate treatment by 48.5% and TC/HDL-C and LDL-C/HDL-C decreased by 25.7 and 26.5%, respectively as compared with statins. CONCLUSIONS: Patients with low levels of HDL-C during statin treatment had far better levels of HDL-C, TC/HDL-C and LDL-C/HDL-C with fibrates. A randomised double-blind crossover trial with simvastatin and fenofibrate has been initiated to corroborate these findings.

Socioeconomic aspects of total hip arthroplasty. A one-year survey in a Belgian university hospital.

We prospectively analysed hospital stay, discharge policy, hospital cost and postoperative recovery of 102 consecutive total hip arthroplasties performed in a Belgian university hospital during a one-year period starting in October 2001. Of the independent patients, 87.4% regained independence after 6 weeks and 19.6% used rehabilitation units. Preoperative residence, hip function and mental scores were the best predictors for postoperative independence. Average hospital stay was 14.4 days and hospital cost 9,500 Euros. Hospitalisation represented over 50% of hospital cost and hip implants between 16.1 and 25.6% depending on prosthesis type. Complications and discharge to a rehabilitation unit increased hospital stay and cost. Six months after surgery, functional hip scores as well as WOMAC, mental and physical SF-12 scores improved significantly. Surgical techniques and faster rehabilitation programs, reducing needs for rehabilitation units and allowing earlier return to independence, are probably the best ways to control the cost of total hip arthroplasty in Belgium.