Effectiveness, safety, and cost-utility of a knee brace in medial knee osteoarthritis: the ERGONOMIE randomized controlled trial.

OBJECTIVE: This pragmatic, multicenter, open-label, randomized controlled trial (RCT) aimed to compare the effectiveness, safety, and cost-utility of a custom-made knee brace versus usual care over 1 year in medial knee osteoarthritis (OA). DESIGN: 120 patients with medial knee OA (VAS pain at rest >40/100), classified as Kellgren-Lawrence grade II-IV, were randomized into two groups: ODRA plus usual care (ODRA group) and usual care alone (UCA group). The primary effectiveness outcome was the change in VAS pain between M0 and M12. Secondary outcomes included changes over 1 year in KOOS (function) and OAKHQOL (quality of life) scores. Drug consumption, compliance, safety of the knee brace, and cost-utility over 1 year were also assessed. RESULTS: The ODRA group was associated with a higher improvement in: VAS pain (adjusted mean difference of -11.8; 95% CI: -21.1 to -2.5); all KOOS subscales (pain: +8.8; 95% CI: 1.4-16.2); other symptoms (+10.4; 95% CI: 2.7-18); function in activities of daily living (+9.2; 95% CI: 1.1-17.2); function in sports and leisure (+12.3; 95% CI: 4.3-20.3); quality of life (+9.9; 95% CI: 0.9-15.9), OAKHQOL subscales (pain: +14.8; 95% CI: 5.0-24.6); and physical activities (+8.2; 95% CI: 0.6-15.8), and with a significant decrease in analgesics consumption at M12 compared with the UCA group. Despite localized side-effects, observance was good at M12 (median: 5.3 h/day). The ODRA group had a more than 85% chance of being cost-effective for a willingness-to-pay threshold of €45 000 per QALY. CONCLUSIONS: The ERGONOMIE RCT demonstrated significant clinical benefits of an unloader custom-made knee brace in terms of improvements in pain, function, and some aspects of quality of life over 1 year in medial knee OA, as well as its potential cost-utility from a societal perspective.

Vitamin D supplementation, bone turnover, and inflammation in HIV-infected patients.

OBJECTIVE: To assess whether vitamin D supplementation could be associated with a modification of inflammatory markers and bone turnover in HIV-1-infected patients. PATIENTS AND METHODS: Patients who participated in an initial survey in 2010 and who were followed in the same department were included in a new study in 2012. Between 2010 and 2012, vitamin D supplementation was offered to patients presenting with hypovitaminosis D as per appropriate guidelines. Clinical examinations were performed, and fasting blood samples were taken for inflammation and bone marker evaluations. RESULTS: Of the 263 patients who participated in the 2010 study, 198 were included in the 2012 study. Hypovitaminosis D was observed in 47% (36/77) of participants supplemented as per appropriate guidelines, in 78% (75/97) of transiently or incompletely supplemented participants, and in 71% (17/24) of non-supplemented participants (mainly because vitamin D levels in 2010 were normal). No significant correlation between vitamin D supplementation and the 2-year inflammation outcome (IL-6 and hsCRP) or C-terminal telopeptide levels was observed. However, a decrease in IL6 levels over the 2 years significantly correlated with reaching a normal vitamin D level (OR=0.89 per+1pg/mL IL6 increase, 95% CI=0.81-0.97, P=0.015). CONCLUSIONS: Vitamin D supplementation decreases the risk of hypovitaminosis D but does not decrease the risk of inflammation nor bone turnover, unless normal 25-OH vitamin D levels are reached.

Clinical effectiveness and safety of a distraction-rotation knee brace for medial knee osteoarthritis.

OBJECTIVE: Evaluation of the clinical effectiveness and safety of a new custom-made valgus knee brace (OdrA) in medial knee osteoarthritis (OA) in terms of pain and secondary symptoms. METHODS: Open-label prospective study of patients with symptomatic medial knee OA with clinical evaluation at 6 and 52 weeks (W6, W52). We systematically assessed pain on a visual analog scale (VAS), Knee injury and Osteoarthritis Outcome Score (KOOS), spatio-temporal gait variables, use of nonsteroidal anti-inflammatory drugs (NSAIDs) and analgesic-sparing effects of the brace and tolerance. Mean scores were compared at baseline, W6 and W52 and the effect size (ES) and 95% confidence intervals (95% CIs) were calculated. RESULTS: We included 20 patients with knee OA (mean age 64.2±10.2 years, mean body mass index 27.2±5.4 kg/m2). VAS pain and KOOS were improved at W6 and W52: pain (ES=0.9 at 1 year), amelioration of other symptoms (ES=0.4), and function in activities of daily living (ES=1.1), sports and leisure (ES=1.5), quality of life (ES=0.9) and gait speed (ES=0.41). In total, 76% of patients showed clinical improvement at 1 year. Analgesic and NSAIDs consumption was significantly decreased at W6 and W52. One serious adverse effect noted was lower-limb varices, and observance was deemed satisfactory at 1 year. CONCLUSION: This new unloader brace appeared to have good effect on medial knee OA, with an acceptable safety profile and good patient compliance.

Test-retest reliability and responsiveness of centre of pressure measurements in patients with hip osteoarthritis.

OBJECTIVE: The aim of this study was to determine a set of measures for the evaluation of balance in patients suffering from hip osteoarthritis (OA) that were both reliable and responsive to change. DESIGN: Three groups of subjects; Healthy, hip OA patients without surgery, and hip OA with surgery (pre and post-surgery) were included in this study. Subjects had to perform balance tests in two positions: standard and narrowed stance. CoP-based measures test-retest reliability was assessed in hip OA without surgery group, responsiveness were assessed between all groups and between pre and post-surgery. RESULTS: Intraclass Correlation Coefficient (ICC) values from hip OA without surgery ranged from -0.03 to 0.9 for only five parameters (CoP path length, SD velocity, mean velocity, and antero-posterior Root Mean Square (RMS(AP)) having values over 0.7. SD velocity and RMS(AP) showed significant differences between healthy and surgery group in standard stance whereas narrowed stance revealed most differences between all groups. RMS(AP) showed the best responsiveness (Standardized Response Mean ∼0.5) between pre vs post-surgery in both conditions. RMS(AP) was also capable of discriminating between hip OA with surgery vs without surgery groups with good sensitivity and specificity. CONCLUSIONS: Our results showed there to be reliability and responsiveness of five postural parameters in hip OA patients in two conditions of standing balance. More parameters were significantly different in narrowed stance whereas sensitivity was better in standard stance. SD velocity and RMS(AP) discriminate between degrees of OA severity and highlight potential balance deficits even after arthroplasty. Selected parameters during standing balance could be assessed to complete the set of quantitative measures to quantify hip OA patient deficiencies.

A classification study of kinematic gait trajectories in hip osteoarthritis.

The clinical evaluation of patients in hip osteoarthritis is often done using patient questionnaires. While this provides important information it is also necessary to continue developing objective measures. In this work we further investigate the studies concerning the use of 3D gait analysis to attain this goal. The gait analysis was associated with machine learning methods in order to provide a direct measure of patient control gait discrimination. The applied machine learning method was the support vector machine (SVM). Applying the SVM on all the measured kinematic trajectories, we were able to classify individual patient and control gait cycles with a mean success rate of 88%. With the use of an ROC curve to establish the threshold number of cycles necessary for a subject to be identified as a patient, this allowed for an accuracy of higher than 90% for discriminating patient and control subjects. We then went on to determine the importance of each trajectory. By ranking the capacity of each trajectory for this discrimination, we provided a guide on their order of importance in evaluating patient severity. In order to be clinically relevant, any measure of patient deficit must be compared with clinically validated scores of functional disability. In the case of hip osteoarthritis (OA), the WOMAC scores are currently one of the most widely accepted clinical scores for quantifying OA severity. The kinematic trajectories that provided the best patient-control discrimination with the SVM were found to correlate well but imperfectly with the WOMAC scores, hence indicating the presence of complementary information in the two.

[Rheumatoid arthritis and meningeal nodules]. / Polyarthrite rhumatoïde et nodules méningés.

INTRODUCTION: Rheumatoid nodules are possible extra-articular manifestations of rheumatoid arthritis. These lesions are mainly located in subcutaneous tissues but may also rarely affect deep organs, exceptionally the meninges. CASE REPORT: We report herein a case of meningeal nodules observed in a 52-year-old man with rheumatoid arthritis who underwent brain MRI to explore an acute visual impairment. Subsequent MRIs showed similar new lesions contrasting with total regression of the initially observed lesions. The final control brain MRI performed four years after the onset of the ocular symptoms disclosed total involution of all the extra-axial nodular lesions, a course highly suggestive of meningeal rheumatoid nodules. CONCLUSION: During the follow-up period of this case, the patient was treated with methotrexate at doses too low to cross the blood brain barrier. Consequently, it is most likely that the meningeal lesions developed during the natural course of the disease. Despite the non-specific features of the first imaging findings, the radiological changes observed over time were consistent with the final diagnosis of rheumatoid nodules.

Test-retest reliability of 3D kinematic gait variables in hip osteoarthritis patients.

OBJECTIVES: (1) to investigate the test-retest reliability of 3D gait analysis (3DGA) in hip Osteoarthritis (OA) patients; (2) to find the minimum number of gait trials needed to overcome intrinsic variability; (3) to check the accuracy of angles measured by the 3D system. DESIGN: 23 Patients suffering from hip OA with no other major disease were recruited. We evaluated the reliability of spatio-temporal variables and body angles (lower-limb joints, trunk and pelvis angles) during two sessions of 3DGA using intra-class correlation coefficients (ICC). The minimum number of trials needed to overcome intrinsic variability was evaluated using an exponential fit model and the Bland and Altman coefficient of repeatability (CoR). The accuracy of measurement was evaluated using a manual goniometer and the recording of 18 different angles. RESULTS: Spatio-temporal variables and most of the kinematic joint and trunk angles calculated demonstrated good to excellent reliability (ICC from 0.77 to 0.97). This was not the case for pelvic angles. The fitting model combined with the CoR showed that 5-10 trials are sufficient to obtain good reliability [ICC>0.7; CoR<2 standard deviation (SD)] for most of the spatio-temporal variables. All body angles showed good reliability (ICC>0.7) and low CoR (<2 SD) after five trials except for the pelvic angles. The reliability of marker positioning was found to be good (ICC>0.7) to excellent (ICC>0.9). Differences between angles measured using 3DGA and angles measured with a manual goniometer were found to be less than one percent. CONCLUSION: The present study shows that most of variables obtained using 3DGA in hip OA patients are reliable. Moreover, for most variables, 5-10 trials are needed to obtain good reliability and to overcome intrinsic variability, rather than 30 or more, thus improving the feasibility of measurement.

Aspartame-induced fibromyalgia, an unusual but curable cause of chronic pain.

We report for the first time an unusual musculoskeletal adverse effect of aspartame in two patients. A 50-year-old woman had been suffering from widespread pain and fatigue for more than 10 years leading to the diagnosis of fibromyalgia. During a vacation in a foreign country, she did not suffer from painful symptoms since she had forgotten to take her aspartame. All of the symptoms reappeared in the days following her return when she reintroduced aspartame into her daily diet. Thus, aspartame was definitively excluded from her diet, resulting in a complete regression of the fibromyalgia symptoms. A 43-year-old man consulted for a 3-year history of bilateral forearm, wrist, and hand and cervical pain with various unsuccessful treatments. A detailed questioning allowed to find out that he had been taking aspartame for three years. The removal of aspartame was followed by a complete regression of pain, without recurrence. We believe that these patients' chronic pain was due to the ingestion of aspartame, a potent flavouring agent, widely used in food as a calorie-saver. The benefit/ risk ratio of considering the diagnosis of aspartame-induced chronic pain is obvious: the potential benefit is to cure a disabling chronic disease, to spare numerous laboratory and imaging investigations, and to avoid potentially harmful therapies; the potential risk is to temporarily change the patient's diet. Thus, practitioners should ask patients suffering from fibromyalgia about their intake of aspartame. In some cases, this simple question might lead to the resolution of a disabling chronic disease.

Cross-cultural adaptation and validation of the French version of the Hip disability and Osteoarthritis Outcome Score (HOOS) in hip osteoarthritis patients.

OBJECTIVE: To translate and adapt the Hip disability and Osteoarthritis Outcome Score (HOOS) into French and to evaluate the psychometric properties of this new version, by testing feasibility, internal consistency, construct validity, reliability and responsiveness, in patients with hip osteoarthritis (OA). METHODS: The French version of the HOOS was developed according to published international guidelines to ensure content validity. The new version was then evaluated in two symptomatic hip OA populations, one with no indication for joint replacement (medical group), and the other waiting for total hip replacement (THR) (surgery group). The psychometric properties assessed were feasibility: percentage of responses, floor and ceiling effects; internal consistency using Cronbach's alpha; construct validity by evaluating correlations with the Lequesne's index and the visual analogic scale (VAS) for pain (Pearson's correlation coefficient); reliability: intra-class correlation coefficient (ICC), Bland et Altman representation; responsiveness by comparing the results of before and 1 month after injection of hyaluronic acid (medical group) and by comparing the pre and 3 months post THR results (surgery group) by calculating standardized response mean (SRM) and effect size (ES). RESULTS: A total of 88 patients were recruited; 58 in the medicine group (mean age=61.8+/-9 years, range 42-81, 70% women) and 30 in the surgery group (mean age=67.5+/-9 years, range 50-81, 68% women). The percentage of item responses was excellent (99%). Neither a floor nor a ceiling effect was observed, except for a ceiling effect (17.8% of patients with worst possible score) observed prior to surgery in the sport and recreation subscale. The internal consistency was good for four of the five HOOS subscales. As expected, the strongest correlations were observed between all HOOS subscales and Lequesne's index or VAS pain, indicating good construct validity. The reliability was good, with an ICC>0.8 for all subscales. The responsiveness was good for all domains 1 month after hyaluronic acid injection (ES ranging from 0.73 to 1.86 and SRM from 0.51 to 1.04) and high for all domains 3 months after THR (ES ranging from 1.47 to 2.08 and SRM ranging from 1.97 to 3.24). CONCLUSION: The French version of HOOS demonstrated good psychometric properties and appears to be useful for the evaluation of patient-relevant outcome whatever the severity of hip OA. This study provides a basis for the use of this French version of the HOOS in future clinical trials.

Cross-cultural adaptation and validation of the French version of the Rheumatoid and Arthritis Outcome Score (RAOS).

OBJECTIVES: The Rheumatoid and Arthritis Outcome Score (RAOS) was recently developed to evaluate functional disability and quality of life in rheumatoid arthritis (RA) patients suffering from lower limb symptoms. The aims of this study were to cross-culturally adapt the RAOS into French and to assess its psychometric properties, in particular, responsiveness following intra-articular therapy. METHODS: The French RAOS was developed according to cross-cultural guidelines and was then evaluated in symptomatic RA patients with lower limb joint involvement. The psychometric properties assessed were - feasibility: percentage of missing data and floor and ceiling effects; reliability: intra-class correlation coefficients (ICC, and Bland and Altman representation; internal consistency: Cronbach's alpha; construct validity by correlation with the SF-36 and HAQ (Spearman's rank test); responsiveness to intra-articular corticosteroid injection (hip, knee, hindfoot) using standardised response mean (SRM) and effect size. RESULTS: Sixty patients were included (mean age 50.1±10.5 years). Neither floor nor ceiling effects were observed. Reliability was good with ICC for different RAOS subscales ranging from 0.76 to 0.91. Results for internal consistency (Cronbach's alpha ranging from 0.73 to 0.91) and construct validity were good. The responsiveness was moderate to large with SRMs ranging from 0.75 to 0.87 and effect sizes from 0.77 to 1.75 at two weeks following intra-articular corticosteroid injection. CONCLUSIONS: The French version of the RAOS demonstrated good psychometric properties to capture functional disability and quality of life in RA. Moreover, the results suggest that the RAOS could be used as an outcome in trials evaluating single joint intra-articular injections.

Psychometric properties of the French translation of the reduced KOOS and HOOS (KOOS-PS and HOOS-PS).

OBJECTIVE: To evaluate the psychometric properties of the French KOOS physical function (KOOS-PS) and HOOS physical function (HOOS-PS), specifically its feasibility, reliability, construct validity, and responsiveness. METHODS: Consecutive outpatients consulting for primary knee or hip osteoarthritis (OA) in a rheumatology department were included. During the initial assessment, patients were asked to complete the Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS) questionnaire and the OsteoArthritis Knee and Hip Quality Of Life questionnaire (OAKHQOL). The patients were given a second KOOS or HOOS questionnaire to complete and return by mail 2 weeks later. Feasibility was assessed by calculating the percentage of missing items and the floor and ceiling effects. Test-retest reliability was evaluated using the intra-class correlation coefficient (ICC). Convergent and divergent construct validity was determined by comparing the results of the KOOS-PS or HOOS-PS and OAKHQOL questionnaires using Spearman's rank test. Responsiveness was evaluated using data obtained in other hip or knee OA patients prior to and 1 month after intra-articular hyaluronic acid injection, using standardized response mean (SRM) and effect-size (ES). RESULTS: Eighty-seven patients with knee OA and 50 hip OA patients were included. The KOOS-PS and HOOS-PS scores were obtained for all patients as there were no missing items. Neither a floor nor a ceiling effect was observed. The ICC of KOOS-PS and HOOS-PS was 0.861 (0.763-0.921) and 0.859 (0.725-0.929), respectively. A strong or moderate correlation was observed, as expected, between KOOS-PS, HOOS-PS, and the OAKHQOL physical activities, pain, and mental health domains. A weak correlation was observed, as expected, between KOOS-PS, HOOS-PS, and the other OAKHQOL domains, except for a moderate correlation between the KOOS-PS and social functioning. The responsiveness was demonstrated with SRM and ES of 0.80 and 0.51 (KOOS-PS), 1.10 and 0.62 (HOOS-PS), respectively. CONCLUSION: The French versions of KOOS-PS and HOOS-PS are reliable, valid, and responsive questionnaires for capturing functional disability in people with knee and hip OA.

OARSI-OMERACT definition of relevant radiological progression in hip/knee osteoarthritis.

BACKGROUND: Joint space width (JSW) evaluated in millimeters on plain X-rays is the currently optimal recognized technique to evaluate osteoarthritis (OA) structural progression. Data obtained can be presented at the group level (e.g., mean+/-standard deviation of the changes). Such presentation makes difficult the interpretation of the clinical relevance of the reported results. Therefore, a presentation at the individual level (e.g., % progressors) seems more attractive but requires to determining a cut-off. Several methodologies have been proposed to define cut-offs in JSW: arbitrary chosen cut-off, cut-off based on the validity to predict a relevant end-point such as the requirement of total articular replacement or cut-off based on the measurement error such as smallest detectable difference (SDD). OBJECTIVES: The objective of this OARSI-OMERACT initiative was to define a cut-off evaluated in millimeters on plain X-rays above which a change in JSW could be considered as relevant in patients with hip and knee OA. METHODS: The first step consisted in a systematic literature research performed using Medline database up to July 2007 to obtain all manuscripts published between 1990 and 2007 reporting a cut-off value in JSW evaluated in millimeters at either the knee or hip level. The second step consisted in a consensus based on the best knowledge of the 11 experts with the support of the available evidence. RESULTS: Among the 506 articles selected by the search, 47 articles reported cut-off of JSW in millimeters. There was a broad heterogeneity in cut-off values, whatever the methodologies or the OA localization considered (e.g., from 0.12 to 0.84 mm and from 0.22 to 0.78 mm for Knee (seven studies) and hip (seven studies), respectively when considering the data obtained based on the reliability). Based on the data extracted in the literature, the expert committee proposed a definition of relevant change in JSW based on plain X-rays, on an absolute change of JSW in millimeters and on the measurement error e.g., calculation of the SDD using the Bland and Altman technique. The results of the analysis of JSW should be expressed in terms of a dichotomous variable (e.g., progressors yes/no): a patient with a change in JSW during the study over such SDD will fulfill the definition of "progressor". Moreover, the pilot study aimed at evaluating the measurement error should be designed to reflect the different characteristics of the primary study in which the analysis of the radiological findings will be based on (patient's characteristics, centers characteristics, readers). CONCLUSION: This initiative based on both an Evidence Based Medicine (Systematic Literature Research) and Expert Opinion approach resulted in a proposal of definition of relevant radiological progression in OA to be used as end-point in clinical trials and also recommendations on the conduct of the reliability study allowing such definition.

Cross-cultural adaptation and validation of the French version of the Knee injury and Osteoarthritis Outcome Score (KOOS) in knee osteoarthritis patients.

OBJECTIVE: To adapt the Knee injury and Osteoarthritis Outcome Score (KOOS) into French and to evaluate the psychometric properties of this new version. METHODS: The French version of the KOOS was developed according to cross-cultural guidelines by using the "translation-back translation" method to ensure content validity. KOOS data were then obtained in patients with symptomatic knee osteoarthritis (OA). The translated questionnaire was evaluated in two knee OA population groups, one with no indication for joint replacement (medicine), and the other waiting for joint replacement (surgery). The psychometric properties evaluated were feasibility: percentage of responses, floor and ceiling effects; construct validity: internal consistency using Cronbach's alpha, correlations with osteoarthritis knee and hip quality of life domains using Spearman's rank test, and known group comparison between medicine and surgery groups; reliability: intra-class correlation coefficient (ICC), Bland and Altman representation; responsiveness using data obtained prior to and 3 months after surgery: standardized response mean (SRM), and effect size. RESULTS: Thirty-seven patients were included in the medicine group (68% women, mean age=70+/-10 years) and 30 in the surgery group (73% women, mean age=71+/-10 years). The percentage of responses was excellent. Neither a floor nor a ceiling effect was observed, except for the sport and recreation subscale (20.6% of patients with the worst possible score in the medicine group, 40 and 0% in the surgery group prior to and after surgery, respectively). Results for internal consistency (Cronbach's alpha ranging from 0.76 to 0.93), and convergent and divergent construct validity were satisfactory. The patients waiting for knee surgery presented with significantly lower scores in all KOOS domains. The reproducibility of measurements of all KOOS subscales was good to excellent, with ICC ranging from 0.755 to 0.914. The responsiveness was high, with SRM ranging from 0.89 to 1.93, and effect size from 1.31 to 2.8. CONCLUSION: The French version of KOOS is a valid, reliable, and responsive instrument to capture specific aspects of functional disability affecting quality of life of knee OA patients.

[Hypercalcemia of double origin: association of multiple myeloma and ectopic parathyroidal adenoma]. / Une hypercalcémie d'origine double: association myélome et adénome parathyroïdien ectopique.

INTRODUCTION: Multiple myeloma and primary hyperparathyroidism are two causes of hypercalcemia. This association has already been described to be not casual, despite their link is still unknown. OBSERVATION: We describe a 68 years old woman, without notable background, was admitted for low back pain. Biology showed an IgG Kappa multiple myeloma (stade 3) and an hypercalcemia without renal failure. Hypercalcemia was difficult to control with bisphosphonate and calcitonin. At first, there was also an hypophosphoremia and a high parathormone level (287 pg/ml). Imaging showed spread myeloma impairment and a right paramediastinal tissular mass. Biopsy diagnosed an ectopic parathyroidal adenoma. DISCUSSION: Multiple myeloma and primary hyperparathyroidism can be associated. They are often revealed by an hypercalcemia difficult to control or refractory to the treatment. Hypophosphoremia can suggest the diagnosis of hyperparathyroidism. Both this observation and litterature (about twenty case reports) suggest that this double diagnosis should be systematicly evoked and explored by an assay of parathormone and a seric proteins electrophoresis in all hypercalcemia. CONCLUSION: Multiple myeloma and parathyroidal adenoma should be both explored in all hypercalcemia, because they can be associated.

[Anti TNF-alpha treatment of a refractory polymyositis]. / Traitement d'une polymyosite réfractaire par anti TNF-alpha.

INTRODUCTION: Anti TNF-alpha agents may represent a possibility of treatment in cases of refractory polymyositis. CASE REPORT: We report a case of polymyositis refractory to corticosteroids and immunosuppressive agents in whom adjunction of infliximab led to a mild and transient improvement, and a secondary improvement after discontinuation of the treatment. DISCUSSION: In the reported cases of polymyositis treated with infliximab or etanercept a short-term response was seen in 9 out of 11 cases. Adverse events of the treatment are mentioned, and should be taken into account in the decision of treatment.

Fatigue in patients with cardiovascular disease.

Fatigue is a frequent complaint during cardiovascular disease and can sometimes constitute the first clinical manifestation of this disease. It is responsible for deterioration of the quality of life and prognosis. Although physical and mental fatigue are often intimately interrelated, these two aspects of fatigue correspond to different pathophysiological mechanisms and different clinical features and the neurobiological links between the two are only just beginning to be studied. Physical fatigue is related to loss of efficacy of the effector muscle, due to multiple causes: mismatch of cardiac output during exercise, muscle and microcirculatory deconditioning, neuroendocrine dysfunction, associated metabolic disorders. Mental fatigue corresponds to predominantly depressive mood disorders with a particular entity, vital exhaustion. The diagnostic approach is designed to eliminate other organic causes of fatigue. Functional tests investigating physical (exercise capacity) and mental dimensions (mood disorders) can be used to analyse their respective roles and to propose personalized management, in which rehabilitation has an essential place due to its global approach. The objective of this reduction of fatigue is threefold: to improve independence, to improve quality of life and to limit morbidity and mortality.

Effects of loss of metatarsophalangeal joint mobility on gait in rheumatoid arthritis patients.

OBJECTIVE: To evaluate the effects of loss of range of motion (ROM) of the metatarsophalangeal (MTP) joint on the kinematic parameters of walking in rheumatoid arthritis (RA) patients. METHODS: Inclusion of RA patients with inactive disease, no synovitis of the inferior limb and reduced ROM of the MTP joints. Evaluation of the ROM of the MTP dorsal and plantar flexion, and gait analysis using a three-dimensional computerized movement analysis. Calculation of gait parameters and maximal flexion and extension of the hips and knees during walking. Analysis 1 compared the ROM of dorsal and plantar flexion in patients with or without walking pain; 2 compared the gait parameters between patients and controls; 3 investigated a relationship between gait parameters and (i) the ROM of the MTP dorsal and plantar flexion and (ii) the pain at walking; 4 investigated the relationship between the ROM of the MTP dorsal and plantar flexion and maximal flexion and extension of the hip and knee joints during walking. RESULTS: Nine patients and seven controls were included. The MTP ROM was no different in patients presenting with or without pain at walking. The walking velocity was lower and the stride length shorter in patients than in controls. The walking velocity and the stride length were positively related to the MTP dorsal flexion ROM (r(2)=0.75 and 0.67). There was a negative relationship between maximal flexion of the knee and hips during walking and the underlying MTP dorsal flexion ROM (r(2)=0.67 and 0.54). CONCLUSION: In RA patients, reduced MTP dorsal flexion mobility induces changes in the walking parameters, including the kinematics of the overlying lower limb joints. Treatment of an RA-impaired forefoot should focus on MTP mobility as well as on pain.