Ultrasound-Guided Transcutaneous Injection in the Lacrimal Gland: A Description of Sonoanatomy and Technique.

Purpose: To develop a method of injecting a volume up to 50% of the lacrimal gland (LG) volume while minimizing patient discomfort and maximizing accurate drug delivery. Herein we describe a series of ultrasound (US)-guided transcutaneous injections in the LG and discuss the safety and feasibility of this technique. Methods: Ultrasonography was performed in 40 patients with aqueous deficient dry eye disease using a GE Logic E10 (Milwaukee, Wisconsin, USA) US machine with a 6-24 MHz transducer. US was performed by 2 medical experts in ultrasonography. We recorded the injection and observed an enlargement of the LG ensuring delivery within the LG before the needle was removed. Assessment of injection-related adverse event was performed immediately after the injection. Results: The position of the injection needle within the LG was documented in all 40 patients. Injection of the stem cells and vehicle (N = 20) or solely vehicle (N = 20) led to an enlargement of the glandular structures in all cases. No serious adverse reactions related to the injections were observed. Conclusion: US-guided injection into the LG enables injection on a closed eye causing minimum patient discomfort and maximum certainty of accurate drug delivery. US can provide real-time images and may be used to safely guide the needle ensuring correct placement and injection within the gland capsule. This reduces the risk of injury to the eye and adjacent structures and makes a precise transcutaneous injection possible. Clinical Trial Registration number: NCT04615455.

Diagnostic Considerations of Intermetatarsal Bursitis: A Systematic Review.

Intermetatarsal bursitis (IMB) is an inflammation of the intermetatarsal bursas. The condition causes forefoot pain with symptoms similar to those of Morton's neuroma (MN). Some studies suggest that IMB is a contributing factor to the development of MN, while others describe the condition as a differential diagnosis. Among patients with rheumatic diseases, IMB is frequent, but the scope is yet to be understood. The aim of this paper was to investigate the diagnostic considerations of IMB and its role in metatarsalgia by a systematic review approach. We identified studies about IMB by searching the electronic databases Pubmed, Embase, Cochrane Library, and Web of Science in September 2022. Of 1362 titles, 28 met the inclusion criteria. They were subdivided according to topic: anatomical studies (n = 3), studies of patients with metatarsalgia (n = 10), and studies of patients with rheumatic diseases (n = 15). We conclude that IMB should be considered a cause of pain in patients with metatarsalgia and patients with rheumatic diseases. For patients presenting with spreading toes/V-sign, IMB should be a diagnostic consideration. Future diagnostic studies about MN should take care to apply a protocol that is able to differ IMB from MN, to achieve a better understanding of their respective role in forefoot pain.

Clinical Applicability of Ultrasound in Systemic Large Vessel Vasculitides.

The systemic large vessel vasculitides consist mainly of giant cell arteritis and Takayasu arteritis. Both diseases affect the large blood vessels and can lead to ischemia and end-organ damage. Ultrasound is an imaging technique that can depict inflammation of the vessel wall in large and medium vessel vasculitis. In this article, we critically review the current evidence for the clinical use of ultrasound for systemic large vessel vasculitides, regarding the clinical applicability, technical requirements, challenges, and cost. A roadmap for the development of a fast-track ultrasound clinic for giant cell arteritis is also provided.

Ultrasound pathology of the entheses in an age and gender stratified sample of healthy adult subjects: a prospective cross-sectional frequency study.

OBJECTIVES: Ultrasound (US) examination of the entheses is increasingly used. However, little is known about US findings in the entheses in asymptomatic persons. The aim of this study was to investigate the appearance of US signs in the enthuses of the lower limb in asymptomatic subjects. METHODS: We recruited 64 subjects, eight women and eight men whose ages covered four decades, from 20 to 60 years. None had tendon or joint disease in the lower limbs. Participants were examined by a rheumatologist and blood samples were collected to rule out enthesis pathology. The enthesis of the dominant leg were examined with grey-scale and Doppler US to evaluate increased thickness, changed structure, enthesophytes/calcifications, erosions, and colour Doppler signal. RESULTS: Ultrasound examination of 320 entheses was made. At enthesis level, elementary lesions were seen at 73 (22.8%) sites, at subject-level 47 (73.4%) persons showed elementary lesions, in 27 (57%) only one enthesis was affected. Doppler activity was seen in four sites, three at the quadriceps insertion. Most common US elementary lesion was enthesophytes at the Achilles and quadriceps tendon insertion. A tendency towards more elementary lesions was seen in men, and a slight increase was seen with increasing age, however, not statistically significance. CONCLUSIONS: Our findings suggest that US can be used to diagnose/examine subjects in adulthood for pathological changes in the entheses; however, caution should be taken regarding enthesophytes of the quadriceps and Achilles tendon.

Association between IL-6 production in synovial explants from rheumatoid arthritis patients and clinical and imaging response to biologic treatment: A pilot study.

INTRODUCTION: The need for biomarkers which can predict disease course and treatment response in rheumatoid arthritis (RA) is evident. We explored whether clinical and imaging responses to biologic disease modifying anti-rheumatic drug treatment (bDMARD) were associated with the individual's mediator production in explants obtained at baseline. METHODS: RA Patients were evaluated by disease activity score 28 joint C-reactive protein (DAS 28-)), colour Doppler ultrasound (CDUS) and 3 Tesla RA magnetic resonance imaging scores (RAMRIS). Explants were established from synovectomies from a needle arthroscopic procedure prior to initiation of bDMARD. Explants were incubated with the bDMARD in question, and the productions of interleukin-6 (IL-6), monocyte chemo-attractive protein-1 (MCP-1) and macrophage inflammatory protein-1-beta (MIP-1b) were measured by multiplex immunoassays. The changes in clinical and imaging variables following a minimum of 3 months bDMARD treatment were compared to the baseline explant results. Mixed models and Spearman's rank correlations were performed. P-values below 0.05 were considered statistically significant. RESULTS: 16 patients were included. IL-6 production in bDMARD-treated explants was significantly higher among clinical non-responders compared to responders (P = 0.04), and a lack of suppression of IL-6 by the bDMARDS correlated to a high DAS-28 (ρ = 0.57, P = 0.03), CDUS (ρ = 0.53, P = 0.04) and bone marrow oedema (ρ = 0.56, P = 0.03) at follow-up. No clinical association was found with explant MCP-1 production. MIP-1b could not be assessed due to a large number of samples below the detection limit. CONCLUSIONS: Synovial explants appear to deliver a disease-relevant output testing which when carried out in advance of bDMARD treatment can potentially pave the road for a more patient tailored treatment approach with better treatment effects.

[Bursitis after vaccination in the shoulder region].

Shoulder pain may develop after vaccination in the deltoid area due to inadvertent injection of the vaccine into the subdeltoid bursa, which may be located close to the skin. As far as we know, such vaccination reactions occur more frequently than officially registered, and doctors may not be aware of the problem. We present two of these cases of a suspected inflammatory reaction in the shoulder bursa after vaccination. Injection of cortisone in the bursa may relieve the reaction to some extent, but chronic shoulder pain may develop.

Tenosynovitis Evaluation Using Image Fusion and B-Flow - A Pilot Study on New Imaging Techniques in Rheumatoid Arthritis Patients.

Aim The aim of this study was to compare the assessment of tenosynovitis by ultrasound (US) and magnetic resonance imaging (MRI) using the image fusion technique and to investigate whether US B-flow imaging (BFI) is an alternative to Doppler US when assessing tenosynovitis. Materials and Methods 15 patients with rheumatoid arthritis (RA) had US-verified tenosynovitis in the wrist/hand. An MRI was performed of the wrist/hand with subsequent repeated US and image fusion. Images were compared in three steps: 1. Visual image comparison, 2. Quantitative measurement of transverse areas of the affected tendon and tendon sheath, using two tendon measures on MRI, area 1 and area 2, excluding and including partial volume artifacts, respectively, 3. Assessment using the OMERACT semi-quantitative scoring systems for US and MRI. Furthermore, BFI was assessed as: 0: No flow, 1: Focal flow, 2: Multifocal flow, 3: Diffuse flow, in the tendon sheath. Results The median areas on US and MRI (areas 1 and 2) were 0.16 cm2 (25;75 pctl: 0.10; 0.25), 0.9 cm2 (0.06; 0.18) and 0.13 cm2 (0.10; 0.25), respectively, for included tendons and 0.18 cm2 (0.13; 0.26), 0.27 cm2 (0.20; 0.45) and 0.23 cm2 (0.16; 0.40) for tendon sheaths. No statistically significant difference was found between US tendon area and MRI tendon area 2 (Wilcoxon's test; p = 0.47). Overall, the agreement between grayscale and color Doppler (CD) US and MRI tenosynovitis visualization and scoring was good, but not between CD and BFI. Conclusion US and MRI have high agreement using image fusion for the assessment of tenosynovitis when partial volume artifacts are taken into account. BFI is not an alternative to CD for the measurement of slow flow in tenosynovitis.

Validation of Navigation Ultrasound for Clavicular Length Measurement.

Accurate clavicular length measurement is considered important for the selection of patients requiring surgical treatment after a midclavicular fracture. As radiographic length measurements can be inaccurate to varying degrees, new measurement methods are needed. Use of novel technology, navigation ultrasound, to deliver accurate measurements seems promising. To examine the reliability and validity of navigation ultrasound for length measurements of the clavicle, a study was performed using length measurements performed before forensic autopsies from 2012 to 2013. In total, 38 bodies with a median age of 52.5 (range: 21-78 y) were included. Navigation ultrasound exhibited high reliability (intra-class correlation coefficient: 0.942-0.997, standard error of the mean: 0.7-2.9 mm, minimal detectable change: 2.3-8.1 mm) and validity (measurement error: 1.3%-1.8%, limits of agreement (95% confidence interval): approximately ± 7.5 mm, Pearson's correlation R: 0.948-0.974). Navigation ultrasound can measure clavicular length with an intra-rater reliability matching that of 3-D rendered computed tomography scans and with high validity. Its use could spread to other fields requiring accurate musculoskeletal length measurements.

Exercise therapy after ultrasound-guided corticosteroid injections in patients with subacromial pain syndrome: a randomized controlled trial.

BACKGROUND: Subacromial pain syndrome (SAPS) accounts for around 50 % of all cases of shoulder pain. The most commonly used treatments are glucocorticosteroid (steroid) injections and exercise therapy; however, despite treatment SAPS patients often experience relapse of their symptoms. Therefore the clinical effect of combining steroid and exercise therapy is highly relevant to clarify. The aim of this randomized controlled trial was to investigate if exercise therapy added to steroid injection in patients with SAPS will improve the effect of the injection therapy on shoulder pain. METHODS: In this two-arm randomized trial running over 26 weeks, patients with unilateral shoulder pain (> 4 weeks) and thickened subacromial bursa (> 2 mm on US) were included. At baseline all participants received two steroid injections into the painful shoulder with an interval of one week. Subsequently they were randomized (1:1) to either 10 weeks exercise of the involved shoulder (intervention group) or exercise of the uninvolved shoulder (control group). The patients were re-examined after the exercise program (at week 13) and again at week 26. The primary outcome assessed after 26 weeks was change in shoulder pain analyzed using the intention-to-treat principle (non-responder imputation). RESULTS: Ninety-nine SAPS patients (58 female) participated (49 intervention/50 control). At both follow up visits (week 13 and 26) no statistically significant between-group differences in pain changes on a visual analog scale (mm) were seen (13 weeks: pain at rest 1.7 (95 % CI -3.6 to 7.0; P = 0.53); pain in activity 2.2 (95 % CI -6.5 to 10.9; P = 0.61), 26 weeks: rest 5.6 (95 % CI -0.9 to 12.1; P = 0.09); activity 2.2 (95 % CI -6.8 to 11.2; P = 0.62). The reduction in pain was most evident in the control group at all four pain measurements. The only difference between groups was seen by US examination at week 13, where fewer participants with impingement were observed in the intervention group compared with the controls (9 vs. 19 participants; P = 0.03). CONCLUSION: Exercise therapy in the painful shoulder in SAPS patients did not improve the effectiveness of steroid injections for shoulder pain in patients with unilateral SAPS and enlarged subacromial bursa on US examination. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT01506804 ). Registration date 5 May 2011.

Three-dimensional Doppler ultrasound findings in healthy wrist and finger tendon sheaths - can feeding vessels lead to misinterpretation in Doppler-detected tenosynovitis?

BACKGROUND: The aim was to investigate the presence of feeding vessels in or in close proximity to extensor and flexor tendon sheaths at the wrists level and in finger flexor tendon sheaths in healthy controls, using 3D ultrasound (US), which may cause pitfalls, in order to ensure correct interpretation of Doppler signals when diagnosing tenosynovitis. METHOD: Forty healthy participants (20 women and 20 men age 23-67 years) without prior history of arthritis, tendon diseases or present pain in their hands were included. Twenty participants had 3D Doppler US of the second and third finger and twenty of the right wrist. US was carried out using a GE Logiq E9 unit with a 3D US probe. The colour Doppler settings were to published recommendation. RESULTS: The feeding vessels in or in close proximity to the tendon sheaths were found in the flexor and extensor tendons sheaths at least once in each participant. No significant difference in feeding vessels was seen between the radial and carpal level in the wrist (p = 0.06) or between the second and third flexor tendon sheath (p = 0.84). CONCLUSION: Doppler findings in or in close proximity to the tendon sheaths were common in wrists and fingers in healthy participants. These feeding vessels can be a source of error, not only due to their presence but also because they may be interpreted as being inside the tendon sheath due to blooming and reverberations artefacts. These vessels should be taken into consideration when diagnosing Doppler tenosynovitis.

Power and color Doppler ultrasound settings for inflammatory flow: impact on scoring of disease activity in patients with rheumatoid arthritis.

OBJECTIVE: To determine how settings for power and color Doppler ultrasound sensitivity vary on different high- and intermediate-range ultrasound machines and to evaluate the impact of these changes on Doppler scoring of inflamed joints. METHODS: Six different types of ultrasound machines were used. On each machine, the factory setting for superficial musculoskeletal scanning was used unchanged for both color and power Doppler modalities. The settings were then adjusted for increased Doppler sensitivity, and these settings were designated study settings. Eleven patients with rheumatoid arthritis (RA) with wrist involvement were scanned on the 6 machines, each with 4 settings, generating 264 Doppler images for scoring and color quantification. Doppler sensitivity was measured with a quantitative assessment of Doppler activity: color fraction. Higher color fraction indicated higher sensitivity. RESULTS: Power Doppler was more sensitive on half of the machines, whereas color Doppler was more sensitive on the other half, using both factory settings and study settings. There was an average increase in Doppler sensitivity, despite modality, of 78% when study settings were applied. Over the 6 machines, 2 Doppler modalities, and 2 settings, the grades for each of 7 of the patients varied between 0 and 3, while the grades for each of the other 4 patients varied between 0 and 2. CONCLUSION: The effect of using different machines, Doppler modalities, and settings has a considerable influence on the quantification of inflammation by ultrasound in RA patients, and this must be taken into account in multicenter studies.

Diagnostic utility of musculoskeletal ultrasound in patients with suspected arthritis--a probabilistic approach.

INTRODUCTION: This study aimed to assess the utility of musculoskeletal ultrasound (MSUS) in patients with joint symptoms using a probabilistic approach. METHODS: One hundred and three patients without prior rheumatologic diagnosis and referred to our clinic for evaluation of inflammatory arthritis were included. Patients were assessed clinically including joint examination, laboratory testing including acute-phase reactants, rheumatoid factor (RF) and anti citrulinated protein antibody (ACPA), and radiographs of hands and feet if clinically indicated. A diagnostic assessment was then performed by the responsible rheumatologist where the probability of a) any inflammatory arthritis and b) rheumatoid arthritis was given on a 5-point scale ranging from 0 to 20% up to 80 to 100% probability. Subsequently, an ultrasound examination of the wrist, metacarpophalangeal (MCP), proximal interphalangeal (PIP) joints 2 to 5 in both hands, metatarsophalangeal (MTP) joints 2 to 5 in both feet and any symptomatic joints was performed and the results presented to the same rheumatologist. The latter then assessed the diagnostic probabilities again, using the same scale. RESULTS: The rheumatologists' certainty for presence/absence of inflammatory arthritis and rheumatoid arthritis was increased significantly following ultrasound performance. The proportion of patient for whom diagnostic certainty for inflammatory arthritis was maximal was 33.0% before and 71.8% after musculoskeletal ultrasound (P <0.001). With regard to a diagnosis of RA, the proportions were 31.1% pre-test and 61.2% post-test (P <0.001). MSUS findings agreed with the final diagnosis in 95% of patients. CONCLUSION: Musculoskeletal ultrasound, when added to routine rheumatologic investigation, greatly increases the diagnostic certainty in patients referred for the evaluation of inflammatory arthritis. The changes from pre-test to post-test probability quantify the diagnostic utility of musculoskeletal ultrasound in probabilistic terms.

Comparison of discrimination and prognostic value of two US Doppler scoring systems in rheumatoid arthritis patients: a prospective cohort study.

OBJECTIVES: The aim of this paper is to investigate sensitivity to change (SRM), predictive validity and discriminative ability of a quantitative (QS) and a semi-quantitative (SQS) Doppler ultrasound scoring systems in patients with rheumatoid arthritis (RA) treated with anti-TNF-α therapy. METHODS: RA patients with wrist joint affection treated with TNF-α inhibitor were followed for one year. The wrist was examined with Doppler before initiating therapy and after one year. DAS28 was determined at both visits. One person trained in the SQS system and one in the QS system evaluated the anonymised images. The SRM, predictive validity and discriminative ability for both systems were calculated using DAS28 as the measure of disease improvement. RESULTS: Fourty-six patients with RA (80% females) were included. The mean Doppler activity at baseline was QS:24.4% (SD=17.7%) and SQS:2.0 (SD=0.6). A decrease in Doppler activity was seen for both systems after anti-TNF-α therapy. Sensitivity to change was seen, SRM=-0.52 (95%CI; -0.83 to -0.21; QS) and -0.24 (-0.53 to -0.05; SQS). Predictive value was poor (QS rs=-0.24; SQS rs=-0.05). Construct validity was; QS: rs=0.29, SQS: rs=0.23. CONCLUSIONS: Both systems were to some extent sensitive to change. Predictive validity and discriminate capacity of both systems showed only a weak association to DAS 28 in the study population. The QS was a little superior to the SQS. The results do not necessarily reflect Doppler evaluation as being ineffective, but may be caused by DAS28 not being a perfect marker of inflammation.

Synovial explant inflammatory mediator production corresponds to rheumatoid arthritis imaging hallmarks: a cross-sectional study.

INTRODUCTION: Despite the widespread use of magnetic resonance imaging (MRI) and Doppler ultrasound for the detection of rheumatoid arthritis (RA) disease activity, little is known regarding the association of imaging-detected activity and synovial pathology. The purpose of this study was to compare site-specific release of inflammatory mediators and evaluate the corresponding anatomical sites by examining colour Doppler ultrasound (CDUS) and MRI scans. METHODS: RA patients were evaluated on the basis of CDUS and 3-T MRI scans and subsequently underwent synovectomy using a needle arthroscopic procedure of the hand joints. The synovial tissue specimens were incubated for 72 hours, and spontaneous release of monocyte chemoattractant protein 1 (MCP-1), interleukin 6 (IL-6), macrophage inflammatory protein 1ß (MIP-1ß) and IL-8 was measured by performing multiplex immunoassays. Bone marrow oedema (BME), synovitis and erosion scores were estimated on the basis of the rheumatoid arthritis magnetic resonance imaging score (RAMRIS). Mixed models were used for the statistical analyses. Parsimony was achieved by omitting covariates with P > 0.1 from the statistical model. RESULTS: Tissue samples from 58 synovial sites were obtained from 25 patients. MCP-1 was associated with CDUS activity (P = 0.009, approximate Spearman's ρ = 0.41), RAMRIS BME score (P = 0.01, approximate Spearman's ρ = 0.42) and RAMRIS erosion score (P = 0.03, approximate Spearman's ρ = 0.31). IL-6 was associated with RAMRIS synovitis score (P = 0.04, approximate Spearman's ρ = 0.50), BME score (P = 0.04, approximate Spearman's ρ = 0.31) and RAMRIS erosion score (P = 0.03, approximate Spearman's ρ = 0.35). MIP-1ß was associated with CDUS activity (P = 0.02, approximate Spearman's ρ = 0.38) and RAMRIS synovitis scores (P = 0.02, approximate Spearman's ρ = 0.63). IL-8 associations with imaging outcome measures did not reach statistical significance. CONCLUSIONS: The association between imaging activity and synovial inflammatory mediators underscores the high sensitivity of CDUS and MRI in the evaluation of RA disease activity. The associations found in our present study have different implications for synovial mediator releases and corresponding imaging signs. For example, MCP-1 and IL-6 were associated with both general inflammation and bone destruction, in contrast to MIP-1ß, which was involved solely in general synovitis. The lack of association of IL-8 with synovitis was likely underestimated because of a large proportion of samples above assay detection limits among the patients with the highest synovitis scores.

Temporal summation of pain and ultrasound Doppler activity as predictors of treatment response in patients with rheumatoid arthritis: protocol for the Frederiksberg hospitals Rheumatoid Arthritis, pain assessment and Medical Evaluation (FRAME-cohort) study.

INTRODUCTION: Chronic pain is common in rheumatoid arthritis (RA) and may still persist despite regression of objective signs of inflammation. This has led researchers to hypothesise that central pain sensitisation may play a role in the generation of chronic pain in RA. Application of the disease activity score DAS28 can classify some patients with active RA solely based on a high tender joint count and poor patient global health score. In such cases, intensified treatment with anti-inflammatory drugs would be expected to yield poorer results than in cases with DAS28 elevation due to a high score for swollen joints and C reactive protein (CRP). Evaluation of central pain sensitisation in patients with few inflammatory indices may be a predictive tool regarding the effect of anti-inflammatory treatment. Computerised pneumatic cuff pressure algometry (CPA) is a method for assessing temporal summation (ie, degree of central sensitisation). The main objective of this study was to examine the prognostic values of pressure pain-induced temporal summation, ultrasound Doppler activity and the interaction between them in relation to treatment response (DAS28-CRP change) in patients with RA initiating any anti-inflammatory therapy. METHOD AND ANALYSIS: 120 participants ≥18 years of age will be recruited. Furthermore, they must be either (1) diagnosed with RA, untreated with disease-modifying antirheumatic drugs for at least 6 months and about to initiate disease-modifying antirheumatic drug treatment or (2) about to begin or switch treatment with any biological drug for their RA. Data (clinical, imaging, blood samples, patient reported outcomes and CPA measurements) will be collected from each participant at baseline and after 4 months of anti-inflammatory treatment. ETHICS AND DISSEMINATION: This study has been approved by the ethics committee for the Copenhagen region (H-4-2013-007). Dissemination will occur through presentations and publication in international peer-reviewed journals.

Ultrasound colour Doppler is associated with synovial pathology in biopsies from hand joints in rheumatoid arthritis patients: a cross-sectional study.

OBJECTIVES: Little is known regarding the association between ultrasound-determined pathological synovial blood flow and synovial pathology in rheumatoid arthritis (RA). We therefore examined the association between colour Doppler ultrasound imaging and synovitis assessed by histopathology and specific cell markers by immunohistochemistry in patients with RA. METHODS: 81 synovial sites from wrist and finger joints from 29 RA patients were evaluated by ultrasound colour Doppler and subsequently biopsied by needle arthroscopy. The association between ultrasound colour fraction and an overall synovitis score and immunohistochemical staining for CD3, CD68, Ki67 and von Willebrand factor was investigated, including repeated samples from the same patients. The overall synovitis score (total 0-9) assessed synovial lining hyperplasia (0-3), stromal activation (0-3) and inflammatory infiltration (0-3). Data were clustered within patients, thus a linear mixed model was applied for the statistical tests. Parsimony in the statistical models was achieved omitting covariates from the model in the case of what was judged no statistical significance (p>0.1). RESULTS: Doppler colour fraction showed an association with the overall synovitis score (approximated Spearman, approximately r=0.43, p=0.003). The density of all immunohistochemical stainings showed a significant association with Doppler colour fraction: von Willebrand factor (approximately r=0.44, p=0.01), CD68 (approximately r=0.53, p=0.02), Ki67 (approximately r=0.57, p=0.05) and CD3 (approximately r=0.57, p=0.0003). CONCLUSIONS: Colour Doppler activity is associated with the extent of inflammation present in the synovial biopsies from RA patients. However, synovial pathology was also seen in biopsies taken from Doppler negative sites.

Assessment of pressure-pain thresholds and central sensitization of pain in lateral epicondylalgia.

OBJECTIVE.: To assess pain sensitivity and spreading hyperalgesia in lateral epicondylalgia (LE). SUBJECTS.: Twenty-two women with LE, and 38 controls were included. OUTCOME MEASURES.: Computerized cuff pressure algometry was used for assessment of pressure-pain threshold and tolerance. The stimulus was applied using a single (stimulation-area: 241 cm(2) ) or double-chambered (stimulation-area: 482 cm(2) ) tourniquet on the arm and leg. Spatial summation was expressed as the ratio between pressure-pain thresholds to single and double cuff-chamber stimulation. During 10-minute constant pressure stimulation at intensity relative to the individual pain threshold, the pain intensity was continuously recorded using an electronic visual analogue scale (VAS), and from this the degree of temporal summation was estimated. For LE, a Doppler ultrasound examination of the elbow was made to identify inflammation. RESULTS.: In LE compared with controls the pressure-pain threshold and tolerance were on average reduced by respectively 31% (nonsignificant) and 18% (nonsignificant) on the lower arm and by 32% (P < 0.05) and 22% (P < 0.05) on the lower leg (spreading sensitization). Within the LE group, pressure-pain thresholds were on average reduced by 20% (P < 0.05) and pain tolerance by 10% (nonsignificant) on the painful compared with the asymptomatic side. Spatial summation (P < 0.01) and temporal summation (P < 0.05) was facilitated in LE compared with controls. In LE patients without signs of peripheral inflammation assessed by Doppler ultrasound, temporal summation was significantly stronger than in patients with ongoing inflammation (P < 0.01). CONCLUSION.: Patients with LE may be subgrouped based on pain hypersensitivity and Doppler ultrasound into clinically meaningful subgroups with varying duration of symptoms and different degrees of central sensitization. These groups may require different pain management strategies.

The effect of isometric exercise of the hand on the synovial blood flow in patients with rheumatoid arthritis measured by color Doppler ultrasound.

In 90% of patients with rheumatoid arthritis (RA), the joints of the hand are affected. Studies of grip strength training have not indicated a negative effect on disease activity after training. Introduction of ultrasound Doppler (USD) to measure increased blood flow induced by inflammation has made it possible to investigate the direct effect on blood supply in the synovium after training. In this case-control study, 24 patients with RA with USD activity in the wrist joint participated. The USD activity was measured by the color fraction (CF) (CF = colored pixels/total number of pixels in ROI). Twenty-four patients were assigned to an 8-week grip strength training program. At baseline and after 8 weeks of training, an USD examination of the wrist joint was performed. In the training group, we measured grip strength and pain in the wrist joint. Six patients withdrew from the training because of pain or change in medication. Eighteen patients served as control group. There was a modest, not significant, decrease in the CF in response to training (1.86%; P = 0.08). Grip strength increased 8.8% after training (P = 0.055). Pain in motion deceased after training (P = 0.04). No difference in the CF was seen between the training and control groups, neither at baseline nor at follow-up (P = 0.82 and P = 0.48). Patients withdrawing from training had a significantly higher CF than the other patients (P > 0.001). The results in this study might indicate that the flow in the synovium assessed by USD is not affected by grip strength training.