Isometric progressive resistive exercise for osteoporosis.

OBJECTIVE: To assess the effect of site-specific resistive isometric exercises on muscle strengthening of 10 muscle groups over 2 months. A second study measured bone alkaline phosphatase (ALP) as a marker of bone formation and bone resorption [urine deoxypyridinoline (D-Pyr) crosslinks] in a similar cohort. METHODS: Twenty postmenopausal Caucasian women aged 56 to 69 yrs (mean 61) on a stable or no medication regimen for the previous 6 months participated in the initial exercise cohort. Twenty-one women ages 52-69 (mean 62) participated in the second cohort. All women had osteopenia (DXA T less than -1.0) or osteoporosis (DXA T less than -2.5). An inflatable ball with attached nonelastic straps provided progressive resistance. Exercises consisted of a 5 s maximum contraction against progressively increasing resistance of the ball or nonelastic straps. Muscle strengthening was measured by a hand held dynamometer at 0, 4, and 8 weeks. Twenty women completed 8 weeks of the initial study and 21 women completed the second study. RESULTS: Muscles showing increased strength in the first cohort were neck extensors (p < 0.04), hand grips (p < 0.02), elbow flexors (p < 0.05), quadriceps (p < 0.04), trunk extensors (p > 0.05, not significant = NS). Elbow extensors were purposely not exercised (as a control) and showed no significant strength increase. In the second cohort, increased muscle strength was measured in the neck extensors (p < 0.001), trunk extensors (p < 0.001), and left quadriceps (p < 0.024); and bone ALP increased (p < 0.05), with no change detected in bone resorption (urine D-Pyr). CONCLUSION: Brief progressively resisted isometric exercises for 10 min daily are an adequate stimulus for muscle strengthening of the neck, back, upper and lower extremities, and are capable of enhancing bone formation measured by bone ALP.

Fibromyalgia: a risk factor for osteoporosis.

OBJECTIVE: To investigate associations of bone mineral density (BMD) and osteoporosis in patients with fibromyalgia (FM) and healthy controls. METHODS: Twenty-four women meeting the American College of Rheumatology criteria for FM (23 Caucasians, one Asian) were each compared to 2 age (+/-3 years) and ethnically matched controls by bone densitometry of the femoral neck and lumbar spine. The patients' ages were 33 to 60 years. No patient or control used steroids or other bone demineralizing agents. Simple T tests were used to compare hip and lumbar spine BMD of FM cases to controls by 3 decades (31-40, 41-50, 51-60 years). RESULTS: The patients with FM in all 3 decades had a lower mean BMD of the spine (p<0.05). The femoral neck BMD were also lower, but reached significance (p<0.05) only in the 51-60 age group. CONCLUSION: FM in this pilot study was frequently associated with osteoporosis. Early detection and implementation of appropriate nutritional supplementation (calcium/vitamin D), resistive and weight bearing exercise, and specific bone mineral enhancing pharmacological therapy may be indicated in pre, peri, and postmenopausal subjects.

Efficacy of home cervical traction therapy.

Cervical traction is administered by various techniques ranging from supine mechanical motorized cervical traction to seated cervical traction using an over-the-door pulley support with attached weights. Duration of cervical traction can range from a few minutes to 20 to 30 min, once or twice weekly to several times per day. Anecdotal evidence suggests efficacy and safety, but there is no documentation of efficacy of cervical traction beyond short-term pain reduction. Because of a clinical impression that a simplified, inexpensive, over-the-door home cervical traction method of treatment requiring 5 min of cervical traction twice daily was efficacious for both cervical pain and radiculopathic syndromes, we undertook a retrospective study of 58 outpatients treated between 1994 and 1996. Age range was 29 to 84 (mean, 56) yr. Twenty-three males and 35 females were classified as Grade 1 to Grade 3 according to the Quebec Task Force of Whiplash-Associated Disorders Cohort Study. Outcomes were as follows: Grade 1 (mild)--4 of 4 (100%) patients improved; Grade 2 (moderate)--34 of 44 (77%) patients improved (P < 0.01), 5 were unchanged, and 5 felt their symptoms were aggravated by cervical traction; Grade 3 (patients with radiculopathy)--9 of 10 (90%) patients improved (P < 0.01). In a retrospective study, a brief (3-5 min), over-the-door home cervical traction modality provided symptomatic relief in 81% of the patients with mild to moderately severe (Grade 3) cervical spondylosis syndromes. Prospective, randomized assessment of cervical traction for this and other methods is needed.

Conservative treatment of cervical radiculopathy.

To assess the efficacy of nonsurgical treatment of cervical radiculopathy, 50 patients with objective signs and symptoms of cervical discogenic radiculopathy (CDR) without myelopathy, treated conservatively on an outpatient basis with a mean follow-up of 9.4 months were retrospectively reviewed. Then an additional 33 patients were entered sequentially onto a prospective study to assess conservative treatment; they were followed for 100 days or longer with a mean follow-up of 24.7 months. All 83 patients (50 + 33) had objective neurologic deficits (sensory, motor, or both).Of the initial 50 patients, 27 achieved full remission (no neurologic deficits and pain free), 17 were markedly improved (minimal residual sensory or motor deficit and mild to minimal pain), and 6 were unchanged at the time of their last examination. Of the 33 patients followed prospectively, 13 were in full remission and 16 were markedly improved requiring no treatment at the 100-day follow-up evaluation (< 0.05 by one tailed t-test). Of the 33 patients with complicating depression or fibromyalgia, 4 demonstrated minimal or no pain improvement, although 3 of the 4 had full remission of sensory/motor findings. Motor vehicle accidents precipitated symptoms of CDR in 14 patients in the retrospective and 5 in the prospective study. CDR of 15 patients was in full remission by 90 days, and 4 had ongoing chronic and/or mild sensory or motor deficits at 300 days. At the final follow-up, all 33 prospectively studied patients had maintained at least the level of improvement achieved at 100 days (p < 0.05 by one tailed f-test). No one in the total group of 83 patients required surgical intervention or hospitalization.Our results suggest that outpatient nonsurgical conservative management with careful patient education and monitoring of a coordinated conservative regimen can be successful for the majority of patients with CDR.

The sacroiliac joint. Nothing is sacred.

One hundred years ago, the sacroiliac joint was considered to be the most common cause of sciatica; over time, however, it became increasingly apparent that the major back enterprise lay in disc extractions. Still, despite the lack of specific clinical tests, the same clinical symptoms suggesting lumbar disc and lumbar facet joint pathology may also justify consideration of the sacroiliac joint as the pain generator. Treatment approaches, including manual therapies, bracing, and exercises, may benefit both the facet and sacroiliac joints as well as intradiscal pathologies. The possibility of utilizing specific local intra-articular steroid injections into the sacroiliac joint may add another useful tool to the armamentarium of back pain relief strategies.

Exercise for osteoporosis--is walking enough? The case for site specificity and resistive exercise.

Historic and clinical references obtained by general literature review and a medlars search from 1984-1994 on the impact of muscle strengthening on bone mineralization were reviewed and analyzed. The efficacy of site-specific resistive exercise on bone mineral enhancement and/or preservation as a supplement to weight-bearing exercise is documented. Previous reports demonstrated that resistive exercises enhance bone mineralization and play an equivalent, or perhaps greater role, than weight-bearing activities in the management of osteoporosis.

Bone densitometry: comparison of dual energy x-ray absorptiometry to radiographic absorptiometry.

OBJECTIVE: To assess the reliability and validity of radiographic absorptiometry of middle phalanges when compared to dual energy x-ray absorptiometry (DEXA) of the spine and hip as an indicator of osteoporosis. METHODS: DEXA readings from the spine and femur were compared with radiographic absorptiometry measurements obtained the same day in a sample of 50 women (average age 63 yrs; range 23-86). RESULTS: Both spine and femur DEXA scores were significantly correlated with radiographic absorptiometry scores (R = 0.70 and 0.68, respectively; approximate standard errors 0.08). DEXA scores were used as the standard, defining moderate fracture risk by a standardized t score < -2 and marked risk by t < -3. Using cutpoints of t < -2 for DEXA and t < -3 for standardized radiographic absorptiometry values, the sensitivity to osteopenia was 0.62 for DEXA of the spine and 0.63 for DEXA of the femur, with specificities of 0.90 and 0.96, respectively, at these cutpoints; the corresponding false positive and false negative rates for our cohort of women were 0.19 and 0.24 (spine) and 0.07 and 0.24 (femur). Receiver operating characteristic (ROC) curves were plotted, varying DEXA measurement site from spine to femur and standardized cutoff from -2 to -3; the areas under the resulting ROC curves ranged from 0.82 to 0.91. CONCLUSIONS: Radiographic absorptiometry holds promise as a practical method for screening for osteoporosis.

Chronic neck pain.

The disorders most commonly seen in rheumatologic practice are acute to chronic cervical disc-related strains, radiculopathies, and degenerative spondylosis. Inflammatory disorders including ankylosing spondylitis and rheumatoid arthritis, although generally rare, are not uncommonly seen in a rheumatologic practice. The pertinent anatomic and pathologic features of cervical disorders are examined in the context of their implications for the hierarchy of specific therapeutic interventions. The basis for the usually favorable prognosis for these conditions, particularly in response to a rational, structured, and phased conservative regimen, is delineated.

Outcomes for lumbar stenosis.

To document the natural history and outcomes of lumbar spinal stenosis in patients with neurogenic claudication, 47 patients who had been evaluated 5 years earlier were evaluated by telephone interview. Thirty-one were reexamined. The average duration of symptoms was 8 years. All patients had bilateral lower extremity symptoms, which were more pronounced unilaterally in three patients.Of the nonsurgically treated cases, 43% (20/47) improved; 30% (14/47) were unchanged. Seven of 11 patients treated with intermittent traction 1-2 times weekly improved walking tolerance and reported less back pain. Eight of 13 improved their walking tolerance after 1-3 epidural cortico-steroid injections. The 23% (11/47) who did not improve or worsened reported improvement after laminectomy.The majority of patients with symptomatic spinal stenosis will stabilize or improve without surgery. For those with intolerable symptoms, laminectomy can usually provide appreciable symptomatic relief.

Pathophysiology and treatment of intervertebral disk disease.

Back pain is like quality--you know it when you see it--but it is hard to precisely identify and quantify all the factors that are responsible for it. Quality of care in back pain compounds this dilemma. Because we cannot often precisely identify specific causes of back pain (we are usually overwhelmed by an excess of putative factors) and we cannot often assess therapeutic results with precision (double-blind randomized studies of multivaried pathologic and psychologic factors and multiple coexistent therapies and compliance variables), assessment of treatment modes is extremely difficult. Nonetheless, we ultimately must treat the patient. Nihilism is unrealistic. The art and science of medicine must be integrated. Pseudoscience based on high-tech dazzle must be viewed with appropriate skepticism. Treatments must enlist patients' understanding of their options with carefully directed self-care and home therapies augmented when needed by proven safe treatments as well as reasonable, inexpensive, safe remedies still lacking proof of efficacy to help comfort and support the patient during the healing process. Surgical interventions, with a few exceptions, are a last resort and should be employed judiciously and skillfully by experienced surgeons. The surgeon also must be both knowledgeable and experienced in the conservative treatment of low back pain to know when conservative treatment has truly failed. Failure to profit from an investment in a poorly managed business does not mean that the business per se has no value but rather that the business can only prosper with committed qualified management. No less can be asked of conservative rehabilitative therapies before they have been judged a bankrupt failure. Conservative treatment of low back pain is not complicated, but it does require knowledge, skill, and persistence and the ability to recognize when its failure is the result of a lack of response to optimal therapy and when further therapy is procrastination, redundant, and wasteful of time, suffering, and resources.

Obturator internus bursitis: a common factor in low back pain.

The presence of irritation of the obturator internus bursa (OIB) is identified as a common but thus far overlooked focus of myofascial irritability in association with low back pain. Eighteen of 50 consecutive patients with low back pain (36%) demonstrated the presence of tenderness at the anatomical site of the OIB. OIB was found in 11% of men and 43% of women. Nineteen of the 50 patients had regional myofascial pain; of these, eight (42%) had OIB tenderness. Palpation of the OIB will commonly reveal local tenderness in patients suffering from low back pain. In these patients, conservative treatment of regional myofascial disorders may be made more effective when therapy and/or local steroid injections are appropriately directed to the obturator internus bursa.

Ankylosing spondylitis in nonhuman primates: the drill and the siamang.

Nonhuman primates are known to be susceptible to many of the arthritides that afflict humans. Psoriatic like spondyloarthropathies have been reported in gorillas and skeletal hyperostosis in gibbons, rhesus monkeys, and gorillas, and additional cases of both of these conditions occurring in drills (baboons) are noted in this report. One western lowland gorilla and two rhesus monkeys with clinical features consistent with ankylosing spondylitis have been documented previously. Two additional nonhuman primate species with radiographic evidence of ankylosing spondylitis are described. A siamang (gibbon) and two drills (baboons) with the classic radiographic features of ankylosing spondylitis, namely a bamboo spine and sacroiliac joint fusion, are reported.

Non-fibrositic lumbar subcutaneous nodules: prevalence and clinical significance.

Lumbar subcutaneous nodules (LSNs) have been associated with fibrositis but are distinct from painful myalgic trigger points and tender points. One hundred and twenty-six adults (53 males and 73 females) were examined for LSNs. LSNs varied in size from a +/- 3 mm 'corn kernel' (15/47) to +/- 5 mm 'pea' (21/47) to +/- 10 mm, 'grape' (11/47), occurred singly (22/47) and in clusters of two to seven uni- and bilaterally. Eight of 47 LSNs overlying the posterior superior iliac spines (PSIS) were tender. The results of a cross-tabular analysis using disease as the independent variable and presence or absence of LSNs as the dependent, found no differences (chi 2 = 1.06, df = 2). LSNs occur near the PSIS in approximately 25% of white adults, are rarely a cause of back pain, and should seldom require biopsy.

Rheumatoid arthritis: the role of the kinder and gentler therapies.

Rehabilitative therapies, as adjuncts to pharmacological and surgical therapies in rheumatoid arthritis (RA), help minimize pain and inflammation, improve functional capabilities, and, above all, enhance quality of life. The effects of heat, cold, and electrical stimulation on neurohumoral, inflammatory, and immunological mechanisms has been noted, although knowledge about their mode of action is lacking. There is, however, much that these modalities, in addition to splints, bracing, exercise, activities-of-daily-living training, and psychological, social, and vocational counseling can offer to reduce suffering and disability in patients with RA. Far more, however, needs to be learned to provide precise prescriptions and more effective applications.