The Physical Attributes Most Required in Professional Ballet: A Delphi Study.

Background It is commonly accepted that dancers are undoubtedly athletes, with ballet perhaps the most demanding dance form. No previous study has sought to define the physical attributes most desired for classical ballet by professional companies and vocational schools. These are likely to include both aesthetic features and attributes that reduce the risk of injury as well as enhance performance. Method An initial survey question using the modified Delphi technique was sent using Opinio Survey Software to a selected international expert panel. This was drawn both from those involved in selection of elite professional ballet dancers, and the international medical professionals involved in the care of dancers. The first questionnaire was open-ended to scope for all the physical attributes most favoured by the professional experts. Results There were 148 responses from the panel of international experts. In total 34 physical attributes were suggested. The 2 most recommended physical criteria for selection into the profession were overall flexibility and overall strength. These results are discussed in the context of the published literature on the mechanics, anatomy and physiology of ballet. Conclusion Flexibility and strength are the 2 features most sought after in elite ballet dancers.

Hypermobility and proprioception in the finger joints of flautists.

BACKGROUND: Ergonomically, the flute is especially complex among wind instruments, and flautists may therefore be at particular risk of performance-related musculoskeletal disorders. Yet little is known about injury prevalence among flute players, and even less in those flautists who are also hypermobile. Recent research has found hand and wrist pain to be common complaints among flautists. Understanding of the predictors of injury and pain is therefore crucial as the presence of pain decreases performance quality and causes unnecessary time loss. There is a strong relationship between hypermobility and impaired proprioception, although many musicians may acquire greater proprioception than the average population. We have compared flexibility and proprioception of the hand in a study of flautists. METHODS: Twenty flautists took part in the study. General hypermobility, the passive range of motion of the 3 specific joints most involved in flute playing, and proprioception acuity were all measured accurately for the first time in this awkward instrument that needs high levels of dexterity. RESULTS: Flautists' finger joints have a greater range of movement than in the general population. This group of flute players had especially large ranges of movement in the finger joints, which take the weight of the instrument. Although flautists have hypermobile finger joints, they are not generally hypermobile elsewhere as measured by the Beighton Scale. Flautists, even with very mobile finger joints, have very accurate proprioception, which may be acquired through training. CONCLUSIONS: The study of instrumentalists may provide an ideal model for study of the interaction between localized joint flexibility and joint proprioception, both inherited and acquired.

The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial.

OBJECTIVE: To determine the clinical effectiveness and cost-effectiveness of nurse-led care (NLC) for people with rheumatoid arthritis (RA). METHODS: In a multicentre pragmatic randomised controlled trial, the assessment of clinical effects followed a non-inferiority design, while patient satisfaction and cost assessments followed a superiority design. Participants were 181 adults with RA randomly assigned to either NLC or rheumatologist-led care (RLC), both arms carrying out their normal practice. The primary outcome was the disease activity score (DAS28) assessed at baseline, weeks 13, 26, 39 and 52; the non-inferiority margin being DAS28 change of 0.6. Mean differences between the groups were estimated controlling for covariates following per-protocol (PP) and intention-to-treat (ITT) strategies. The economic evaluation (NHS and healthcare perspectives) estimated cost relative to change in DAS28 and quality-adjusted life-years (QALY) derived from EQ5D. RESULTS: Demographics and baseline characteristics of patients under NLC (n=91) were comparable to those under RLC (n=90). Overall baseline-adjusted difference in DAS28 mean change (95% CI) for RLC minus NLC was -0.31 (-0.63 to 0.02) for PP and -0.15 (-0.45 to 0.14) for ITT analyses. Mean difference in healthcare cost (RLC minus NLC) was £710 (-£352, £1773) and -£128 (-£1263, £1006) for PP and ITT analyses, respectively. NLC was more cost-effective with respect to cost and DAS28, but not in relation to QALY utility scores. In all secondary outcomes, significance was met for non-inferiority of NLC. NLC had higher 'general satisfaction' scores than RLC in week 26. CONCLUSIONS: The results provide robust evidence to support non-inferiority of NLC in the management of RA. TRIAL REGISTRATION: ISRCTN29803766.

A home exercise programme is no more beneficial than advice and education for people with neurogenic claudication: results from a randomised controlled trial.

OBJECTIVE: To compare the effectiveness of a physiotherapy programme with a control treatment of advice and education in patients with neurogenic claudication symptoms. DESIGN: Pragmatic randomised controlled clinical trial. SETTING: Primary care-based musculoskeletal service. PATIENTS: Adults aged 50 or over with neurogenic claudication symptoms causing limitation of walking. INTERVENTIONS: Condition-specific home exercises combined with advice and education, or advice and education alone. MAIN OUTCOME MEASURES: The primary outcome was the difference in improvement of symptom severity scores on the Swiss Spinal Stenosis Scale at eight weeks. Secondary outcomes included measures of physical function, pain and general well-being at eight weeks and 12 months. RESULTS: There was no significant difference between groups in the Swiss Spinal Stenosis symptom severity scale at eight weeks (t = 0.47, p = 0.643): mean change (SD) control group -0.18 (0.47), treatment group -0.10 (0.66), difference (95% CI) 0.08 (-0.19, 0.35); baseline-adjusted difference 0.06 (-0.19, 0.31)]. An unplanned subgroup analysis suggested that for patients with the top 25% of baseline symptom severity scores, the physiotherapy exercise programme resulted in an improvement in the primary outcome, and modest but consistently better secondary outcomes at both time-points compared to the control group. The effectiveness in different subgroups requires further direct evaluation. CONCLUSIONS: In the treatment of patients with neurogenic claudication symptoms, a physiotherapist-prescribed home exercise programme is no more effective than advice and education. ETHICAL APPROVAL: The study was approved by Leeds Central Ethics Committee and informed consent was given by all participating patients. COPYRIGHT: The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all forms, formats and media (whether known now or created in the future), to i) publish, reproduce, distribute, display and store the Contribution, ii) translate the Contribution into other languages, create adaptations, reprints, include within collections and create summaries, extracts and/or, abstracts of the Contribution, iii) create any other derivative work(s) based on the Contribution, iv) to exploit all subsidiary rights in the Contribution, v) the inclusion of electronic links from the Contribution to third party material where-ever it may be located; and, vi) licence any third party to do any or all of the above. TRIAL REGISTRATION: ISRCTN 78288224 - doi10.1186/ISRCTN35836727; UKCRN 4814.

Expert care of the performing artist.

Compared to elite athletes, elite performers, especially musicians and dancers, invariably lack expert medical backup even though their needs are just as great as the sportspeople. In some countries, this is now being realised and addressed. It is hoped that a new MSc in Performing Arts Medicine, recently introduced in the UK, will go some way towards correcting this, and its syllabus has provided the catalyst for this themed issue.

Haemorrhoids and joint hypermobility: a new extra-articular association.

An association has been demonstrated between haemorrhoids and joint hypermobility. Reasons for this are discussed. Many performing artists are hypermobile and the extra-articular features of joint hypermobility should not be forgotten or underestimated as a potential constraint upon performance.

Release of growth factors and the effect of age, sex, and severity of injury after long bone fracture. A preliminary report.

BACKGROUND AND PURPOSE: The systemic response after fracture is regulated by a complex mechanism involving numerous growth factors. In this study, we analyzed the kinetics of key growth factors following lower-limb long bone fracture. MATERIALS AND METHODS: Human serum was isolated from 15 patients suffering from lower-limb long bone fracture (tibia/femur) requiring surgical fixation. The levels of platelet-derived growth factor (PDGF-BB), vascular edothelial growth factor (VEGF), insulin growth factor-I (IGF-I), and transforming growth factor ß1 (TGF-ß1) were assayed by colorimetric ELISA at different time points during the first week after fracture. 10 healthy volunteers made up the control group of the study. Serum levels of the growth factors measured were compared to age, sex, and injury severity score. RESULTS: We found that there was a decline in the levels of PDGF-BB, IGF-I and TGF-ß1 during the first 3 days after fracture. However, VEGF levels remained unchanged. The levels of all the growth factors studied then increased, with the highest concentrations noted at day 7 after surgery. No correlation was found between circulating levels of growth factors and age, injury severity score (ISS), blood loss, or fluid administration. INTERPRETATION: There are systemic mitogenic and osteogenic signals after fracture. Important growth factors are released into the peripheral circulation, but early after surgery it appears that serum levels of key growth factors fall. By 7 days postoperatively, the levels had increased considerably. Our findings should be considered in cases where autologous serum is used for ex vivo expansion of mesenchymal stem cells. There should be further evaluation of the use of these molecules as biomarkers of bone union.

The effect of antibiotics on bone healing: current evidence.

INTRODUCTION: Bone healing is a complex cascade of events that involves the proliferation and differentiation of osteoblastic cells under the influence of signals from growth factors, cytokines and mechanical loading. Several medications have been found to interact negatively with this process including cytostatics, NSAIDs and corticosteroids; however, the effect of antibiotics on bone repair processes remains obscure. AREAS COVERED: The authors offer a comprehensive review of the existing literature on the in vivo and in vitro effect of antibiotics on bone, bone cells and fracture healing. The authors describe the pharmacokinetic characteristics of antibiotics after parenteral administration as well as their levels when applied locally together with a delivery vehicle. EXPERT OPINION: The available experimental data and clinical evidence are rather limited to allow safe conclusions. In vitro studies indicate that high doses administered after systemic administration have little or no direct effect on bone cells. Further studies are desirable to define the effect of higher or prolonged concentrations on bone biology and especially that of high concentrations released by locally implanted antibiotic-delivery systems, that is, bone cement, spacers and beads.

The effectiveness of nurse-led care in people with rheumatoid arthritis: a systematic review.

OBJECTIVES: The objective of this systematic review was to determine the effectiveness of nurse-led care in rheumatoid arthritis. DESIGN: Systematic review of effectiveness. DATA SOURCES: Electronic databases (AMED, CENTRAL, CINAHL, EMBASE, HMIC, HTA, MEDLINE, NHEED, Ovid Nursing and PsycINFO) were searched from 1988 to January 2010 with no language restrictions. Inclusion criteria were: randomised controlled trials, nurse-led care being part of the intervention and including patients with RA. REVIEW METHODS: Data were extracted by one reviewer and checked by a second reviewer. Quality assessment was conducted independently by two reviewers using the Cochrane Collaboration's Risk of Bias Tool. For each outcome measure, the effect size was assessed using risk ratio or ratio of means (RoM) with corresponding 95% confidence intervals (CI) as appropriate. Where possible, data from similar outcomes were pooled in a meta-analysis. RESULTS: Seven records representing 4 RCTs with an overall low risk of bias (good quality) were included in the review. They included 431 patients and the interventions (nurse-led care vs usual care) lasted for 1-2years. Most effect sizes of disease activity measures were inconclusive (DAS28 RoM=0.96, 95%CI [0.90-1.02], P=0.16; plasma viscosity RoM=1 95%CI [0.8-1.26], p=0.99) except the Ritchie Articular Index (RoM=0.89, 95%CI [0.84-0.95], P<0.001) which favoured nurse-led care. Results from some secondary outcomes (functional status, stiffness and coping with arthritis) were also inconclusive. Other outcomes (satisfaction and pain) displayed mixed results when assessed using different tools making them also inconclusive. Significant effects of nurse-led care were seen in quality of life (RAQoL RoM=0.83, 95%CI [0.75-0.92], P<0.001), patient knowledge (PKQ RoM=4.39, 95%CI [3.35-5.72], P<0.001) and fatigue (median difference=-330, P=0.02). CONCLUSIONS: The estimates of the primary outcome and most secondary outcomes showed no significant difference between nurse-led care and the usual care. While few outcomes favoured nurse-led care, there is insufficient evidence to conclude whether this is the case. More good quality RCTs of nurse-led care effectiveness in rheumatoid arthritis are required.

A randomised, controlled study of outcome and cost effectiveness for RA patients attending nurse-led rheumatology clinics: study protocol of an ongoing nationwide multi-centre study.

BACKGROUND: The rise in the number of patients with arthritis coupled with understaffing of medical services has seen the deployment of Clinical Nurse Specialists in running nurse-led clinics alongside the rheumatologist clinics. There are no systematic reviews of nurse-led care effectiveness in rheumatoid arthritis. Few published RCTs exist and they have shown positive results for nurse-led care but they have several limitations and there has been no economic assessment of rheumatology nurse-led care in the UK. OBJECTIVE: This paper outlines the study protocol and methodology currently being used to evaluate the outcomes and cost effectiveness for patients attending rheumatology nurse-led clinics. DESIGN AND METHODS: A multi-centred, pragmatic randomised controlled trial with a non-inferiority design; the null hypothesis being that of 'inferiority' of nurse-led clinics compared to physician-led clinics. The primary outcome is rheumatoid arthritis disease activity (measured by DAS28 score) and secondary outcomes are quality of life, self-efficacy, disability, psychological well-being, satisfaction, pain, fatigue and stiffness. Cost effectiveness will be measured using the EQ-5D, DAS28 and cost profile for each centre. POWER CALCULATIONS: In this trial, a DAS28 change of 0.6 is considered to be the threshold for clinical distinction of 'inferiority'. A sample size of 180 participants (90 per treatment arm) is needed to reject the null hypothesis of 'inferiority', given 90% power. Primary analysis will focus on 2-sided 95% confidence interval evaluation of between-group differences in DAS28 change scores averaged over 4 equidistant follow up time points (13, 26, 39 and 52 weeks). Cost effectiveness will be evaluated assessing the joint parameterisation of costs and effects. RESULTS: The study started in July 2007 and the results are expected after July 2011. TRIAL REGISTRATION: The International Standard Randomised Controlled Trial Number ISRCTN29803766.

NSAIDS inhibit in vitro MSC chondrogenesis but not osteogenesis: implications for mechanism of bone formation inhibition in man.

The non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for analgesia but may inhibit bone formation. We investigated whether the reported NSAID effect on bone is related to inhibition of bone marrow mesenchymal stem cell (MSC) proliferation and osteogenic and chondrogenic differentiation and evaluated both cyclooxygenase (COX)-1 and COX-2 specific drugs. The effects of seven COX-1 and COX-2 inhibitors on MSC proliferation and osteogenic and chondrogenic differentiation were tested using Vybrant, sodium 3'-[1-(phenylaminocarbonyl)- 3,4-tetrazolium]-bis (4-methoxy-6-nitro) benzene sulfonic acid hydrate (XTT), functional and quantitative assays of MSC differentiation. The MSC expression of COX-1 and COX-2 and prostaglandin E2 (PGE-2) levels were evaluated serially during lineage differentiation by quantitative PCR and ELISA. None of the NSAIDs at broad range of concentration (range 10(-3) to 100 µg/ml) significantly affected MSC proliferation. Surprisingly, MSC osteogenic differentiation inhibition was not evident. However, NSAIDs affected chondrogenic potential with a reduction in sulphated glycosaminoglycans (sGAG) content by 45% and 55% with diclofenac and ketorolac, respectively (P < 0.05 compared to controls). Parecoxib and meloxicam, more COX-2 specific reagents inhibited sGAG to a lesser degree, 22% and 27% respectively (P < 0.05 compared to controls). Cartilage pellet immunohistochemistry confirmed the above results. Pellet chondrogenesis was associated with increased COX-1 expression levels but not COX-2, and COX-1 specific drugs suppressed MSC PGE-2 more than COX-2 specific inhibitors. These findings suggest that NSAIDs may inhibit bone formation via blockage of MSC chondrogenic differentiation which is an important intermediate phase in normal endochondral bone formation.

Effects of walking with a shopping trolley on spinal posture and loading in subjects with neurogenic claudication.

OBJECTIVES: To explore possible mechanisms underpinning symptom relief and improved walking tolerance in patients with neurogenic claudication (NC) when pushing a shopping trolley by evaluating the effects of a shopping trolley on spinal posture and loading patterns. DESIGN: An exploratory study of kinematic and kinetic changes in walking with and without pushing a shopping trolley in persons with NC symptoms and a comparison with asymptomatic control subjects. SETTING: A primary care-based musculoskeletal service. PARTICIPANTS: Participants (n=8) with NC symptoms who have anecdotally reported symptomatic improvement when walking with a shopping trolley and a control group of asymptomatic persons (n=8). INTERVENTIONS: Shopping trolley. MAIN OUTCOME MEASURES: Changes in lumbar spinal sagittal posture and ground reaction force. RESULTS: Subjects with NC and asymptomatic controls walked with significantly more flexed spinal posture (increase in flexion, 3.40°; z=3.516; P<.001) and reduced mean ground reaction forces (-6.9% of body weight; z=-3.46; P=.001) when walking with a shopping trolley. However, at the midstance point of the gait cycle, controls showed minimal reliance on the trolley, whereas, people with NC showed continued offloading. CONCLUSIONS: Both posture and loading are affected by pushing a shopping trolley; however, patients with NC were found to offload the spine throughout the stance phase of gait, whereas asymptomatic controls did not.

The effect of bone morphogenetic protein-2, bone morphogenetic protein-7, parathyroid hormone, and platelet-derived growth factor on the proliferation and osteogenic differentiation of mesenchymal stem cells derived from osteoporotic bone.

INTRODUCTION: It has been previously shown that in patients with osteoporosis, mesenchymal stem cell (MSC) growth rate and osteogenic potential is decreased contributing to inferior fracture consolidation. The aim of this study was to investigate the effect of bone morphogenetic protein-2 (BMP-2), BMP-7, parathyroid hormone (PTH), and platelet-derived growth factor (PDGF) on proliferation and osteogenic differentiation of MSCs derived from patients with osteoporosis. MATERIALS AND METHODS: Trabecular bone was obtained from 10 patients (four males, mean age 76 years) with lower extremity osteoporotic fractures. MSCs were isolated by enzymatic digestion. Functional assays of proliferation and osteogenic differentiation were performed under the influence of a wide range of concentrations of BMP-2, BMP-7, PTH, and PDGF-BB. Proliferation was assessed using CFU-F and XTT assays. Osteogenic differentiation was assessed by alkaline phosphatase activity and total calcium production. RESULTS: MSC proliferation was found to be stimulated by supplementation with BMP-7 and PDGF-BB, whereas BMP-2 and PTH had little effect. The largest increase in proliferation rate was observed after administration 100 ng/mL of BMP-7. All four molecules induced alkaline phosphatase activity and calcium production in growing osteoblasts with a dose-dependent effect noted. BMP-2 and BMP-7 at their highest studied concentration (100 ng/mL) produced a threefold increase in the osteogenic potential of MSCs. CONCLUSION: BMP-7, BMP-2, PTH, and PDGF-BB were observed to have a positive effect on osteogenic differentiation of MSCs. BMP-7 and PDGF-BB (in high doses) could be considered most potentially advantageous because they enhance both proliferation and osteogenic differentiation of MSCs derived from elderly osteoporotic bone.

The effectiveness of walking stick use for neurogenic claudication: results from a randomized trial and the effects on walking tolerance and posture.

UNLABELLED: Comer CM, Johnson MI, Marchant PR, Redmond AC, Bird HA, Conaghan PG. The effectiveness of walking stick use for neurogenic claudication: results from a randomized trial and the effects on walking tolerance and posture. OBJECTIVES: To determine the immediate effects of using a stick on walking tolerance and on the potential explanatory variable of posture, and to provide a preliminary evaluation of the effects of daily walking stick use on symptoms and function for people with neurogenic claudication. DESIGN: A 2-phase study of neurogenic claudication patients comprising a randomized trial of 2 weeks of home use of a walking stick and a crossover study comparing walking tolerance and posture with and without a walking stick. SETTING: A primary care-based musculoskeletal service. PARTICIPANTS: Patients aged 50 years or older with neurogenic claudication symptoms (N=46; 24 women, 22 men, mean age=71.26y) were recruited. INTERVENTION: Walking stick. MAIN OUTCOME MEASURES: Phase 1 of the trial used the Zurich Claudication Questionnaire symptom severity and physical function scores to measure outcome. The total walking distance during a shuttle walking test and the mean lumbar spinal posture (measured by using electronic goniometry) were used as the primary outcome measurements in the second phase. RESULTS: Forty of the participants completed phase 1 of the trial, and 40 completed phase 2. No significant differences in symptom severity or physical function were shown in score improvements for walking stick users (stick user scores - control scores) in the 2-week trial (95% confidence interval [CI], -.24 to .28 and -.10 to .26, respectively). In the second phase of the trial, the ratio of the shuttle walking distance with a stick to without a stick showed no significance (95% CI, .959-1.096) between the groups. Furthermore, the use of a walking stick did not systematically promote spinal flexion; no significant difference was shown for mean lumbar spinal flexion for stick use versus no stick (95% CI, .351 degrees -.836 degrees ). CONCLUSIONS: The prescription of a walking stick does not improve walking tolerance or systematically alter the postural mechanisms associated with symptoms in neurogenic claudication.

Assessment and management of neurogenic claudication associated with lumbar spinal stenosis in a UK primary care musculoskeletal service: a survey of current practice among physiotherapists.

BACKGROUND: Neurogenic claudication (NC) is the clinical syndrome commonly associated with lumbar spinal stenosis (LSS). Non-surgical management is recommended as initial treatment, but little is known about current practice in relation to the assessment and management of these patients in the non-surgical setting. METHODS: We conducted a questionnaire survey of physiotherapists in a large UK primary care musculoskeletal service which provides a city-wide multidisciplinary assessment and treatment facility for patients with spinal and other musculoskeletal problems. Data on therapists' recognition and management of patients with NC and LSS were collected. RESULTS: Fifty out of 54 therapists completed questionnaires, and all but one of these identified a clearly recognised posture-related clinical syndrome of NC. Almost all respondents (48: 96%) reported the routine use of physiotherapy treatments. In particular, advice and education (49: 98%) along with an exercise programme (47: 94%) incorporating flexion-based exercises (41: 82%) and trunk muscle stabilising exercises (35: 70%) were favoured. CONCLUSION: Musculoskeletal physiotherapy clinicians in this survey recognised a clear clinical syndrome of NC, based on the findings of posture-dependent symptoms. Most therapists reported the routine use of flexion-based exercise, reflecting recommendations in the literature which are based on theoretical benefits, but for which trial evidence is lacking. There is a need for research evidence to guide the choice of physiotherapy treatments.

Do OA patients gain additional benefit from care from a clinical nurse specialist?--a randomized clinical trial.

OBJECTIVES: To assess whether OA patients attending a clinical nurse specialist (CNS) clinic gain 'additional benefit' compared with those attending a traditional junior hospital doctor (JHD) clinic. METHODS: A total of 100 patients with OA attending rheumatology clinics at a UK teaching hospital were randomly allocated to a CNS or JHD clinic and seen at 0, 16, 32 and 48 weeks. The study assessed (i) non-inferiority of the CNS with respect to clinical outcomes (pain, morning stiffness, self-efficacy, physical function and psychological status) and (ii) superiority of the CNS in terms of patient knowledge and satisfaction. RESULTS: Average pain at follow-up was lower in the CNS group: unadjusted mean difference for the JHD group minus the CNS group was 5.3 (95% CI -4.6, 15.2); adjusted was 1.6 (95% CI -5.7, 8.9). The corresponding effect size estimates were 0.20 (95% CI -0.17, 0.57) and 0.06 (95% CI -0.21, 0.33), respectively. There were similar outcomes in morning stiffness, physical function and self-efficacy. Patient knowledge and satisfaction were statistically significant at the 5% level attaining moderate to large effect sizes in favour of the CNS. CONCLUSIONS: Our findings demonstrate that the clinical outcome of CNS care is not inferior to that of JHD care, and patients attending CNS gain additional benefit in that they are better informed about their disease and significantly more satisfied with care than are their counterparts.