[Influence of testing position on lumbar isokinetic measurements]. / Influence de la position de test sur l'évaluation isocinétique lombaire.

UNLABELLED: The studies carried out on the lumbar spine, using an isokinetic type machine, showed the importance of the extensor muscles and the force they develop, compared with the flexor muscles. Both the sitting and standing positions were used without determining the better position. MAIN OBJECTIVE OF THE STUDY: To determine how the patients position influenced the performance of the muscles. We also studied a new parameter : the angle to maximal peak torque (APT). MATERIAL AND METHOD: 17 healthy subjects and 19 suffering from low back pain were chosen. We perform the test in both positions for each subject. We compare in each group the peak torque of the extensor and flexor muscles on both positions and the angle of this torque. RESULTS: Low back pain subjects flexor/extensor ratio were 1.71 sitting and 1.56 standing. Healthy subjects showed normal ratio of 0.69 and 0.84. CONCLUSION: The position of the subject has no influence on the results in the low back pain subjects, and the sitting position is preferred. The angle of development of the maximal peak torque in both groups of muscles was very interesting, especially in the subjects suffering from low back pain and shines a new light on the different functions of the muscles of the low back pain suffering subjects and the healthy subjects. This angle (APT) is inversed in low back pain subjects who develop more torque for the extensors in extension of the spine.

The occurrence of the ilio-lumbar syndrome in a spinal cord injury patient.

STUDY DESIGN: Case report of a 71-year-old man having sustained a spinal cord injury (SCI) for 26 years. He started to suffer from low back pain 21 years after his onset and this was diagnosed as ilio-lumbar syndrome (ILS). OBJECTIVES: To describe the problem of low back pain occurring after a change of wheelchair in a SCI, and to indicate the importance of the ilio-lumbar syndrome as a possible cause of low back complaint. OUTCOME: Clinical findings supported by echotomography confirmed the diagnosis of ILS in our case. CONCLUSION: ILS should be considered when some changes and deterioration of the status of SCI occur due to low back complaint.

Effect of calcitonin on bone and connective tissue metabolism in hemiplegic patients: a two-year prospective study.

OBJECTIVES: To test the effects of 200 IU/day of a nasal spray of salmon calcitonin in modulating the increased bone tissue metabolism observed in hemiplegic patients. DESIGN: A two-year, prospective, randomized, double-blind, placebo-controlled study. PATIENTS: Thirty-four patients with hemiplegia due to a cerebrovascular accident were included in the study during the first month after onset of hemiplegia after giving their informed consent. All patients followed a suitably planned course of active rehabilitation according to Bobath. They were randomly allocated to either the calcitonin or the placebo group but all of them received a daily oral calcium supplementation of 1000 mg. RESULTS: Biochemical markers of bone formation, serum total alkaline phosphatase, osteocalcin and type I procollagen did not vary during the two years of follow-up. Cross-linked carboxy-terminal telopeptide of type I collagen, a biochemical marker of bone resorption, was elevated initially after stroke and then decreased significantly (p <0.001), stabilizing as of month 12. Urinary calcium/creatinine and total hydroxyproline/creatinine ratios presented with similar profiles. The serum levels of the type III procollagen, a marker of connective tissue metabolism, were also elevated upon entry and decreased thereafter. No significant difference could be found between the calcitonin-treated and the placebo group for any of the biochemical markers at any time point. CONCLUSION: This prospective study demonstrated that biochemical markers of bone and connective tissue metabolism were elevated shortly after the occurrence of stroke and then gradually decreased during the first two years after injury. The daily administration of 200 IU of intranasal calcitonin did not influence the levels of these markers.

Shoulder pain and dysfunction in hemiplegia: effects of functional electrical stimulation.

OBJECTIVE: To determine the influence of functional electrical stimulation (FES) on subluxation and shoulder pain in hemiplegic patients. DESIGN: Controlled study of 24 months' duration beginning in the first month after onset of stroke. SUBJECTS AND SETTING: One hundred twenty hemiplegic patients with both subluxed and painful shoulder were followed for rehabilitation before and after discharge between 1989 and 1993. All subjects received conventional rehabilitation based on the Bobath concept. In addition, patients were alternately assigned to a control group or to receive additional FES for 5 weeks on muscles surrounding their subluxed and painful shoulder. MAIN MEASURES: Clinical examinations, including range of motion, pain assessment, and x-rays, were performed at the start of the study, between the second and fourth weeks after onset of stroke, and subsequently at 6, 12, and 24 months. RESULTS: The FES group showed significantly more improvement than the control group in both pain relief (80.7% vs. 55.1%, p<.01) and reduction of subluxation (78.9% vs. 58.6%, p<.05). Furthermore, recovery of arm motion appeared to be significantly improved in the FES group (77.1% vs. 60.3% in the control group, p<.01). CONCLUSION: The FES program was significantly effective in reducing the severity of subluxation and pain and possibly may have facilitated recovery of the shoulder function in hemiplegic patients.

Effects of oral chondroitin sulfate on the progression of knee osteoarthritis: a pilot study.

The aim of this study was to assess the clinical, radiological and biological efficacy and tolerability of the SYSADOA, chondroitin 4- and 6-sulfate (CS, Condrosulf, IBSA, Lugano, Switzerland), in patients suffering from knee osteoarthritis. This was a 1-year, randomized, double-blind, controlled pilot study which included 42 patients of both sexes, aged 35-78 years with symptomatic knee OA. Patients were treated orally with 800 mg chondroitin sulfate (CS) per day or with a placebo (PBO) administered in identical sachets. The main outcome criteria were the degree of spontaneous joint pain and the overall mobility capacity. Secondary outcome criteria included the actual joint space measurement and the levels of biochemical markers of bone and joint metabolism. This limited study confirmed that chondroitin sulfate was well-tolerated and both significantly reduced pain and increased overall mobility capacity. Treatment with CS was also associated in a limited group of patients with a stabilization of the medial femoro-tibial joint width, measured with a digitized automatic image analyzer, whereas joint space narrowing did occur in placebo-treated patients. In addition, the metabolism of bone and joint assessed by various biochemical markers also stabilized in the CS patients whereas it was still abnormal in the PBO patients. These results confirm that oral chondroitin 4- and 6-sulfate is an effective and safe symptomatic slow-acting drug for the treatment of knee OA. In addition, CS might be able to stabilize the joint space width and to modulate bone and joint metabolism. This is the first preliminary demonstration that a SYSADOA might influence the natural course of OA in humans.

Effects of a 110 kilometers ultra-marathon race on plasma hormone levels.

To assess changes of sex hormones, cortisol, prolactin (PRL) and beta-endorphins in an exhaustive aerobic performance, blood samples were taken in 11 endurance trained runners (R) along an ultra-marathon race of 110 km (T1 before the start, T2 at km 33, T3 at km 75 and T4 immediately after completing the race). Results were compared to a control group (C) who followed the race. Cortisol (p < 0.001) and beta-endorphins (p = 0.009) showed a significant increase during the race without significant modification after T2. Testosterone decreased along the race (p = 0.02). Luteinising hormone (LH) was lower at the end of the race as compared to the start in the R. No modification of PRL was noticed in the runners. Most of the modifications except for testosterone were observed from the start to T2, even in exhaustive performance no further modification was noticed from that point onwards.

Bone metabolism in spinal cord injured individuals and in others who have prolonged immobilisation. A review.

Immobilisation or disuse is a condition known to be associated with a decrease in bone mass, osteopenia and in some people leading to osteoporosis with an increased risk of fractures. In this condition, previous histomorphometric and biochemical reports have shown an uncoupling between bone formation and resorption, but the exact sequence of the events resulting in bone loss is still not fully understood. In spinal cord injury for instance, the main finding soon after the onset is decreased osteoblastic activity associated with a dramatic increase in bone degradation. The overall consequence of these metabolic events is the development of a rapid and severe osteoporosis only observed in the paralysed part of the body associated with the loss of biomechanical strength and the biosynthesis of a structurally modified matrix which is unable to sustain normal mechanical stress. This situation dramatically increases the risk of fractures. The same uncoupling phenomenon has been described in healthy individuals who have been submitted to long duration bedrest and also in astronauts during spaceflight; but the timing, intensity and the metabolic subset may be different as these people do recover after cessation of the disuse period, which does not occur in paralysed patients. As new accurate and sensitive non-invasive techniques have become available recently to assess bone and connective tissue metabolism, more information is now available regarding bone loss in paralysed and/or immobilised individuals. These techniques should be definitely helpful in orientating new therapeutic trials with drugs and/or procedures intended to correct the musculoskeletal deleterious effects of disuse. This paper is therefore aimed at a review of bone metabolism in those with a severe spinal cord injury, or with a long duration of bedrest, or with loss of biomechanical function, or with actual or simulated spaceflight, in all instances using non-invasive techniques.

Biochemical analysis of heterotopic ossification in spinal cord injury patients.

Heterotopic ossification (HO) represents a frequent complication in spinal cord injury (SCI) patients. Samples of HO taken from SCI patients were studied and compared to normal bone. We used a procedure of bone particle fractionation (according to their degree of mineralisation) which allowed us to establish a profile reflecting the metabolic remodeling of bone and to analyse the organic matrix of the newly synthesised tissue. In paraplegic patients, we noted that there was a large increase of the proportion of a degree of calcified bone in the HO as we had previously observed in cortical as well as in cancellous bone of the same patients. Based on aminoacid analyses, we observed in the newly synthesised organic matrix of HO a decreased proportion of hydroxyprolyl residues resulting either from an alteration of the prolyl hydroxylation or from the presence of an excess of non-collagen polypeptides. These results are similar to those seen in sublesional bone of the SCI patients. This study demonstrates that HO is a newly formed bone which has a high rate of turnover as is seen in growing bone. This must be taken into account for the treatment of the patients.

Early modifications of biochemical markers of bone metabolism in spinal cord injury patients. A preliminary study.

Spinal cord injury is associated with the development of a rapid and severe osteoporosis which might reflect uncoupling between bone formation and resorption. A prospective study was made in 6 spinal cord injury patients followed up to 2-3 months after onset with various markers of a) bone formation: osteocalcin and C-terminal peptide of type I procollagen, b) bone resorption: pyridinolines and C-terminal telopeptide of type I collagen, c) connective tissue metabolism: amino-terminal propeptide of type III collagen (PIIINP). Preliminary results show that early after onset, bone formation was depressed as compared to dramatically increased bone resorption. Low bone formation rate lasted two weeks before it began to raise, while bone resorption showed a continuous tendency to increase. The dramatic increase in PIIINP levels might represent some attempt of bone to repair. This paper describes the evolution of various biochemical markers of bone and connective tissue metabolism after onset of paralysis and critically reviews the use of those markers in patients with spinal cord injury.

[Eating behavior and bone mineral density in young women marathon participants]. / Comportement alimentaire et densité minérale osseuse chez des jeunes marathonniennes.

Although reduced gonadal steroid hormone concentration appear to play a major role in lower trabecular bone density (BMD) in female marathon runners, dietary deficiencies and eating behaviors may also affect BMD. To investigate that possibility, dietary patterns and BMD were examined in 27 female regular marathon runners classified as eumenorrheic (8), amenorrheic (10) and under oral contraception (9). The results show a significant lower BMD in amenorrheic athletes but no dietary deficiencies. These results suggest that the eating behavior don't play any role in the lower BMD of our athletes.

Electroacupuncture in fibromyalgia: results of a controlled trial.

OBJECTIVE: To determine the efficacy of electroacupuncture in patients with fibromyalgia, a syndrome of unknown origin causing diffuse musculoskeletal pain. DESIGN: Three weeks' randomised study with blinded patients and evaluating physician. SETTING: University divisions of physical medicine and rehabilitation and rheumatology, Geneva. PATIENTS: 70 patients (54 women) referred to the division for fibromyalgia as defined by the American College of Rheumatology. INTERVENTIONS: Patients were randomised to electroacupuncture (n = 36) or a sham procedure (n = 34) by means of an electronic numbers generator. MAIN OUTCOME MEASURES: Pain threshold, number of analgesic tablets used, regional pain score, pain recorded on visual analogue scale, sleep quality, morning stiffness, and patient's and evaluating physician's appreciation. RESULTS: Seven of the eight outcome parameters showed a significant improvement in the active treatment group whereas none were improved in the sham treatment group. Differences between the groups were significant for five of the eight outcome measures after treatment. CONCLUSIONS: Electroacupuncture is effective in relieving symptoms of fibromyalgia. Its potential in long term management should now be studied.

[Sports and arthrosis]. / Sport et arthrose.

Recent changes in lifestyle have considerably reduced the loads that joints have to bear through occupational stresses. It is now essentially during leisure time that most people use somewhat intensely their locomotive systems, mostly as sustained bouts of physical exercise. The physician is therefore led to examining critically these sports activities and their consequences. One has to be aware of the fact that some sports may bring about an articular overuse, partly through trauma and partly through microtrauma. Nevertheless, when reviewing recent literature on the implied relation between exercise and degenerative joint disease, one is amazed in observing how contradictory the current opinions are. This article intends to be both a review and a synthesis of the various factors which are commonly accepted as playing a role in the etiology of degenerative joint disease consecutive to exercise. We take into account by the same token the well-known advantages of physical activity such as prevention of cardiovascular disease and atherosclerosis, the enhancement of psychic well-being and the delaying of the onset of ageing. Thus, knowing which sports may promote degenerative joint disease under given conditions, the physician will be able to counsel people with an identified proneness to joint disease into undertaking more healthful physical workouts.

A biophysical study of posttraumatic ectopic ossification. A case report.

Sites of ectopic ossification (EO) due to sports injury in a long-distance runner were biopsied and analyzed. The mineral content was compared to that of normal adult bone and to paraosteoarthropathy (POA) using biophysical methods. The degree of mineralization of bone tissue (DMBT) was employed as an evaluation of maturity of calcified tissue. Fluoride and carbonate content were determined. The crystal lattice dimensions expressed by the a and c parameters, crystal size, and/or lattice perfection were obtained with x-ray diffraction. All values were near those found in nonpathologic, newly deposited human compact bone. DMBT, crystal size, and/or lattice perfection were near those observed in a 24- to 30-month-old POA. The data suggest that posttraumatic EO represents otherwise normal young bone.

Bone metabolism in hemiplegic patients.

Bone metabolism has been assessed in 36 hemiplegic patients (18-77 years), 26 with CVA and 10 with head injuries. The results show an increase of serum calcium and phosphorous levels in the first month as well as hydroxyprolinuria. The radiological examination showed signs of demineralisation, as well as single photon absorptiometry of both arms. Bone scan by 99Te demonstrated a hypercaptation in both paralysed limbs. From the 36 patients, 17 had a 47Ca kinetic study which showed an average of normal values as far as bone accretion (Vo+) is concerned. However, the two youngest patients (18 and 32 years) had a high value of this parameter. The urinary calcium excretion (Vu) and the fecal calcium excretion (Vf) was also increased in the 17 patients. The bone resorption measured by Vo- was also high at the beginning of the study and significantly decreased 12 months later. Our observations show that neurologic osteoporosis of the hemiplegic patient is related to an unbalance between the synthesis and the degradation of a bone whose metabolism is active. Related to the determination of the intramedullary pressure and intraosseous phlebography, it seems that this resorption is due to a venous stasis. This circulatory modification regime can influence cell differentiation and probably be responsible in a way for this osteoporosis.

Modified release tizanidine in the treatment of spasticity.

A 6-week study of a modified release formulation of tizanidine designed for once daily administration was performed in 27 patients with spasticity due to cerebral lesions. The dosage of tizanidine used ranged from 6 to 18 mg/day. At the start of the study all patients had at least moderate spasticity and 20 (74%) patients had severe or very severe spasticity. All had a decrease in muscle strength. After 1 week of treatment 22 (81%) patients showed improvement in overall spastic state and, after 6 weeks, all 27 patients had improved. At the end of treatment 25 (93%) patients showed an improvement in overall disability. The drug was well tolerated. Side-effects were reported in only four patients, and these were minor and mostly mild. Tizanidine had no clinically important effects on blood pressure, heart rate, body weight or laboratory values. Overall, once daily treatment with modified release tizanidine is well tolerated and gives good clinical efficacy in patients with spasticity.