Benefits and liabilities of hypermobility in the back pain disorders of industrial workers.

OBJECTIVES: Back pain disorders, sometimes called 'the nemesis of medicine and the albatross of industry', are ubiquitous, but have stubbornly defied diagnosis and treatment. Hypermobility syndrome, which is also very common, has been called 'an enigma of human physiology'. Both conditions have attracted wide attention and interest only recently. In an earlier study, we considered the benefits and liabilities of joint hypermobility by studying 660 musicians in the USA. In a parallel manner, the present study analysed the back pain disorders of 606 workers in a Swedish high-technology industrial plant in the context of spinal hypermobility. SUBJECTS AND METHODS: The 606 industrial workers were examined for spinal hypermobility using a standard protocol, and interviewed for work-related body-posture requirements and the low back, shoulder and neck pain disorders experienced by them. The data were analysed for associations between hypermobility and physical complaints as a whole, and by taking into account gender and body-postures at work. RESULTS: Twenty-six per cent (37) of 144 workers with hypermobility but only 14% (64) of 453 without hypermobility experienced back pain (P < 0.002). Among the 326 workers with sitting or standing jobs, 40% (29) of 71 with hypermobility had back pain, whereas only 12% (30) of the 255 without hypermobility experienced back pain (P < 0.001). The corresponding numbers with back pain for 235 in jobs with changing body-postures were 4.5% (3) of 66 with hypermobility and 14% (14) of 169 without hypermobility (P = 0.04). CONCLUSIONS: Hypermobility of the spine is an asset if the work requires change of body-posture, but a liability for those in a standing or sitting assignment. It reinforces a similar hypothesis proposed by Larsson et al.

Benefits and disadvantages of joint hypermobility among musicians.

BACKGROUND: Joint hypermobility is considered to be both an advantage and a disadvantage. However, the degree of hypermobility in members of particular occupations requiring intense physical activity and the nature of the association between symptoms referable to specific joints and their hypermobility are unknown. METHODS: We interviewed 660 musicians (300 women and 360 men) about work-related symptoms such as joint pain and swelling and examined them for joint hypermobility according to a standard protocol. We then determined the relation between the mobility of their fingers, thumbs, elbows, knees, and spine and any symptoms referable to these regions. RESULTS: Five of the 96 musicians (5 percent) with hypermobility of the wrists, mostly instrumentalists who played the flute, violin, or piano, had pain and stiffness in this region, whereas 100 of the 564 musicians (18 percent) without such hypermobility had symptoms (P = 0.001). Hypermobility of the elbow was associated with symptoms in only 1 of 208 musicians (< 1 percent), whereas 7 of 452 (2 percent) without this hypermobility had symptoms (P = 0.45). Among the 132 musicians who had hypermobile knees, 6 (5 percent) had symptoms, whereas only 1 of 528 (< 1 percent) with normal knees had symptoms (P < 0.001). Of the 462 musicians who had normal mobility of the spine, 50 (11 percent) had symptoms involving the back, as compared with 46 of the 198 musicians (23 percent) who had hypermobility of the spine (P < 0.001). CONCLUSIONS: Among musicians who play instruments requiring repetitive motion, hypermobility of joints such as the wrists and elbows may be an asset, whereas hypermobility of less frequently moved joints such as the knees and spine may be a liability.

Hypermobility: prevalence and features in a Swedish population.

In this investigation, parallel to an earlier study [1] of 660 musicians from the USA, 606 individuals from a factory in Ostersund, Sweden, were studied to determine the prevalence and nature of their hypermobility. They were examined using the same protocol and by the same examiner as in the earlier study for the presence of five well recognized features of hypermobility. In this mostly middle-aged population of workers, as in the earlier population of mostly young musicians, joint laxity was found to be far more common among females. In both sexes hypermobility is seen to decline with age, the rate of fall being about the same for men and women.

A controlled trial of propoxyphene and naltrexone in patients with Tourette's syndrome.

To investigate the effect of drugs acting on the endogenous opioid system, we studied 10 adults with Tourette's syndrome who received propoxyphene hydrochloride (260 mg/day), naltrexone hydrochloride (50 mg/day), and placebo in a double-blinded, randomized clinical trial. Using a self-report scale (Tourette's Syndrome Symptom List), subjects noted a significant (p less than 0.04) lessening of tics after treatment with naltrexone when compared with placebo. An improvement in performance on the Trail Making B test, a measure of attention and visuomotor sequencing and planning, occurred after receiving naltrexone when compared with placebo (p less than 0.08) or propoxyphene (p less than 0.02). The Trail Making B test best discriminated the treatments (p less than 0.02, analysis of variance). No other treatment effects were observed for several other measures of tic severity, attentional ability, or obsessive-compulsive symptoms. Our findings indicate that pharmacological manipulation of the endogenous opioid system does influence symptoms of Tourette's syndrome.

Hypermobility: features and differential incidence between the sexes.

Six hundred sixty individuals from a music school were studied to determine the frequency of incidence and the nature of their hypermobility. They were interviewed and examined for the 5 recognized features of hypermobility (laxity of the thumbs, fingers, elbows, spine, and knees). The incidence of hypermobility, according to the number of joints involved, followed an empiric geometric law. Approximately 27% of the individuals had 1 lax joint, whereas only 3% possessed all 5 features. Specific features were present at different frequencies in the 2 sexes. The ratio of the occurrence of 2 features in women compared with the occurrence in men was 2:1. Ratios for the occurrence of 3, 4, and 5 features were 4:1, 8:1, and 3:1, respectively. Thus, hypermobility was a predominantly female characteristic. Joint laxity declined with age, although not to a statistically significant degree. In men, the decline started when they were in their mid-twenties; however, in women, joint laxity continued through the mid-forties.

Specific immunotherapy with suppressor function inhibition for metastatic renal cell carcinoma.

In this pilot clinical investigation we have investigated the concept of modulating suppressor T lymphocyte (Ts) function to augment delayed type hypersensitivity (DTH) and antitumor immunity in patients with metastatic renal cell carcinoma. Cyclophosphamide (CY) was used for modulating Ts function. We used three doses of CY per 100 mg/m2, 500 mg/m2, and 1000 mg/m2. Cyclophosphamide was administered i.v. 24 h prior to the first of 6 weekly immunizations with irradiated autologous tumor cells mixed with Corynebacterium parvum. Twenty of 26 patients were evaluable for response. Five of these 20 (25%) evaluable patients had responses, one complete response and four partial responses. Fifteen patients had post-treatment skin testing with autologous tumor cells. Four of these 15 (26%) patients developed DTH to autologous tumor cells. Of the four patients acquiring skin test positivity three also had clinical responses, whereas among the 11 skin-test negative patients, only one clinical response was observed. Six of six (100%) patients who had serial T lymphocyte subset studies done had increases in their mean T helper/inducer:T suppressor/cytotoxic ratios after CY administration and immunization. These observations in an exploratory study suggest that further investigations of Ts modulation, autologous tumor cell skin testing, and T lymphocyte subsets may be of value.

In vivo enhancement of antitumor immunity by interleukin 2-rich lymphokines.

The ability of interleukin 2 (IL-2) to enhance in vivo antitumor immunity has been evaluated in the line 1 alveolar cell carcinoma (L1) model of BALB/c mice. A crude supernatant from phorbol myristate acetate exposed EL-4 cells rich in IL-2 plus other lymphokines (EL-4 IL-2), a concanavalin A-induced supernatant from murine splenocytes (Con A IL-2), and recombinant IL-2 (rIL-2) provided by Biogen were tested. Mice were immunized with a cloned population of L1 cells (10(6) irradiated L1 cells given s.c. in the left inguinal region) followed by s.c. injections of EL-4 IL-2, Con A IL-2, or rIL-2 given to the same site. Two immunizations of L1 cells each followed by IL-2 administration were given prior to challenge with live L1 cells s.c. on the right chest wall. Mice receiving EL-4 IL-2 survived significantly longer than those receiving L1 cells only. Daily administration of EL-4 IL-2 for 7 days after the last L1 immunization was significantly better than 3 days (P less than 0.01) which in turn was significantly better than 1 day (P less than 0.05). Among the doses tested (normalized in vitro to the Biologic Response Modifiers Program IL-2 standard) 404 units of IL-2/injection was optimal. The EL-4 IL-2 had to be injected adjacent to the site of L1 cells; s.c. injection at a distant site or i.p. was not effective. When rIL-2 or Con A IL-2 was substituted for EL-4 IL-2, survival was not prolonged; however, if Con A IL-2 (low IL-2 levels) was supplemented with rIL-2 to 404 units of IL-2, it augmented immunity as well as 404 units of EL-4 IL-2. The data suggest that IL-2 is not the only lymphokine active in augmenting antitumor immunity induced by L1 cells. Some preliminary experiments indicate that a multilymphokine approach may have potential clinical relevance.

Juvenile rheumatoid arthritis. A comparison of patients from the USSR and USA.

Juvenile rheumatoid arthritis (JRA) in the Union of Soviet Socialist Republics (USSR) and the United States (USA) shows a remarkable similarity in age of disease onset, subtype onset, frequency, and most laboratory measurements. There is variation in the therapeutic approach with heavier reliance on aspirin in the USA. The evolution of JRA from onset subtype to final subtype over 5 years was the same in both groups and was independent of the type of therapy.

Airway hyperreactivity and peripheral airway dysfunction in influenza A infection.

We studied 39 consecutive college students with documented nonpneumonitic influenza A/Victoria/3/75/H3N2 infection to examine alterations in pulmonary mechanics and airway reactivity to cholinergic challenge, and to assess the effect of the antiviral agent amantadine on these changes. Thirty-six of the 39 subjects (92 per cent) demonstrated diminished forced flow rates and decreased density-dependent forced flow rates while breathing a helium-O2 mixture as compared to an air mixture. On initial evaluation, there was no significant difference in forced flow rates or density dependence between a group of 18 subjects treated with amantadine and 21 subjects given a placebo. However, the placebo group demonstrated further decreases in density dependence 7 days after initial presentation, whereas the amantadine group demonstrated a significant increase in density dependence (P less than 0.05), which suggested an accelerated improvement in peripheral airway dysfunction in the treated group. After inhalation of carbachol aerosol, 25 subjects showed a significant (P less than 0.05) increase in total respiratory resistance that was prolonged and independent of hay fever history. Airway hyperreactivity gradually diminished during a 7-week period in both groups. There was no significant difference in the initial degree of hyperreactivity or in the rate of improvement between groups. These data suggest that nonpneumonitic influenza infection may be associated with both an inflammatory response predominantly in the peripheral airways and transient bronchial hyperreactivity. By means of its antiviral effect, amantadine may arrest the proliferation of virus and associated inflammatory response in peripheral airways, but airway hyperreactivity presumably related to initially damaged airway depithelium is not attenuated by inhibition of viral replication after infection has been established.

A comparative study of five commercial reagents for the Coulter Model S: a proposed method for reagent evaluation.

A comparative study of five competitive commercial reagents for the Coulter Model S was performed jointly by two large, busy hospital laboratories with active quality control programs. Both laboratories, independently using the same reagent systems, studied 20 consecutive blood samples from patients from their own respective hospital for 20 days. Data from both laboratories were analyzed by standard and nonstandard statistical methods, and the results from both laboratories were compared. Although all reagent systems performed reasonably well in a clinical setting, highly significant statistical differences in their precisions were demonstrated by using univariate and multivariate techniques. The statistical method developed in this study can be applied to other systematic investigations that compare reagent systems.

The prevalence of alpha-antitrypsin heterozygotes (Pi MZ) in patients with obstructive pulmonary disease.

An increased incidence of intermediate deficiency of serum alpha1-antitrypsin resulting from Pi phenotype MZ has been reported in patients with chronic obstructive pulmonary disease (COPD) by some laboratories but not confirmed by others. Prevalence of Pi MZ was determined in patients with COPD among 502 subjects referred to a pulmonary function testing laboratory in a region with low concentrations of air pollutants. Control prevalences were obtained from 930 randomly selected subjects in the same community as well as from patients without COPD referred to the laboratory. Depending on criteria used to define COPD, 155 to 306 subjects had COPD. Pi MZ prevalence in subjects with COPD varied from 1.5 to 4 times the prevalence in the community control group and in the patients without COPD. This difference approached significance or was significant. Because Pi MZ was present in only 3.5 to 4.5 per cent of patients with COPD, Pi MZ is not a major factor in the etiology of COPD in this community. The higher incidence of Pi MZ inpatients with COPD reported by other investigators may be explained by small sample size, bias in selection of study or control population groups, or the development of COPD from interaction between Pi MZ and air pollutants or other factors not present in this community.

Pulmonary abnormalities in intermediate alpha-1-antitrypsin deficiency.

Pulmonary function studies were carried out in a group of asymptomatic nonsmoking adults with intermediate alpha-1-antitrypsin deficiency who were attending an early disease detection unit in Rochester, N. Y. All subjects were identified by specific protease inhibitor (Pi) typing. Fifteen MZ and 14 MS subjects who had never smoked cigarettes were matched by sex and age to MM controls. Spirometry, static lung volumes, and single breath-diffusing capacity were identical in all Pi type groups with no statistically significant differences noted. Maximal expiratory flow volume curves were obtained in all subjects. MZ subjects demonstrated statistically impaired maximal flow rates at 75%, 50%, and 25% of vital capacity compared to their MM controls. Total pulmonary resistance by the oscillometric method was measured at 3, 5, 7, and 9 cycle/s in the same subjects. Increased frequency dependence of resistance (defined as the difference between total pulmonary resistance at 3 cycle/s and 9 cycle/s) was observed in MZ subjects compared to MM controls. No differences were noted by this method in MS-MM pairs. The data suggest that detectable mechanical abnormalities are present in subjects with the MZ phenotype, even in the absence of established risk factors such as cigarette smoking and high air pollution.