[Fibromyalgia]. / La fibromyalgie.

PURPOSE: We review the current knowledge about fibromyalgia, adding to the clinical aspects, the nosology, epidemiology and pathogenesis. The therapeutic and social management of these suffering patients are discussed. KEY POINTS: The limitations of the American College of Rheumatology classification criteria used as diagnostic criteria are discussed. Fibromyalgia is not a simple psychiatric disorder, even if psychiatric symptoms are constantly found. Based on functional brain imaging, there is some evidence pointing to an abnormal function of the supra-spinal centres for pain regulation. CONCLUSION: Fibromyalgia is a clinical autonomous entity. Physiopathology knowledge is improving, but must be confirmed by new research. Patients will take profit of multimodal individualized treatment programs, including explanations about the diagnosis. In most cases, fibromyalgia is compatible with the maintenance of a professional activity, possibly adapted to the patient. Recognized disability requiring compensation is infrequent.

[Enthesiopathy and bone disease during the course of inflammatory spondylarthropathies. Diagnostic and physiopathologic importance]. / Atteinte des enthèses et de l'os au cours des spondylarthropathies inflammatoires. Signification diagnostique et physiopathologique.

Our studies concerning enthesopathies during the course of spondylarthropathies show that enthesopathies are very frequent: 58% among 48 spondylarthropathies in a preliminary study. The comparison of the frequency of enthesopathies in spondylarthropathies (58%) and in Rheumatoid Arthritis (6.6%) show a highly significant difference. In our latest study enthesopathies were found in 67% among 115 spondylarthropathies. We have also described the mean locations and clinical features. They are observed early in the course of the disease. Histological studies of enthesopatic and normal enthesis were also performed. They were unable to find a specific image. Nevertheless inflammatory changes in some of our cases and in cases retrieved in the medical literature confirm the involvement of enthesis in the pathological process of spondylarthropathies. Enthesopathies represent a very good diagnostic symptom. They are the hallmark of spondylarthropathies for adults and even more for children. Furthermore, if one admits the assertion that peripheral and spinal involvement is the result of bone remodeling enthesitic lesions, then enthesopathies and osteitis, ending in ankylosis, may be considered as the fundamental pathophysiological mechanism of spondylarthropathies in contrast with erosive lesions of rheumatoid arthritis.

Prediction of articular destruction in rheumatoid arthritis: disease activity markers revisited.

OBJECTIVE: To assess the predictive value for joint damage progression of commonly used disease activity or process measures in rheumatoid arthritis (RA). METHODS: Seventy-two patients fulfilling the American Rheumatism Association criteria for RA were assessed twice yearly for 2 years. Primary outcome variables were progression of articular destruction, evaluated by Sharp's method, for 6, 12, 18, and 24 month periods. RESULTS: Regression analysis, using random effects linear models, showed that only C-reactive protein, alpha 1-acid glycoprotein, iron, and erythrocyte sedimentation rate were significantly, but not independently, associated with 6 month radiographic progression. Traditional clinical measures were not predictive. No assessed marker was able to predict longer term outcome (12 or 18 month joint damage progression). Recent onset disease and older age were also associated with more severe radiographic progression. CONCLUSION: The lack of association between clinical measures and laboratory markers as predictors of the progression of articular destruction is further evidence of the need to reconsider processes and outcomes in RA. This study also suggests that clinical measures and laboratory markers probably do not reflect the same underlying process, arguing against gathering these measures under the same heading of "disease activity measures".

Osteonecrosis of the hip in renal transplant recipients. Changes in functional status and magnetic resonance imaging findings over three years in three hundred five patients.

OBJECTIVE: to conduct a retrospective study of the appearance and course of magnetic resonance imaging abnormalities in avascular osteonecrosis of the femoral head in renal transplant recipients and of potential relations between these abnormalities and the functional outcome. PATIENTS AND METHODS: among 305 renal transplant recipients, patients with pain in the hips or knees underwent radiographs and magnetic resonance imaging studies of the hips and, if appropriate, of the knees. The mean time interval between these studies and transplantation was 8.9 months. The outcome was evaluated based on the Lequesne index and findings from a repeat magnetic resonance imaging study after a mean follow-up of 33 months since transplantation. The criteria developed by Mitchell et al. were used to diagnose osteonecrosis on magnetic resonance images. The size of the necrotic area was estimated using the tracing paper method as < 25%, 25-50%, > 50% of the surface of the femoral head. Eleven patients were treated by elimination of weight-bearing and conservative treatments and 15 underwent core decompression (radiographic stage I or II). RESULTS: Fourteen patients (4.5%) developed osteonecrosis of the femoral head, which was bilateral in 12 patients and unilateral in two: thus, the total number of hips with osteonecrosis was 26. The first magnetic resonance imaging study disclosed a crescent-shaped area of low signal intensity in 25 cases, most of which were mild in severity as assessed on radiographs (Arlet and Ficat stage I or II). Extensive necrosis was found in most cases at the first evaluation (> 25% in 15 cases and > 50% in eight). The surface of the necrotic area (as assessed irrespective of the treatment used) remained unchanged in 20 cases and decreased in six. In half the cases the hyperintense signal from the sequestrum converted to a hypointense signal after a mean follow-up of 39 years. A poor functional outcome (Lequesne's index > 7 or total hip arthroplasty) was seen in 61.5% of cases, irrespective of the treatment used. CONCLUSION: Avascular osteonecrosis of the femoral head precipitated by corticosteroid therapy in renal transplant recipients occurred in 4.5% of patients immediately involved a large segment of the epiphysis, and usually remained stable over time, although a decrease in the size of the lesion was seen in a few cases. Overall, the functional prognosis was poor, with a Lequesne's index greater than 7 or total hip arthroplasty in two thirds of cases after three years' follow-up. The incidence of avascular osteonecrosis of the hip in renal transplant recipients has decreased since 1980, when cyclosporin was introduced and doses of corticosteroids used to treat rejection episodes were diminished.

[Low back pain: critical analysis of the state of the art]. / Les lombalgies: analyse critique de l'état actuel des connaissances.

Despite Low Back Pain (LBP) major health impact, its nosology, etiology and natural history remain ill defined in most cases. The studies of our team explored the clinical and psychological features of non specific low back pain on unselected populations of patients. Our first study was conducted in a department of rheumatology. Using multivariate statistical methods we were able to identify three major groups of subjects: --a first group called "purely organic", --a second group called "purely psychiatric", --a third group with both organic and psychiatric features. These last two groups gathered 41% of the subjects. An other complementary study was conducted in primary care practice. Using the General Health Questionnaire 38% patients--a close to the above reported percentage--were classified as having a psychological disorder. In order to describe the natural course of acute low back pain an inception cohort study was conducted in primary care practice. A high rate of fast recovery was found. A critical look of the present knowledge on Low Back Pain shows several unsatisfactory chapters. Further studies on the natural history of LBP, studies on the precise etiology of each variety and researches on their pathophysiology are needed to complete the description of nosologically well defined entities and to pave the way for relevant well designed therapeutic trials.

Reliability of three methods of radiologic assessment in patients with rheumatoid arthritis.

RATIONALE AND OBJECTIVES: To assess the intraobserver reliability of three methods used frequently to evaluate joint destruction in rheumatoid arthritis: the Sharp method, the Larsen method, and the carpo:metacarpal ratio. METHODS: One observer analyzed twice within a 6-week interval 71 radiographs from patients with rheumatoid arthritis. Reliability was estimated by intraclass correlation coefficient (R) and by Altman-Bland graphical method. Correlations were examined by the Spearman's coefficient (r). RESULTS: The intraobserver reliability of each method appeared satisfactory with a good result for the Sharp method (R = 0.97). The correlation was strong (r > 0.80) between the results obtained by Sharp's and Larsen's methods and weaker between the results of the two former methods and the carpo: metacarpal ratio. CONCLUSIONS: Sharp's method should be used preferentially in studies evaluating the radiologic changes in rheumatoid arthritis over time, especially in clinical trials. The carpo:metacarpal ratio may be considered as a complementary method, when wrist destruction is of conceptual importance.

Are classification criteria for spondylarthropathy useful as diagnostic criteria?

The authors used data from a study conducted under the auspices of the Société Française de Rhumatologie to evaluate the sensitivity and specificity of the individual items of two sets of criteria for spondylarthropathy. The study included 124 patients with spondylarthropathy and 1,964 controls. They found that the spondylarthropathy criteria with the highest sensitivities and specificities were useful not only for classifying patients but also for assisting in the diagnosis of spondylarthropathy.

Clinical and psychological classification of non-specific low-back pain. A new study in primary care practice.

This study aimed to explore the clinical and psychological features of non-specific low-back pain (LBP), and to evaluate a classification of patients based on the relationship between psychological disturbances and LBP clinical presentation. An unselected population of consecutive patients (n = 262) complaining of low-back pain to primary care physicians of the Epidemiology Team of the French Rheumatology Society, in October and November 1991, was studied. Measures included a standardized clinical evaluation of the back and a psychological assessment using the General Health Questionnaire. Ninety nine patients (38%) were classified as having a psychological disorder. The following symptoms: psychological precipitating event, permanent pain at night, diffuse spinal pain, pain increased by changing climate, pain increased by psychological factors, dysesthesias in the back, non-anatomical tenderness, were found to be closely associated with the existence of psychological disorder. Correspondence and cluster analyses provided support for the four-group classification of low-back pain previously devised. This classification may be interpreted through the relationships between psychological disturbances and the back clinical features. Although the study was mainly descriptive and used a cross sectional design, its results underline the importance of psychological influence on low-back pain presentation, and suggest the interest of a psychiatric assessment in low-back pain patients. Psychological disorders appear to be frequent in these patients and specific management of these disorders may prove useful.

Inter- and intraobserver variability in the interpretation of computed tomography of the lumbar spine.

In order to assess the variability in interpreting lumbar CT-scans, two radiologists and two rheumatologists examined the same set of 40 CT-scans and evaluated the presence of primary abnormalities using pre-established criteria. Inter- and intraobserver concordance was assessed using kappa statistics. Interpretation of herniated nucleus pulposus appeared reliable in this study (interobserver and intraobserver kappa statistics approximately 0.7 and 0.9, respectively). Conversely, significant variability of interpretation was seen in many findings often considered important in benign low-back pain or sciatica. Particularly low levels of agreement (interobserver kappa statistics lower to 0.20) were found for facet joint osteoarthritis and spinal stenosis. Since herniated nucleus pulposus appeared as the only reliable CT finding, lumbar CT ordering should therefore be currently restricted to confirmation and localization of herniated nucleus pulposus, especially when surgery or any other invasive intervention is planned to treat prolonged sciatica.

Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice.

OBJECTIVE: To describe the natural course of recent acute low back pain in terms of both morbidity (pain, disability) and absenteeism from work and to evaluate the prognostic factors for these outcomes. DESIGN: Inception cohort study. SETTING: Primary care. PATIENTS: 103 patients with acute localised non-specific back pain lasting less than 72 hours. MAIN OUTCOME MEASURES: Complete recovery (disappearance of both pain and disability) and return to work. RESULTS: 90% of patients recovered within two weeks and only two developed chronic low back pain. Only 49 of 100 patients for whom data were available had bed rest and 40% of 75 employed patients lost no time from work. Proportional hazards regression analysis showed that previous chronic episodes of low back pain, initial disability level, initial pain worse when standing, initial pain worse when lying, and compensation status were significantly associated with delayed episode recovery. These factors were also related to absenteeism from work. Absenteeism from work was also influenced by job satisfaction and gender. CONCLUSIONS: The recovery rate from acute low back pain was much higher than reported in other studies. Those studies, however, did not investigate groups of patients enrolled shortly after the onset of symptoms and often mixed acute low back pain patients with patients with exacerbations of chronic pain or sciatica. Several sociodemographic and clinical factors were of prognostic value in acute low back pain. Factors which influenced the outcome in terms of episode recovery (mainly physical severity factors) were only partly predictive of absenteeism from work. Time off work and return to work depended more on sociodemographic and job related influences.

[French validation of a disability rating scale for the evaluation of low back pain (EIFEL questionnaire)]. / Validation française d'une échelle d'incapacité fonctionnelle pour l'évaluation des lombalgies (EIFEL).

Functional disability is one of the main components of low back pain (LBP)-associated morbidity and should be taken into account in the evaluation and care of patients. This article describes the French-language adaptation and validation of the Roland and Morris Disability Questionnaire. This self-administered questionnaire proved rapid, simple to use, reliable, valid, and sensitive to changes in clinical status, suggesting that its widespread use may be possible in settings ranging from epidemiological or clinical research to individual LBP patient evaluation in daily clinical practice.

[Progressive paraparesis, complication of acquired pagetic synostosis of the cervical vertebrae. 2 cases]. / Paraparésie progressive, complication d'un bloc vertébral pagétique acquis de siège cervical. Deux observations.

Two cases of pagetic cervical intervertebral synostosis with spinal cord compression are reported. Computed tomography and magnetic resonance imaging enabled detailed analysis of pagetic bone structure and relationships between the fused spinal segment and spinal cord. Few similar cases have been reported and most authors have advocated conservative therapy with calcitonin and/or diphosphonates, with surgery only in cases unresponsive to pharmacotherapy.

Classification of nonspecific low back pain. I. Psychological involvement in low back pain. A clinical, descriptive approach.

An unselected sample of outpatient subjects (n = 330) with localized nonspecific low back pain (LBP) was studied. Investigation consisted of clinical assessment, physical examination, and psychiatric interview based on the DSM-III classification. A psychiatric disorder, according to the DSM-III criteria (axis I) was found in 41% of the subjects. Multiple correspondence analysis and cluster analysis were used to objectively identify clinical subtypes without preconceived theoretical models. Correspondence analyses suggested the existence of a 'psychological pain' syndrome consisting of several of the following symptoms: diffuse back pain, impossibility to assess intensity of pain on a pain scale, aggravation of pain by changing climate, by domestic activities or by psychological factors and dysesthesias in the back. Cluster analysis provided support for a four-group classification of low back pain, which may be interpreted through the relationships between psychological disturbances and the LBP clinical features. The results call for further investigation of the complex relationship between psychological disturbances and back pain. However, clinicians must be aware of the interest of a minimal psychiatric assessment in low back pain patients: psychiatric disorders frequently appear in these patients and an appropriate treatment of the psychiatric syndrome may reduce back pain.

Classification of nonspecific low back pain. II. Clinical diversity of organic forms.

A classification study was conducted in an unselected sample of outpatient subjects with localized nonspecific low back pain. The heterogeneity of a subgroup of patients without a psychiatric disorder according to the DSM-III classification (axis I), and whose low back pain may be labeled as 'purely organic' (see part 1 of the study in the companion paper), led to further evaluation of this group by correspondence and cluster analysis. A seven-cluster population structure emerged from the cluster analysis. Comprehensive description of these clusters suggests at least four well-differentiated clinical entities or 'syndromes.' Although no satisfactory correlation with pre-existing 'pathoanatomic' classification or hypotheses was found, this variable clinical presentation suggests different etiological or physiopathologic patterns for low back pain (and possibly more specific management of this condition). More comprehensive descriptions and evaluations of clinical symptoms and syndromes appear necessary in order to elaborate a clinical classification of LBP.