[Optimized assessment of the outcome in patients with radicular back pain of the lumbar spine. The modified NASS questionnaire]. / Bessere Verlaufsdokumentation bei Patienten mit lumboradikulären Schmerzsyndromen. Der modifizierte NASS-Fragebogen.

BACKGROUND: The purpose of the study was to present a reliable instrument with easy application to assess the outcome and improvement of therapy in patients with radicular symptoms of the lumbar spine. METHODS: Data from patients who underwent microdiscectomy because of lumbar radicular symptoms were collected and analyzed and interviews were performed using the well-known North American Spine Society (NASS) lumbar spine questionnaire (17 items) before and after the intervention. In addition patient data including comorbidities were collected. By calculating effect size (ES) and standardized response mean (SRM) for each item of the questionnaire, the questions with the highest change before and after the intervention could be selected. RESULTS: A total of 139 patients undergoing microdiscectomy for lumbar radicular symptoms due to a disc herniation were included in the analysis. Concerning the three dimensions pain, neurological symptoms and impairment of activities in daily life, the questions with best predictive value (high ES and SRM) were selected. According to their clinical relevance eight questions of the NASS questionnaire were finally selected for the short form. CONCLUSION: This short, significant and easy to use questionnaire is in our opinion a useful instrument to assess the course of patients with radicular back pain and especially to measure and monitor the outcome of therapeutic interventions, in addition to conventional clinical diagnostics and examinations. This novel instrument could be a useful tool for improving quality assurance in conventional and interventional pain management of these patients.

Better functional mobility in community-dwelling elderly is related to D-hormone serum levels and to daily calcium intake.

The influence of calcitropic hormones on functional mobility has been studied in vitamin D (calcidiol) deficient elderly or elderly with a history of falls, however, data in community-dwelling independent vitamin D replete elderly are missing. We therefore assessed in an observational survey the association of calcidiol (25(OH)D3) and calcitriol (D-hormone / 1,25(OH)2D3) status as well as of daily calcium intake on functional mobility in older subjects We evaluated 192 women and 188 men, aged superior 70 years and living independently. Average Timed-up and go test (TUG-test) in seconds was taken as measure of functional mobility. Calcidiol and D-hormone serum concentrations and daily calcium intake were studied in multivariate controlled linear regression models with TUG-test performance as the dependent variable and/or as dichotomous variables (deficient vs. non-deficient, above vs. below the median, respectively). Subjects with low D-hormone serum concentrations took significantly more time to perform the TUG-test (low = 7.70s +/- 2.52 SD ; high = 6.70s +/- 1.29 SD; p = 0.004). In the linear multivariate controlled regression model increased D-hormone serum concentrations predicted better TUG-test performance (estimate -0.0007, p = 0.044). Participants with a calcium intake of > or =512 mg/day were significantly faster to perform the TUG-test than participants with a daily calcium intake of <512 mg/day (estimate:-0.43, p = 0.007). Other significant predictors of better TUG-test performance in both models were: male gender, less comorbid conditions, younger age, lower BMI, iPTH serum levels and creatinine clearance. Calcidiol serum levels were not associated with TUG-test performance. Higher D-hormone status and a calcium intake of > or =512 mg/day in community-dwelling independent older persons are significant determinants of better functional mobility. Therefore, to ensure optimal functional mobility, the care of older persons should address correction of D-hormone deficiency and increasing daily calcium intake.

Clinical evaluation of the WOMAC 3.0 OA Index in numeric rating scale format using a computerized touch screen version.

BACKGROUND: The Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index is a previously described self-administered questionnaire covering three domains: pain, stiffness and function. It has been validated in patients with osteoarthritis (OA) of the hip or knee in a paper-based format. AIM: To validate the WOMAC 3.0 using a numerical rating scale in a computerized touch screen format allowing immediate evaluation of the questionnaire. In the computed version cartoons, written and audio instruments were included in order facilitate application. METHODS: Fifty patients, demographically balanced, with radiographically proven primary hip or knee OA completed the classical paper and the new computerized WOMAC version. Subjects were randomized either to paper format or computerized format first to balance possible order effects. RESULTS: The intra-class correlation coefficients for pain, stiffness and function values were 0.915, 0.745 and 0.940, respectively. The Spearman correlation coefficients for pain, stiffness and function were 0.88, 0.77 and 0.87, respectively. CONCLUSION: These data indicate that the computerized WOMAC OA index 3.0 is comparable to the paper WOMAC in all three dimensions. The computerized version would allow physicians to get an immediate result and if present a direct comparison with a previous exam.

Self-reported exercise before age 40: influence on quantitative skeletal ultrasound and fall risk in the elderly.

OBJECTIVES: To compare musculoskeletal factors with bone structure, as measured by quantitative ultrasound (QUS) at the calcaneus, and their potential to predict fall risk in geriatric inpatients. DESIGN: Longitudinal. SETTING: Two geriatric hospitals in Switzerland. PARTICIPANTS: A total of 134 of 207 long-stay geriatric patients (96 women, 38 men) who were able to perform the timed up and go (TUG) test. INTERVENTIONS: Five musculoskeletal tests: 2 functional tests (TUG, for mobility; functional reach test, for balance), and 3 muscle strength tests (knee flexor, knee extensor, grip). Falls were monitored prospectively in a subgroup of 94 mobile subjects of 1 geriatric hospital throughout each individual length of stay (median, 31.4wk: interquartile range, 16-56.4wk). MAIN OUTCOME MEASUREMENTS: Functional and strength tests, mobility status, and self-reported exercise before age 40 were musculoskeletal factors to be compared with QUS. RESULTS: QUS was higher in mobile subjects without walking aid (p < .0001) and correlated significantly with muscle strength (knee flexor: r = .36; knee extensor: r = .30) and functional tests (TUG: r = -.25; functional reach: r = .16). Women who reported regular exercise before age 40 had higher QUS (p = .01) and fewer falls (p = .01). Falls were less frequent in subjects with walking aid (p = .03). No single musculoskeletal test, but rather a combination of demographic variables, musculoskeletal factors, and QUS could predict 76% of total variation of fall risk. CONCLUSION: This study showed the important impact of current mobility and muscle strength status on bone structure, as measured by QUS at the calcaneus. In addition, a beneficial effect of former exercise on QUS and fall risk at advanced age could be documented in women. Both findings support life-long engagement in exercise, which might be particularly meaningful for women.

In situ detection of 1,25-dihydroxyvitamin D3 receptor in human skeletal muscle tissue.

Growing evidence suggests that intracellular vitamin D receptors are present in skeletal muscle tissue mediating vitamin D hormone response. The aim of the work reported here was to investigate the in situ expression of 1,25-dihydroxyvitamin D3 receptor in human skeletal muscle tissue. Intraoperative periarticular muscle biopsies were taken from 20 female orthopaedic patients (17 middle-aged and elderly patients receiving total hip arthroplasty due to osteoarthritis of the hip or an osteoporotic hip fracture and 3 young patients who received back surgery). The immunohistological distribution of the vitamin D3 receptor was investigated using a monoclonal rat antibody to the receptor (Clone Nr. 9A7). The receptor-positive nuclei were quantified by counting 500 nuclei per biopsy. Strong intranuclear immunostaining of the vitamin D receptor was detected in human muscle cells. Biopsies of hip patients had significantly fewer receptor-positive nuclei compared to those of back surgery patients (Mann-Whitney U-test: p = 0.0025). VDR expression (number of antigen-positive nuclei) was significantly correlated with age (coefficient of correlation = 0.46; p = 0.005), but not with 25-hydroxyvitamin D or 1,25-dihydroxyvitamin D levels. The data clearly demonstrate presence of nuclear 1,25-dihydroxyvitamin D3 receptor in human skeletal muscle. To our knowledge this is the first in situ detection of the receptor in human skeletal muscle. The difference in the expression of the receptor between hip and spinal muscle biopsies might be explained by age or location. Further research is needed in order to evaluate whether vitamin D3 receptor expression in human skeletal muscle is age-dependent and varies between different muscles.

Influence of physical mobility and season on 25-hydroxyvitamin D-parathyroid hormone interaction and bone remodelling in the elderly.

OBJECTIVE: To investigate influences of physical mobility and season on 25-hydroxyvitamin D-intact parathyroid hormone (iPTH) interaction in the elderly. DESIGN: We examined 188 frail institutionalized elderly at the expected nadir of their serum vitamin D concentrations (winter). This group was compared with 309 healthy ambulatory elderly at the expected time of maximum vitamin D repletion (summer), to accentuate the influences of season and physical activity. METHODS: Serum concentrations of 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, iPTH and urinary deoxypyridinoline (DPD) were measured. RESULTS: Vitamin D metabolites were significantly lower in the institutionalized elderly (P<0.0001), with an 82.5% prevalence of vitamin D deficiency (25-hydroxyvitamin D <12ng/ml) in institutionalized elderly in wintertime and 15.5% in ambulatory elderly in summertime. Overall, median iPTH did not differ between groups. However, median iPTH secretion in the presence of low vitamin D serum concentrations (5-30ng/ml) was greater in ambulatory elderly. This could be explained by lower mobility status being correlated with greater serum calcium concentrations (r=0.24, P=0.02 in women; r=0.35, P=0. 001 in men) and greater urinary excretion of DPD (r=0.41, P=0.0001 in women; r=0.42, P=0.0002 in men), independent of 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D and iPTH. CONCLUSIONS: These data support the hypothesis that immobility, even in the presence of vitamin D deficiency, acts as an overriding influence on bone metabolism by promoting bone resorption (measured as urinary DPD) and increasing serum calcium independent of iPTH. Therefore mobility status may substantially affect 25-hydroxyvitamin D threshold values and the degree to which patients benefit from vitamin supplementation.

Relationship between muscle strength and vitamin D metabolites: are there therapeutic possibilities in the elderly?

To test the hypothesis that muscle weakness associated with aging is in part due to low serum levels of vitamin D, we investigated the relationship between muscle strength and serum levels of vitamin D metabolites in ambulatory elderly people who were not receiving vitamin D supplementation. We enrolled 319 ambulatory elderly subjects (103 women: mean age 74.2, age range 65-86; 216 men: mean age 76.6, age range 66-95) between April and August 1995. The study design was cross-sectional. Muscle strength was measured as leg extension power in watts (LEP). Mean 25-hydroxyvitamin D serum concentrations were higher in male participants at 36.2 ng/ml (range 3.0-85.0) versus 27.4 ng/ml (range 5.0-88.0) in female subjects (p = 0.008). We found 12 percent of female and 18 percent of male subjects with 25-hydroxyvitamin D values below the lower threshold (< 12 ng/ml). Mean 1,25-dihydroxyvitamin D levels were similar in both sexes: 39.8 pg/ml (range 15.0-73.0) in women and 37.9 pg/ml (range 13.0-69.0) in men. LEP declined with age in women and men (f: r = -0.35, p = 0.001; m: r = -0.48, p < 0.0001). Men were significantly stronger than women (p < 0.0001). In men both 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D showed pairwise correlation with LEP (r = 0.24; p = 0.0004/r = 0.14; p = 0.045). In women only 1,25-hydroxyvitamin D was significantly correlated with LEP (r = 0.22; p = 0.03). In ANCOVA, including all participants, explaining LEP by sex (p < 0.0001), age (p < 0.0001), BMI (p = 0.013), 1,25-dihydroxyvitamin D (p = 0.02), 25-hydroxyvitamin D (p = 0.18) and iPTH (p = 0.82), all factors showed significant effects except 25-hydoxyvitamin D and iPTH (r2 of the whole model: 0.41). In conclusion our results support the view that, in concert with other factors, deficiency of both 25-hydroxyvitamin D and 1,25-hydroxyvitamin D contributes to the age-related decline in muscle strength. Modest, but significant relationships between 1,25-dihydroxyvitamin D and muscle strength in both sexes, and 25-hydroxyvitamin D in male participants could be documented. Whether the impact of vitamin D on calcium homeostasis and bone mineral density or directly on the muscle tissue level is more important for prevention of hip fractures remains unclear. Further prospective and comparative treatment studies should be performed, in order to evaluate whether and in which dose requirements, vitamin D supplementation can improve muscle strength in the elderly.

No influence of osteoarthritis of the hand on phalangeal osteography in elderly women.

We investigate the influence of hand osteoarthritis on skeletal quantitative ultrasound (QUS) measurement through the proximal phalanges in female geriatric inpatients. In a cross-sectional study, bone status was assessed with QUS at the distal metaphysis of the first phalanges of fingers II-V. Thirty-three of 101 female geriatric inpatients met the clinical criteria of the American College of Rheumatology for osteoarthritis of the hands (median age: 85 years) and were compared to 68 female inpatients without swellings of the small finger joints (median age: 88 years). Amplitude-dependent speed of sound at the distal metaphysis, the electronic signal of the ultrasonic wave after crossing the phalanx (graphic trace), and the thickness of the each phalanx were measured and compared between the two groups by a phalangeal QUS device (DBM-Sonic 1200). There were no significant differences between the phalangeal QUS readings of both groups. The only statistically significant difference was observed in the comparison of the small finger thickness with a lower value in the osteoarthritis group (p = 0.02). These findings suggest that at the metaphyseal level of phalanges, the degenerative process of osteoarthritis doesn't influence the QUS assessment. This could be explained by the finger thickness at metaphyseal level, which was not increased in patients with osteoarthritis compared with control subjects, at least as detected by the applied finger ultrasound method.

High bone turnover in the elderly.

OBJECTIVES: To document lifestyle-associated variations in biochemical markers of bone metabolism in advanced age. STUDY DESIGN: Cross-sectional study. SETTING: Department of Geriatrics, University Hospital, Basel, Switzerland. SUBJECTS: Three hundred twelve ambulatory and 193 institutionalized men and women, aged 54 to 99 yrs. OUTCOME MEASUREMENTS: Biochemical markers of bone resorption (urinary deoxypyridinolin and N-telopeptides), serum vitamin D metabolites, and serum intact parathyroid hormone (iPTH) concentrations were assessed. Mean values of all parameters were correlated with a six-grade activity score. Physical activity score reflected the degree of weight bearing, ranging from walking independently to primarily bed-bound. Ambulatory subjects were measured in summertime and institutionalized subjects in wintertime to accentuate seasonality of vitamin D hormone levels. RESULTS: Excretion of bone resorption markers was significantly higher in the institutionalized and physically inactive patients compared with those who were ambulatory and physically active (p = .0001). Vitamin D deficiency (25-hydroxyvitamin D of <12 ng/mL) was present in 86% of institutionalized and 15% of ambulatory subjects, and 1,25-dihydroxyvitamin D serum concentrations were lower in institutionalized than in ambulatory subjects (p = .0001). Mean serum concentrations for iPTH were similar for both the institutionalized and ambulatory groups. When subjects were arranged according to activity score, mean excretion of urinary bone resorption markers increased with degree of inactivity. CONCLUSION: Despite the difference in vitamin D metabolites, iPTH serum concentrations did not differ significantly between the institutionalized and ambulatory groups. However, institutionalized and physically inactive participants had markedly elevated excretion of urinary bone resorption markers compared with ambulatory and physically active subjects. These results suggest that high bone turnover in the elderly may be caused by physical inactivity related to low mechanical loading rather than secondary hyperparathyroidism.

Calcidiol, calcitriol and parathyroid hormone serum concentrations in institutionalized and ambulatory elderly in Switzerland.

AIM: The aim of the present study was to measure concentrations of vitamin D metabolites and intact parathyroid hormone (iPTH) serum concentrations and an urinary bone resorption marker in two groups of elderly subjects, who differed markedly in their sedentary status and seasonality. DESIGN: 193 institutionalized elderly people of a long-stay geriatric ward (106 women: mean age 82; 87 men: mean age 78) were studied during wintertime. 312 ambulatory elderly people (109 women: mean age 74; 203 men: mean age 76) were studied during summertime. Concentrations of calcidiol (25(OH)D), calcitriol (1,25(OH)2D) and serum iPTH, as well as urinary N-telopeptides (NTX) were measured. RESULTS: Vitamin D deficiency (defined as serum 25(OH)D < 12 ng/ml) was present in 86% of institutionalized at the expected nadir (wintertime), compared to 15% of the ambulatory elderly subjects at the expected maximum (summertime). Serum calcitriol concentrations were significantly lower in institutionalized subjects (p = .0001). However intact PTH concentrations did not differ significantly between institutionalized and ambulatory elderly. Institutionalized and female subjects showed higher urinary NTX excretion (female institutionalized: 131.9; female ambulatory: 66.8/male institutionalized: 76.3 male ambulatory: 45.8 nmol/mmol). CONCLUSION: This cross-sectional study documented very low serum calcidiol and calcitriol concentrations and high urinary N-telopeptide excretion in institutionalized elderly people. There was no difference in serum iPTH concentrations between institutionalized and ambulatory elderly. This finding could not be explained by the differences in calcidiol and calcitriol concentration, nor urinary NTX excretion. These results suggest that other factors than vitamin D deficiency, such as lower mobility status and sedentary life style, might have an important role in the regulation of iPTH and mechanisms of bone loss in the elderly.

Muscle strength in the elderly: its relation to vitamin D metabolites.

OBJECTIVE: To identify a relation between loss of muscle strength and vitamin D deficiency in ambulatory elderly persons not receiving vitamin D supplementation. DESIGN: Cross-sectional study. SETTING: All measurements were taken at the Department of Geriatrics, University Hospital, Basel, Switzerland. SUBJECTS: Three hundred nineteen patients (103 women, 216 men) selected by random sampling from participants in an ongoing interdisciplinary study on aging (mean age for women, 74.2 yrs; for men, 76.7 yrs). OUTCOME MEASURES: Leg extension power (LEP) and body mass index (BMI); serum values of 25-hydroxyvitamin D [calcidiol, 25(OH)D], 1,25-hydroxyvitamin D [calcitriol, 1,25(OH)2D], and intact parathyroid hormone (iPHT). RESULTS: Twelve percent of women and 18% of men had 25(OH)D values below the normal range (<12 ng/mL). Muscle strength was lower in older subjects (female: r = -.35; p = .0005/male: r = -.48; p < .0001) and was lower in women than in men (p < .0001). In men both 25(OH)D and 1,25(OH)2D was significantly correlated with LEP (r = 0.24; p = .0004/r = .14; p = .045). In women, only 1,25(OH)2D was significantly correlated with LEP (r = 0.22; p = .034). In an ANCOVA including all participants and explaining LEP by sex, age, BMI, 1,25(OH)2D, 25(OH)D, and iPTH, all factors showed significant effects except 25(OH)D and iPTH (r2 = .41). CONCLUSION: Muscle strength declined with age in ambulatory elderly people and showed modest, but significant, positive correlation with 1,25(OH)2 vitamin D in both sexes and with 25(OH)D in male subjects. Therefore vitamin D deficiency appears to contribute to the age-related loss of muscle strength, which might be more pronounced in institutionalized elderly people with a high prevalence of vitamin D deficiency.