Work in inflammatory and degenerative joint diseases.

This article focuses on work disability and sick leave and their cost; it also discusses the value of vocational rehabilitation programmes in rheumatic conditions such as rheumatoid arthritis, ankylosing spondylitis, hip and knee osteoarthritis. It acknowledges the importance of work not only for the worker who has one of these diseases but also for the public purse. Much can be done to improve the health of the persons and reduce their disability and its impact in the workplace which will have an important effect on their and their family's quality of life. It is important that neither rehabilitation nor vocational rehabilitation are regarded as bolt-on activities after drug treatment but are seen as an integral part of effective management. Publications dealing with return to work are relatively common in rheumatoid arthritis, less common in ankylosing spondylitis and relatively rare in osteoarthritis. Vocational rehabilitation programmes should aim to facilitate job retention or, failing that, to improve the ability to return to work. The process must be started with in the health arena and it has to be recognised that slow or poor practice in the health service can jeopardise the patient's work potential.

Vocational rehabilitation: a multidisciplinary intervention.

Vocational rehabilitation is by definition a multidisciplinary intervention in a process linked to the facilitation of return to work or to the prevention of loss of the work. Clinical staff in contact with a person who has lost his job (general practitioner, specialized physician) must promote vocational rehabilitation. Medical rehabilitation for those with disabilities, whether new or old, has to be followed without delay by vocational rehabilitation. It is even better if these two intertwined processes are overlapping. They involve many professionals including physiotherapists, occupational therapists, psychologists, vocational trainers, job counsellors, teachers, case-managers, job placement agencies. Vocational rehabilitation has a financial cost, borne by many state organizations (security, social system, social affairs) as well as by employers and private insurances, which are in case of accident, concerned by this process. However, the evidence suggests that this is recouped 2- to 10-fold as suggested by the British Society of Rehabilitation Medicine.

The effect of mountain bike suspensions on vibrations and off-road uphill performance.

AIM: This study evaluates the effect of front suspension (FS) and dual suspension (DS) mountain-bike on performance and vibrations during off-road uphill riding. METHODS: Thirteen male cyclists (27+/-5 years, 70+/-6 kg, VO(2max)59+/-6 mL.kg(-1).min(-1), mean+/-SD) performed, in a random sequence, at their lactate threshold, an off-road uphill course (1.69 km, 212 m elevation gain) with both type of bicycles. Variable measured: a) VO(2) consumption (K4b2 analyzer, Cosmed), b) power output (SRM) c) gain in altitude and d) 3-D accelerations under the saddle and at the wheel (Physilog, EPFL, Switzerland). Power spectral analy- sis (Fourier) was performed from the vertical acceleration data. RESULTS: Respectively for the FS and DS mountain bike: speed amounted to 7.5+/-0.7 km.h(-1) and 7.4+/-0.8 km.h(-1), (NS), energy expenditure 1.39+/-0.16 kW and 1.38+/-0.18, (NS), gross efficiency 0.161+/-0.013 and 0.159+/-0.013, (NS), peak frequency of vibration under the saddle 4.78+/-2.85 Hz and 2.27+/-0.2 Hz (P<0.01) and median-frequency of vertical displacements of the saddle 9.41+/-1.47 Hz and 5.78+/-2.27 Hz (P<0.01). CONCLUSION: Vibrations at the saddle level of the DS bike are of low frequencies whereas those of the FS bike are mostly of high frequencies. In the DS bike, the torque produced by the cyclist at the pedal level may generate low frequency vibrations. We conclude that the DS bike absorbs more high frequency vibrations, is more comfortable and performs as well as the FS bicycle.

[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.

Has botulinum toxin type A a place in the treatment of spasticity in spinal cord injury patients?

OBJECTIVE: To present and discuss treatment of severe spasms related to spinal cord injury with botulinum toxin type A. DESIGN: A 2-year follow-up study of an incomplete T12 paraplegic patient, who was reluctant to undergo intrathecal baclofen therapy, presenting severe painful spasms in his lower limbs treated with intramuscular injections of botulinum toxin type A. SETTING: Department of Physical Medicine and Rehabilitation, Hôpital de Gravelone, Sion, Switzerland. SUBJECT: Single patient case report. MAIN OUTCOME MEASURE: Spasticity, spasms and pain measured with the modified Ashworth scale, spasm frequency score and visual analogue scale. RESULTS: Treatment of spasticity with selective intramuscular injections of botulinum toxin type A resulted in subjective and objective improvement. CONCLUSION: Botulinum toxin type A has its place in the treatment of spasticity in spinal cord injury patients. This treatment is expensive and its effect is reversible. It can complement intrathecal baclofen in treating upper limb spasticity in tetraplegic patients. Tolerance does occur to the toxin. Although high doses of the product are well tolerated, the quantity should be tailored to the patient's need. The minimal amount necessary to reach clinical effects should be adhered to and booster doses at short period intervals should be avoided.

Iliopsoas bursitis and pseudogout of the knee mimicking L2-L3 radiculopathy: case report and review of the literature.

We report the case of a 74-year-old woman who presented with acute-onset right groin pain irradiating to the thigh anteriorly after having suffered for a few weeks from slight knee pain. As a CT scan showed multiple herniated intervertebral discs and spinal stenosis at the L3-L4 level, she was referred to a neurosurgical unit with the tentative diagnosis of L2-L3 radicular pain. Investigations (MR, myelography with CT scan) showed severe acquired lumbar canal stenosis. Decompression surgery was finally postponed because of the patient's serious cardiac medical history and she was referred to us for conservative treatment. She was found to have iliopsoas bursitis with chondrocalcinosis of the knee. Local steroid injections of the two sites abolished her symptoms. We draw attention to the possible pitfalls that the radiographic appearance and one of the multiple clinical presentations of this unrare pathology may represent. Whenever a patient comes walking with crutches, avoids putting weight on his or her leg, and radicular pain is suspected, we advise consideration of other extra-spinal causes for the pain.

[Sports and inflammatory rheumatism]. / Sport et rhumatismes inflammatoires.

The author analyses the impact of sport and it's relation with inflammatory rheumatisms. The mechanisms introducing a muscle atrophy of the patients with inflammatory arthritis permits a good understanding of these relations. The role of the effusion in the articulation, the biochemical disturbances of the synovial fluid, a raised temperature, and finally intrinsic muscle biochemical disturbances are analysed. These different measures are in relation with the beginning and maintenance of muscle atrophy. The practice of sport, especially based on endurance, of patients suffering from inflammatory rheumatisms maintains the muscle bulk and force.

Two years' effectiveness of intravenous pamidronate (APD) versus oral fluoride for osteoporosis occurring in the postmenopause.

Bisphosphonates seem to be effective as antiresorptive agents in the prevention and treatment of osteoporosis. However, the optimal dose and route of administration as well as the specific effects on cortical or trabecular bone have not been clarified. To compare pamidronate (APD) with fluoride (F) in the therapy of postmenopausal osteoporosis, 32 osteoporotic women were treated for 2 years either with APD (30 mg as a single intravenous infusion over 1 h every 3 months, n = 16, mean age 65 years) or with fluoride orally (20-30 mg F/day, n = 16, mean age 67 years) in an open study. Both groups received 1 g calcium and 1000 U vitamin D per day, but no estrogens or other drugs acting on bone. Both groups showed the same initial mean number of fractures per patient (2.8 and 2.7). Bone densitometry was performed every 6 months at three sites: lumbar spine and hip with dual-energy X-ray absorptiometry (BMD), distal forearm with single photon absorptiometry and lumbar spine with quantitative computed tomography. Biochemical assessment was performed in blood and urine every 3 months. Lumbar BMD (g/cm2, mean +/- SEM) increased from 0.632 (+/- 0.030) at time 0 to 0.696 (+/- 0.028) at 24 months in the APD group (p < 0.001), and from 0.684 (+/- 0.025) to 0.769 (+/- 0.028) in the fluoride group (p < 0.001). Femoral neck BMD increased significantly from 0.558 (+/- 0.025) to 0.585 (+/- 0.025) (p < 0.01) in the APD group, whereas it did not change in the fluoride group.(ABSTRACT TRUNCATED AT 250 WORDS)

The frozen shoulder: diagnosis and treatment. Prospective study of 50 cases of adhesive capsulitis.

A prospective study of randomized analysis treatment of 50 cases of frozen shoulder was carried out in 3 Swiss medical centres. Three separate aetiological groups were studied: post-traumatic (40%), neurological (14%) and idiopathic (46%). An increased radioisotope bone scan (99 mTc diphosphonate) was found in 96% of cases, regardless of aetiology. The so-called idiopathic frozen shoulder showed a scapulo-humeral increase in radioisotope uptake in several areas (in 82% of cases) without involvement of the ipsilateral carpus. Clinically, the neurological type was associated with a shoulder-hand syndrome with positive bone scan of the shoulder and the wrist in all cases. The post-traumatic type showed a diffuse (in 50% of the cases) or at several circumscribed areas (also in 50%) increase in radioisotope uptake in the shoulder. In 45% of the post-traumatic type, there was also a shoulder-hand syndrome with uptake in the wrist also. A physical treatment and early mobilization, associated with the administration of subcutaneous salmon calcitonin for 21 days (100 U Calcitonin Sandoz) had a statistically significant increased effect on pain compared to treatment with physiotherapy alone by patients with post-traumatic frozen shoulders (p < 0.02). There was no significant difference, however, in the speed of recovery of function between the two treatment groups. These observations strengthen the hypothesis that adhesive capsulitis behave like an algoneurodystrophic process.

The effect of adding calcitonin to physical treatment on reflex sympathetic dystrophy.

The efficacy of intranasal salmon calcitonin was examined in a double-blind randomized study in reflex sympathetic dystrophy. Sixty-six patients were randomly divided in two groups receiving physiotherapy. In addition group I also received 3 x 100 U/day of salmon calcitonin by intranasal spray whereas group II received 3 sprays of placebo. The pain and the range of motion were improved by calcitonin administration. Similarly the patients' ability to work was also improved. The results confirmed that salmon calcitonin has an effect but that this effect was not equally observed on all parameters analyzed. It was most marked on pain (at rest and on movement) and on the ability to work.

[Muscle training techniques and retropatellar chondropathy]. / Techniques de musculation et chondropathie rétro-patellaire.

The authors have studied the efficacy of 3 different muscle training programs (electromyostimulation, isokinetic training and isometric training) in cases of patellar chondromalacia. The evaluation of the results was made by measuring the isokinetic strength on a Cybex II+ dynamometer at a low (30 degrees/sec) and a high (300 degrees/sec) angular velocity. The clinical evaluation was based on a modified score determined by the Arpege group. The results showed a better improvement of the muscular strength after electromyostimulation or isokinetic training. The clinical improvement was better on patients of groups I and III.

[Rheumatoid arthritis in an Alpine region, incidence, social and occupational consequences]. / La polyarthrite rhumatoïde dans une région alpine, incidence, répercussions sociales et professionnelles.

Two hundred patients with rheumatoid arthritis were identified in our region. This number means a prevalence of around 0,1%, which is far less than usually described. Environmental factors could explain this. We studied the work capacity and the grade of invalidity of our patients. Women seem disadvantaged.

[Arginine aspartate and muscular activity. II]. / Aspartate d'arginine et activité musculaire. Partie II.

We measured the effect of a 4-weeks treatment with arginine aspartate on 21 athletes. By a double blind methodology, we were able to show that the treatment group had an enhanced maximal oxygen consumption as well as a significantly decreased plasma lactate concentration at a work intensity of 200, 300 and 400 W on the treadmill. By the same token, 5 and 20 minutes after completion of the test run, blood lactate levels were significantly lower in the group receiving arginine aspartate. Nevertheless, at the 4 mmol lactate threshold, power and total work output were the same for both controls and treatment groups. These results show a favourable effect of arginine aspartate on blood lactate levels.

[Ankylosing vertebral hyperostosis and pulmonary function]. / Hyperostose vertébrale ankylosante et fonction pulmonaire.

Ankylosing vertebral hyperostosis (HVA) or diffuse idiopathic skeletal hyperostosis (DISH) is a disease often seen in the middle-aged and elderly, frequently in patients older than 70 years (10.1% in men, 6.8% in women). Enthesal ossifications can occur at any site of tendinous or ligamentous insertion. The spine is commonly involved. The characteristic appearance is the presence of thick bony bridges between vertebral bodies of the right side of thoracic spine. Many authors, especially Fischer and Stecher, have described hyperostosis of the rib at the costo-vertebral articulation. In our study, 52 patients were examined. The physical examination consisted essentially in pulmonary function and measurement of thoracic and spinal mobility. In spite of severe ankylosing vertebral hyperostosis, which evokes important ossification of the costo-vertebral articulation, we couldn't demonstrate any change in pulmonary function.

[Double-blind randomized multicenter study with tenoxicam, piroxicam and diclofenac sodium retard in the treatment of ambulatory patients with arthroses and soft tissue rheumatism]. / Doppeltblinde randomisierte Multizenterstudie mit Tenoxicam, Piroxicam und Diclofenac-Natrium retard in der Behandlung von ambulanten Patienten mit Arthrosen und Weichteilrheumatismus.

In a randomized, double-blind comparative study involving a total of 1630 outpatients, tenoxicam, a new nonsteroidal anti-inflammatory drug belonging to the oxicam group, piroxicam and diclofenac retard were tested for their efficacy und tolerability in the treatment of osteoarthritis and extra-articular rheumatism. Single doses of 20 mg tenoxicam, 20 mg piroxicam or 100 mg diclofenac sodium retard were administered daily. Tenoxicam was found to be as effective as piroxicam and diclofenac-sodium retard in treating degenerative and extra-articular rheumatic disorders of the musculoskeletal system. When baseline values were compared with values obtained at all subsequent examinations, all evaluation parameters for all three substances showed improvement. In analyses of frequency, degree of severity and type of undesired effects tenoxicam proved to be superior to the reference drugs. This was particularly evident from an improved GI and CNS tolerance and a lower rate of withdrawal from treatment. Tenoxicam has a favourable risk-benefit ratio and can be recommended for the treatment of chronic pain due to inflammation resulting from degenerative and extra-articular rheumatic disorders of the musculoskeletal system.

A double-blind randomised multicentre study with tenoxicam, piroxicam and diclofenac sodium retard in the treatment of ambulant patients with osteoarthritis and extra-articular rheumatism.

In a randomised, double-blind comparative study involving a total of 1,630 out-patients, tenoxicam (a new non-steroidal anti-inflammatory drug belonging to the oxicam group), piroxicam and diclofenac retard were tested for their efficacy and tolerability in the treatment of osteoarthritis (OA) and extra-articular rheumatism (EAR). Single doses of 20 mg tenoxicam, 20 mg piroxicam or 100 mg diclofenac sodium retard were administered daily. Tenoxicam was found to be as effective as piroxicam and diclofenac sodium retard in the treatment of degenerative and extra-articular rheumatic disorders of the musculo-skeletal system. When baseline values were compared with values obtained at all subsequent examinations, all evaluation parameters for all three substances showed improvement. In analyses of the frequency, degree of severity and type of undesired effects, tenoxicam proved to be superior to the reference drugs. This was particularly evident from an improved gastrointestinal and central nervous system (CNS) tolerance and a lower rate of withdrawal from treatment. Tenoxicam has a favourable risk/benefit ratio and can be recommended for the treatment of chronic pain due to inflammation resulting from degenerative and extra-articular rheumatic disorders of the musculoskeletal system.

A single infusion of the bisphosphonate AHPrBP (APD) as treatment of Paget's disease of bone.

PURPOSE: Disabling pain, skeletal deformity, or risk of joint involvement characterize Paget's disease of bone. Because the disease often affects the elderly, for whom compliance is a problem, we investigated therapy with a single intravenous infusion of amino-hydroxypropylidene bisphosphonate (AHPrBP, previously APD). PATIENTS AND METHODS: Eleven patients with mild but symptomatic Paget's disease and one patient with very severe disease were treated with AHPrBP administered as a single intravenous infusion of 60 mg over 24 hours. Follow-up with clinical and biochemical evaluations was performed over six months for all patients, and over one year for seven patients. RESULTS: Clinical improvement and normalization of biochemical parameters were observed in all patients except one with extremely severe disease. On average, plasma alkaline phosphatase activity fell progressively and significantly from 256 +/- 29 U/liter (mean +/- SEM) to 97 +/- 6 U/liter after six months, and to 102 +/- 11 U/liter after one year (normal: less than 120 U/liter). Urinary excretion of hydroxyproline decreased within seven days to normal (from 4.3 +/- 0.5 mumol/liter of glomerular filtrate [lGF] to 1.7 +/- 0.2 mumol/lGF; normal: 2.2 mumol/lGF). Thereafter, it remained within the normal range until one year (1.8 +/- 0.2 mumol/lGF after six months and 1.9 +/- 0.3 mumol/lGF after one year). Side effects were negligible. Two patients noted only a transient increase in body temperature. When bone scintigraphy was repeated after six months, it revealed a marked decrease of the activity of the disease. CONCLUSION: Due to the important and sustained inhibition of bone resorption induced by AHPrBP, a single infusion of 60 mg of the bisphosphonate leads to a rapid decline in activity and a long-standing remission of moderate Paget's disease, without significant side effects.

Synovial fluid lactic acid in acute and chronic pyrophosphate arthropathy and in osteoarthritis.

A comparison of synovial fluid lactate levels has been made in cases of chronic pyrophosphate arthropathy (PA) with and without joint destruction, acute PA and osteoarthritis. No statistically significant difference could be observed between results of chronic PA and osteoarthritis. By contrast, synovial fluid lactate levels were significantly higher in acute PA in comparison with the two other groups. These data suggest that hypoxia is unlikely to play a role in destructive arthropathy commonly found in chronic PA.