Papillary carcinoma of thyroid metastatic to the pituitary gland.

We describe a 35-year-old woman who presented with diabetes insipidus caused by metastatic papillary carcinoma of the thyroid involving the pituitary gland, 25 years after treatment for a papillary carcinoma of thyroid and 17 years after treatment for multiple pulmonary metastases. The literature contains 10 previously described cases of metastatic thyroid carcinoma involving the sella, but only 2 of these cases had unequivocal metastases to the pituitary gland, making the present case, to our knowledge, the third reported case of unequivocal hematogenous metastasis of thyroid carcinoma to the pituitary gland. The pituitary tumor was removed by transsphenoidal surgery, and the tissue was examined by conventional histology, extensive immunohistochemistry, and electron microscopy. The findings confirmed the tumor to be papillary thyroid carcinoma. To our knowledge, this is the first report citing use of thyroid transcription factor-1 to establish a thyroid source of a pituitary metastasis.

Low back pain: prevalence and risk factors in an industrial setting.

OBJECTIVE: To examine various factors associated with low back pain (LBP) in an industrial setting. METHODS: A cross sectional study was carried out among 1,562 employees of a large utilities corporation in Ontario using a self-administered questionnaire. Abdominal muscle strength was measured using a modified sphygmomanometer. Statistical analysis was carried out with Student's t test, chi-square test, and logistic regression analysis. RESULTS: Among 1,302 male employees the lifetime and point prevalence of LBP were 60% and 11%, respectively. Low back pain was significantly more prevalent among married employees, with more physically demanding jobs, regular lifting, poor general health, and past major illness. Abdominal muscle weakness was associated with current LBP. The mean time lost from work due to LBP over 5 years was 17 days. Sedentary workers developing LBP were more likely to require hospital admission. CONCLUSION: This study confirms the high prevalence of LBP in industry and identifies several risk factors.

Rheumatologists and neck pain.

Many authors have suggested that chronic pain syndromes are psychosocial in origin; maladaptive behaviours favoured by psychosocial and political factors. Sometimes this may be true, but neither the individual patients nor the accumulated scientific evidence deserve such a routine dismissal. In this editorial I will review issues of responsibility, the nature of referred pain and referred tenderness, evidence for the value of tender point examination as an objective measure, techniques of assessment of the cervical spine, techniques of assessment of pain behaviour, and the determinants of the specific symptom patterns associated with cervical injury.

Does strengthening the abdominal muscles prevent low back pain--a randomized controlled trial.

OBJECTIVE: To investigate the effects of abdominal muscle strengthening exercise on low back pain (LBP) risk reduction. METHODS: We compared the effects of abdominal muscle strength (AMS) exercise and back education with back education only on 402 asymptomatic subjects with weak AMS. The primary outcome was the percentage of subjects with at least one episode of LBP at 24 months. A diary was used to monitor compliance. RESULTS: There were no statistically significant differences between experimental (E) and control (C) subjects at 24 months for LBP episodes (E: 34.7%, C: 30.4%; C-E = 4.2%, P2 = 0.481; 95% CI -16.1%, 7.6%). The LBP episodes were also not statistically significantly different at 6 months (E: 13.2%, C: 16.1%; C-E: 2.9%, P2 = 0.493; 95% CI -5.3%, 11.0%) or at 12 months (E: 24.8%, C: 23.6%; C-E = -1.2%, P2 = 0.818; 95% CI -11.6%, 9.2%). Adjusting the data for strata and baseline AMS did not alter the findings. Imputed results for LBP episodes at 6 months (C-E: 4.8%, P2 = 0.191; 95% CI -2.4%, 12.0%), 12 months (C-E: -1.0%, P2 = 0.821; 95% CI -9.5%, 7.6%), and 24 months (C-E: -3.3%, P2 = 0.483; 95% CI -12.6%, 5.9%) were also not statistically significantly different. CONCLUSION: Back education and abdominal exercise instructions are similar to back education alone. There were no group differences in LBP episodes, possibly due to noncompliance with the exercise program. While the estimated benefit of 2.9% at 6 months from the complete data and 4.8% from the imputed data were not statistically significant, a larger study or future metaanalyses may be needed to confirm whether there is a clinical benefit or whether these results should be considered a chance finding.

Examination for tenderness: learning to use 4 kg force.

OBJECTIVE: To minimize interobserver variation in tender point examination, a training program was developed that focused on learning to deliver 4 kg force. METHODS: A 3 step process was designed to provide both measurement and feedback, serving both didactic and research functions. There were 5 repetitions within each step. During the first and 3rd steps, the subjects pressed on the footplate of a dolorimeter with no immediate feedback about the force measured. In the 2nd "training" step, they were given immediate feedback about the force delivered, and were taught to watch the amount and pattern of blanching beneath and around the thumbnail. RESULTS: Twenty-nine observers participated in 30 studies. Initial values varied from 1.78 to 8.92 kg (means within observers), although the mean value was 4.05 kg (means of all observers). The training step reduced observer variation by 65%, with reduction of mean absolute error from 1.25 to 0.44 kg. This improvement was sustained in the 3rd step, in which no feedback was given. Naïve participants performed as well as experts, and there were no detectable sex differences. One observer was retested after an interval of 8 months, and performed no better during the the initial phase of the 2nd test than in the first. Each training session required 3 to 5 minutes. CONCLUSION: Specific training efficiently reduces interobserver variations in pressure used in tender point examinations. These skills should be periodically refreshed to prevent drift into error.

Strategies for assessing pain and pain exaggeration: controlled studies.

OBJECTIVE: To compare structured with intuitive methods of detecting exaggerated pain, in 2 randomized studies, with masked observers, and to compare properties of measures of relative tenderness, as surrogates for measures of pain. METHODS: Pairs of experienced rheumatologists assessed tenderness and behavior in subjects who were either giving honest responses (Not Acting) or exaggerating their tenderness while hiding the deception (Acting). In Study 1 (20 subjects) the assessments of behavior were descriptive only; for Study 2 (25 subjects) a prestructured format was developed. The challenge to the examiners was to detect Acting. The challenge to the analyst was to develop, from the recorded data, an algorithm that described or bettered the examiners' performance. RESULTS: By exaggerating, nontender patients could meet formal ACR criteria for fibromyalgia. The addition of a prestructured pain behavior assessment in Study 2 was associated with improvement in the observers' ability to detect Acting, with improvement of sensitivity from 60 to 90% (p = 0.0003, Study 2 compared with Study 1). False positive diagnoses of Acting by the observers were uniformly uncommon, with specificity of 85 and 86% in the 2 studies. CONCLUSION: Formal numerical techniques are required and feasible for separately assessing the structural and psychogenic components of chronic pain.

Outcome of polyarteritis nodosa and Churg-Strauss syndrome. An analysis of twenty-five patients.

OBJECTIVE: To compare outcome in patients with polyarteritis nodosa (PAN) and patients with Churg-Strauss syndrome (CSS) followed up at a single center. METHODS: A retrospective data review of 13 patients with PAN and 12 patients with CSS who were followed up at a vasculitis clinic. Outcome measures included a global damage index, disability and pain dimensions of the Health Assessment Questionnaire, and mortality rate. RESULTS: Compared with patients with CSS, patients with PAN had a significantly higher mean damage index score (5.15 versus 2.42; P = 0.011), a higher disability score (1.09 versus 0.16; P = 0.007), and a higher pain score (1.04 versus 0.01; P = 0.017). Patients with PAN had more relapses (relative risk = 5.07; P < 0.000) and a higher mortality rate (31%) compared with patients with CSS (8%). CONCLUSION: PAN and CSS differ in their morbidity and mortality; therefore, they should be considered as distinct clinical entities.

The C6-7 syndrome--clinical features and treatment response.

OBJECTIVES: (1) To confirm association of marked tenderness at the coracoid tip, lateral pectoral and medial elbow sites, with tenderness at the C6-7 level in the cervical spine. This had been observed in subjects with prior neck pain, who lost tenderness at C5-6 and standard upper body sites with neck support during sleep, but remained symptomatic; (2) to document apparent risk and prognostic factors; (3) to observe the effects of a modified treatment strategy. METHODS: A protocol including possible risk and prognostic factors was developed, and a case series assembled. Findings on entry tested the hypothesized pattern of linked tender sites. Subjects consenting to followup became a cohort in which outcomes were studied. RESULTS: In 151 subjects, there were associations among the tenderness scores (mean r value of 0.59, p < 0.001) of points in the 6-7 group on the same side, an intermediate level of association with contralateral but homologous points (mean r value of 0.31), but weak associations (mean r value 0.07) with contralateral and different points. During followup, 47% obtained marked or complete relief at their first followup visit, and a final followup (median 18 months), 84% of those without previous fibromyalgia (FM) achieved this satisfactory outcome, and 63% of those with prior FM. CONCLUSION: This experience supports the hypothesis that mechanical factors determine patterns of symptoms and tenderness in many subjects with regional and general pain syndromes, and points to new strategies of diagnosis and treatment which may be critical for success.

Fibromyalgia in familial Mediterranean fever.

OBJECTIVE: To determine whether chronic lower body pain in a subpopulation of patients with familial Mediterranean fever (FMF) is due directly to the musculoskeletal manifestations of FMF or whether they are connected to mechanical problems in the low back and leg/foot or to other factors operative in fibromyalgia (FM). METHODS: In 93 consecutive patients with FMF a point count of 14 tender points (TP) was conducted by thumb palpation. Tenderness thresholds were assessed in some of the TP and of control point sites by Chatillon dolorimeter. RESULTS: In female patients with FMF dolorimeter thresholds of fibrositic and control point sites were significantly lower than in male patients with FMF (p < 0.004). Also patients with FMF with back pain and foot/leg pain are more tender than patients with FMF without this characteristic (p < 0.001). CONCLUSION: The detection of FM and definition of tenderness thresholds is relevant to this disease, since musculoskeletal complaints are common in this group of patients but not always explained by objective findings.

Can specially trained physiotherapists improve the care of patients with rheumatoid arthritis? A randomized health care trial.

OBJECTIVE: To examine the influence of specially trained physical therapists (PT) on patterns and outcome of care, relating to inflammatory disease status as measured by disease outcomes. METHODS: Fifty-four patients were allocated at random to specially trained PT, and to traditional PT. Outcomes were measured at baseline and at 4 months by independent assessors. RESULTS: There was no statistically significant or clinically important difference in outcome between the 2 groups. The advice of specially trained PT significantly improved compliance with salicylates. CONCLUSION: The effectiveness of this therapy was not demonstrated, likely due to incomplete compliance along the therapeutic chain, beginning with the PT's report, through a variety of possible responses, and ending with patient outcome.

Measuring abdominal muscle weakness in patients with low back pain and matched controls: a comparison of 3 devices.

OBJECTIVE: To compare 3 hand held devices used to measure isometric abdominal muscle strength: the adapted sphygmomanometer, the vigorometer and the Penny & Giles myometer. METHODS: Subjects were men, aged 22 to 43 years. Fifteen had a history of low back pain and 18 age matched controls had no low back pain. The test position was a half sit-up at 45 degrees, knees at 90 degrees, feet secured. The single observer applied pressure with one of the devices downwards, just below the sternal notch, while the patient maintained that position. Order of methods was random, controlled by a series of 3 x 3 Latin squares. The vigorometer and myometer were calibrated to mm Hg. Even numbered subjects were tested twice; odd numbered subjects had their measurements timed. RESULTS: One subject was unable to complete the study. Subjects with low back pain had abdominal muscle strength 38.8 mmHg lower than healthy controls [F(1,62) = 72.84, P2 < 0.01]. Order of measurements was similar [F(2,62) = 1.19, P2 = 0.31]; instruments differed [F(2,62) = 27.94, P2 < 0.01]. Duplicate readings were similar (minimum P2 > 0.10); all 3 devices detected significant differences between the 2 groups (P2 < 0.01); mean measurement time was 19 s and time to measure with each device was similar (P2 = 0.70). CONCLUSION: All 3 instruments performed equally well. Since the sphygomanometer is available at about 1/5 the cost of the vigorometer and 1/12 the cost of the myometer, it is the preferred instrument.

Interpretation and power of a pooled index.

OBJECTIVE: To describe, illustrate, provide statistical rationale and give clinical examples of the concept of a pooled index. METHODS: No explicit design. Randomized control trials of patients diagnosed with rheumatoid arthritis from Rheumatic disease clinics, tertiary care hospitals and communities are used as examples to illustrate the pooled index technique. Interventions in rheumatic disease unit inpatient and outpatient care, occupational therapy and physiotherapy provided by Arthritis Society Therapists in the community were compared. Variables included active joint count, morning stiffness in min, mean of right and left grip strength in mm Hg, erythrocyte sedimentation rate in mm/h, a functional change score, and a pooled index. RESULTS: The pooled index in each study detected a clinically important effect while individual measures were generally not able to declare the effect statistically significant. CONCLUSIONS: The pooled index is a more powerful clinical outcome than any individual measure provided it is computed from at least 2 relevant clinical outcome measures that have low correlation with each other.

Performance of scored palpation, a point count, and dolorimetry in assessing unsuspected nonarticular tenderness.

Nonarticular tenderness was measured in 152 patients, 51 with rheumatoid arthritis, 50 with psoriatic arthritis, and 51 with human immunodeficiency virus infection. Three methods for assessing tenderness were used: a 14-site point count, scored tenderness at 10 sites (6 fibrositic and 4 control), and dolorimetry at the same 10 sites. The data from the 3 separate measures were converted into a common scale of standard deviation units for further analysis. There were strong correlations among the 3 measures. In particular, the scored tenderness at just 6 fibrositic sites provided as much information about the presence and severity of widespread tenderness as the other 2, more complex measures. At the interface between nontender and tender, the 2 methods based on palpation were significantly more sensitive to differences among individuals, than was dolorimetry. However, the palpation scales used did not evaluate different degrees of nontenderness. In 102 of the 152 subjects, there were 842 sites scored zero by palpation, and which showed widely different thresholds of tenderness by dolorimetry, significantly associated with diagnosis and sex. For screening and epidemiological purposes, scored tenderness at a limited number of accessible sites may be adequate and feasible, using the 18 point count of the new standard criteria as a gold standard for confirmation. For the assessment of generally acting factors affecting tenderness, dolorimetry is currently superior.

Patients with rheumatoid arthritis are more tender than those with psoriatic arthritis.

Articular and nonarticular tenderness was examined in 51 patients with rheumatoid arthritis (RA) and 50 patients with psoriatic arthritis (PsA) by scored palpation and dolorimeter readings. Fifty-seven percent of patients with RA had 10 or more tender fibrositic points vs 24% of patients with PsA (p = 0.0008). Thresholds of tenderness measured by dolorimetry of 6 fibrositic point sites were 3.97 (1.99) [mean (SD)] for RA vs 5.95 (2.28) for PsA (p less than 0.0001). Thresholds over actively inflamed joints were 4.19 (1.53) for RA vs 6.78 (2.55) for PsA (p less than 0.0001). In both RA and PsA, fibrositic sites were more tender than actively inflamed joints (p less than 0.0001). Nonarticular control sites were also more tender in subjects with RA with dolorimeter thresholds at 5.99 (1.96) in RA vs 7.58 (1.60) in PsA (p less than 0.0001). These data demonstrate that actively inflamed joints, fibrositic and control nonarticular sites were all more tender in patients with RA than PsA. Both groups were similar in their disease duration and clinical assessments of joint inflammation and damage. We suggest that there may be a disease specific diffuse increase in tenderness in patients with RA, which is not related to joint inflammation. Similarly, the severity of articular inflammation may be underestimated in subjects with PsA.