The Impaired Balance Systems Identified by the BESTest in Older Patients With Knee Osteoarthritis.

BACKGROUND: Balance decreases and activities of daily living (ADLs) deteriorate in older people with knee osteoarthritis (KOA); however, little is known about the systems underlying poor balance control and how those impaired systems are related to decreased ADL. OBJECTIVES: To explore which balance systems are particularly impaired and to examine the relationship between physical ADL and balance in older people with KOA. DESIGN: Case-control study. SETTING: Outpatient clinic. PARTICIPANTS: Thirty people with KOA (mean age: 75.4 years) and 30 age-matched healthy adults (mean age: 75.4 years). METHODS: The Balance Evaluation Systems Test (BESTest), consisting of 6 sections to evaluate theoretically driven balance control systems, was used for balance assessment. BESTest section scores were compared by use of the Wilcoxon rank-sum test. Pain and physical ADL in the KOA group were evaluated with the Japanese edition of the Western Ontario and McMaster Universities Osteoarthritis Index. Spearman correlation coefficients and partial rank correlation coefficients were used to investigate the relationship between physical ADL and the BESTest scores, pain, radiography findings, and body mass index. MAIN OUTCOME MEASUREMENTS: The BESTest total and section scores. RESULTS: Compared with controls, 5 of 6 BESTest section scores were significantly lower in the KOA group. Physical ADL was significantly correlated with the total BESTest score (r = -0.484, P = .007), pain (r = 0.635, P < .001), Kellgren and Lawrence grade (r = 0.601, P < .001), and body mass index (r = 0.403, P = .027). Partial rank correlation coefficients between physical ADL and the total BESTest score (r = -0.443, P = .021) or section VI-Stability in Gait (r = -0.466, P = .014) were significant after we controlled for other variables. CONCLUSIONS: Most balance systems were impaired in older people with KOA, and this impairment was associated independently with decreased physical ADL.

Catastrophic head and neck injuries in judo players in Japan from 2003 to 2010.

BACKGROUND: Few studies have documented catastrophic head and neck injuries in judo, but these injuries deserve greater attention. PURPOSE: To determine the features of catastrophic head and neck injuries in judo. STUDY DESIGN: Descriptive epidemiological study. METHODS: This study was based on the accident reports submitted to the All Japan Judo Federation's System for Compensation for Loss or Damage. A total of 72 judo injuries (30 head, 19 neck, and 23 other injuries) were reported between 2003 and 2010. The investigated parameters were mechanism of injury, age at time of injury, length of judo experience, diagnosis, and outcome. RESULTS: Among head injuries, 27 of 30 (90%) occurred in players younger than 20 years of age. The relationship between age, mechanism, and location of injury was more relevant when players younger than 20 years incurred head injury while being thrown (P = .0026). Among neck injuries, 13 of 19 (68%) occurred in players with more than 36 months of experience. The relationship between experience, mechanism, and location of injury was more relevant when experienced players incurred neck injury while executing an offensive maneuver (P = .0294). Acute subdural hematoma was diagnosed in 94% of head injuries. The outcomes of head injury were as follows: 15 players died; 5 were in a persistent vegetative state; 6 required assistance because of higher brain dysfunction, hemiplegia, or aphasia; and 4 had full recovery. Among neck injuries, 18 players were diagnosed with cervical spine injury, 11 of whom had fracture-dislocation of the cervical vertebra; there was also 1 case of atlantoaxial subluxation. The outcomes of neck injury were as follows: 7 players had complete paralysis, 7 had incomplete paralysis, and 5 had full recovery. CONCLUSION: Neck injuries were associated with having more experience and executing offensive maneuvers, whereas head injuries were associated with age younger than 20 years and with being thrown.

Efficacy of acupuncture during post-acute phase of rehabilitation after total knee arthroplasty.

OBJECTIVE: The purpose of this study was to determine whether acupuncture is effective in reducing pain and swelling around the knee and improving range of motion (ROM) during the post-acute phase of rehabilitation after total knee arthroplasty (TKA). METHODS: Following TKA, 80 knees in 80 patients were randomly assigned to either an acupuncture treatment group (Group A) or a control group (Group C). In Group A, the complementary treatment of acupuncture was performed three times/week from postoperative day 7 until postoperative day 21. Outcome measures were: i) pain as assessed by a visual analog scale; ii) reduction of swelling around the knee as indicated by its circumference at the center of the patella; and iii) ROM of the affected knee. RESULTS: Group A patients had significantly reduced pain and swelling around the knees and earlier recovery of ROM than did those in Group C. CONCLUSION: Acupuncture provides effective treatment during the post-acute phase of rehabilitation after TKA with respect to pain relief, reduction of swelling around the knee, and early recovery of ROM.

[Severe head injuries during Judo practice].

The goal of this study is to elucidate the characteristic features of Judo head injuries and to propose safety measures and a reaction manual on how to prevent and to deal with such accidents in Japan. Thirty cases of severe head injuries suffered during Judo practice were enrolled in this study. They have made insurance claims for damage compensation and inquiries about Judo accidents attributed to the All Japan Judo Federation, from 2003 to 2010. The average age of the patients was 16.5 year old. The incidence of injury showed 2 peaks in different academic grade levels; one is in the first year of junior high-school (30.0%, n=9) and the other is in senior high school (26.7%, n=8). Around half of them were beginners. Four cases (13.3%) had past history of head trauma or headache and dizziness before a catastrophic accident, suggesting the presence of a second impact. Lucid interval was observed in 25 cases (83.3%). Most patients (93.3%) suffered acute subdural hematoma associated with avulsion of a cerebral bridging vein. Of patients who underwent emergency removal of the hematoma, 15 patients (50%) died and 7 patients (23.3%) entered a persistent vegetative state. Based on these findings, we propose an emergency manual with safety measures for effectively preventing and treating Judo head injuries in an appropriate manner. To reduce the disastrous head injuries in Judo, the safety measures and an optimal action manual should be reconsidered and widely spread and accepted by society.

The influence of sex on patients with rheumatoid arthritis in a large observational cohort.

OBJECTIVE: To compare the sex differences of various components of rheumatoid arthritis (RA). METHODS: Data of 4823 patients from a large observational cohort study were analyzed. Remarkable differences were noted between the sexes, and overall, women had significantly higher disease activity. RESULTS: When variables were adjusted using sex, age, and duration, Health Assessment Questionnaire, rather than Disease Activity Score, contributed most to sex difference. Further analysis showed evidence that progression of disability was approximately 3 times more rapid in female patients compared to male patients. CONCLUSION: Women overall have higher RA disease activity and are prone to greater and faster progression of disability over time.

Risk factors associated with incident fractures in Japanese men with rheumatoid arthritis: a prospective observational cohort study.

There are limited data in the literature concerning risk factors for incident fractures in men with rheumatoid arthritis (RA). We evaluated the association between potential risk factors and incident clinical fractures in male Japanese patients with RA. A total of 1050 male patients with RA were enrolled in a prospective, observational cohort study from 2000 to 2005. Participants were followed from 6 to 66 months (median follow-up, 48.7 months) and classified into three groups according to their incident fracture status from baseline: no new fracture, any new nonvertebral fracture, and new clinical vertebral fracture. The associations of potential risk factors were analyzed by Cox proportional hazards models. During follow-up, 30 patients (2.9%) developed a new nonvertebral fracture or a vertebral fracture. The baseline age, history of total knee replacement (TKR), and serum C-reactive protein (CRP) levels were associated with any nonvertebral fracture [baseline age: hazard ratio (HR), 1.08, 95% confidence interval (CI), 1.03-1.14; history of TKR: HR 6.02, 95% CI 1.19-30.42; and CRP: HR 0.60, 95% CI 0.38-0.95]. The baseline Japanese health assessment questionnaire (HAQ) score and daily dose of prednisolone were also associated with the incidence of clinical vertebral fractures (HR 7.74, 95% CI 2.10-28.48, and HR 1.28, 95% CI 1.14-1.45, respectively). Older age, history of TKR, and low serum CRP levels appear to be associated with any incident nonvertebral fracture in Japanese men with RA. High HAQ disability score and baseline doses of daily prednisolone may correlate with incident clinical vertebral fracture in Japanese men with RA.

Granzyme B induces apoptosis of chondrocytes with natural killer cell-like cytotoxicity in rheumatoid arthritis.

OBJECTIVE: Granzyme B, an apoptosis-inducing factor, is expressed in natural killer (NK) cells, an important factor in innate immunity. We previously reported that granzyme B is expressed in arthritic cartilage and chondrocytes, and suggested that granzyme B expression is related to apoptosis distribution. We have now investigated whether granzyme B directly induces apoptosis in chondrocytes and whether chondrocytes possess NK cell-like function. METHODS: Chondrocytes included the human C-28/12 chondrocyte cell line, normal chondrocytes, and rheumatoid arthritis (RA) chondrocytes. Apoptosis was analyzed by ELISA and TUNEL after C-28/12 cells were incubated with active granzyme B. NK cell markers were examined in chondrocytes by FACS and immunohistochemistry. Chondrocytes with or without Z-AAD-CMK, a known granzyme B inhibitor, were stimulated with PHA (20 microg/ml), followed by coculture with K562 cells in order to test chondrocyte cytotoxity. RESULTS: Granzyme B was successfully introduced into C-28/12 chondrocytes, and was confirmed to dose-dependently induce apoptosis. Immunohistochemically, chondrocytes expressed the surface antigens of NK cells and exhibited cytotoxicity against K562 cells, which served as an indicator of cytotoxicity. Z-AAD-CMK inhibited cytotoxicity against K562 cells in a dose-dependent manner, thus confirming that chondrocyte cytotoxicity against K562 cells is dependent on granzyme B. CONCLUSION: Our findings indicate that chondrocytes possess NK cell-like activity related to innate immunity, and that apoptosis is induced in these cells by granzyme B. Our findings suggest that inflammation activates granzyme B, which participates in the destruction of RA-affected joints.

Association of STAT4 with susceptibility to rheumatoid arthritis and systemic lupus erythematosus in the Japanese population.

OBJECTIVE: STAT4 encodes a transcriptional factor that transmits signals induced by several key cytokines, and it might be a key molecule in the development of autoimmune diseases. Recently, a STAT4 haplotype was reported to be associated with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) in Caucasian populations. This was replicated in a Korean RA population. Interestingly, the degree of risk of RA susceptibility with the STAT4 haplotype was similar in the Caucasian and Korean populations. The present study was undertaken to investigate the effect of STAT4 on susceptibility to RA and SLE in the Japanese. METHODS: We performed an association study using 3 independent Japanese RA case-control populations (total 3,567 cases and 2,199 controls) and 3 independent Japanese SLE populations (total 591 cases). All samples were genotyped using the TaqMan fluorogenic 5' nuclease assay for single-nucleotide polymorphism (SNP) rs7574865, which tags the susceptibility haplotype. The association of the SNP with disease susceptibility in each case-control study was calculated using Fisher's exact test, and the results were combined, using the Mantel-Haenszel method, to obtain combined odds ratios (ORs). RESULTS: We observed a significant association of the STAT4 polymorphism with susceptibility to both RA and SLE. The combined ORs for RA and SLE, respectively, were 1.27 (P = 8.4 x 10(-9)) and 1.61 (P = 2.1 x 10(-11)) for allele frequency distribution; these ORs were quite similar to those previously observed in the Caucasian population. CONCLUSION: We conclude that STAT4 is associated with RA and SLE in the Japanese. Our results indicate that STAT4 is a common genetic risk factor for autoimmune diseases, with similar strength across major racial groups.

Risk factors for wrist surgery in rheumatoid arthritis.

To assess the risk factors for wrist surgery in a cohort of rheumatoid arthritis (RA) patients recruited and followed prospectively for 6 years. A linked registry study was performed using information from a large observational cohort of RA patients followed at the Institute of Rheumatology, Tokyo Women's Medical University. Baseline routine clinical and laboratory assessments were recorded. The data were analyzed using the multivariate Cox regression model that included variables such as gender, age, disease duration, a visual analog scale (VAS) generated by physicians, a patient-reported VAS for pain (VAS-pain), a VAS for general health, disability level using the Japanese version of the Health Assessment Questionnaire (J-HAQ), erythrocyte sedimentation rate, and serum levels of C-reactive protein and rheumatoid factor as potential risk factors. Of the 5,497 patients registered at baseline, 122 (2.22%) had surgery on one or both wrist joints. Multivariate Cox regression analysis of the variables revealed positive coefficients for J-HAQ and VAS-pain and that advanced age and long RA duration were associated with a reduced risk of wrist surgery. The hazard ratios were: 1.515 for J-HAQ, 1.126 for VAS-pain, 0.985 for age, and 0.964 for RA duration. Advanced age and long RA duration were associated with a decreased risk of wrist surgery, while J-HAQ and VAS-pain were associated with an increased risk. The identification of the risk factors for wrist surgery provides important insights into the course of the disease and its impact on patients, as well as the potential consequences for health care resource utilization planning.

Iliopsoas bursitis-associated femoral neuropathy exacerbated after internal fixation of an intertrochanteric hip fracture in rheumatoid arthritis: a case report.

We present the case of a 63-year-old woman with a six-year history of rheumatoid arthritis (RA) and a left iliopsoas bursitis. Radiography had detected destructive changes in her hip joint associated with her bursitis, and she had reported some paresthesia along the left anterior distal thigh. Her pain and numbness remained tolerable, and her disease activity was well controlled until she accidentally fell on the floor, which resulted in an unstable intertrochanteric fracture of left femur with displacement of the proximal portion. The fracture was successfully treated with open reduction and internal fixation, but after the surgery, her femoral nerve palsy worsened. She subsequently underwent bursa excision after the failure of conservative treatment. Accordingly, after bursa excision, the postoperative course was uneventful, and her neurological symptoms gradually disappeared. We would recommend that bursa excision be considered even in cases of iliopsoas bursitis associated with mild femoral neuropathy when destructive changes in the hip joint are also present.

Factors affecting anteroposterior instability following cruciate-retaining total knee arthroplasty in patients with rheumatoid arthritis.

Controversy persists concerning around posterior cruciate ligament (PCL) retention in total knee arthroplasty (TKA) for patients with rheumatoid arthritis (RA). This study investigated factors affecting anteroposterior (AP) instability following cruciate-retaining (CR)-TKA. In a consecutive series of 70 knees from 52 RA patients, total displacement (TD) was measured using a KT-2000 arthrometer before and after CR-TKA under anesthesia, and changes in TD were defined as DeltaTD. TD was also measured under anesthesia in 65 knees from 48 RA patients at a mean of 7.5 years after CR-TKA. Mean postoperative TD was 9.4+/-0.95 mm, representing an increase of about 1.5-1.8 mm compared to preoperative TD, and possibly reflecting resection of the anterior cruciate ligament. Correlation analysis revealed significant negative correlations between DeltaTD and both preoperative flexion angle (r=-0.67, p<0.001) and preoperative extension angle (r=-0.63, p<0.001), suggesting that TD in knees with flexion contracture increased postoperatively. At medium-term follow-up, no patients displayed AP instability, and mean TD was 8.3+/-0.48 mm. A significant correlation was found between TD and permissible flexion angle (r=0.61, p<0.001). These results indicate that TD is basically maintained during the course of CR-TKA in RA, but may be slightly affected by factors other than the PCL itself.

Risk factors for total knee arthroplasty in rheumatoid arthritis.

We conducted a study to assess the predictive factors for total knee arthroplasty (TKA) in a cohort of rheumatoid arthritis (RA) patients recruited and followed prospectively for 5 years. A linked registry study using information from a large observational cohort of RA patients followed at the Institute of Rheumatology, Tokyo Women's Medical University (IORRA) was done. Baseline routine clinical and laboratory assessments were recorded. The data were analyzed using the multivariate piecewise-linear Cox (PL-Cox) regression model; the model initially included variables such as gender, age, duration of the disease, visual analog scale (VAS) generated by physicians (VAS-physician), patient-reported VAS for pain (VAS-pain), VAS for general health (VAS-GH), disability level using the Japanese version of the Health Assessment Questionnaire (J-HAQ), C-reactive protein, erythrocyte sedimentation rate, rheumatoid factor (RF), and hemoglobin. Of the 3945 patients registered at baseline, 955 (24.2%) had pain or tenderness in their knee joints, and 114 (11.9%) had TKA surgery in one or both knee joints. On PL-Cox regression, the variables with positive coefficients were J-HAQ, VAS-pain, VAS-physician, and RF positive; advanced age was associated with a reduced risk of TKA. The hazard ratios were: 0.920 for age >60 years; 2.64 for J-HAQ <1.5; 1.01 for J-HAQ >1.5; 1.47 for VAS-pain >6 (cm); 1.20 for VAS-physician >4 (cm); and 2.08 for RF positive. The consistently predictive factors for TKA in RA were age, J-HAQ, VAS-pain, VAS-physician, and RF positive. Age greater than 60 years was associated with a decreased risk of TKA, while J-HAQ from 0 to 1.5, VAS-pain >6 (cm), and VAS-physician >4 (cm) were associated with an increased risk for TKA surgery. These results suggest that, when treating RA patients, physicians should pay particular attention to pain complaints, the patient's daily activity level, and the RF factor status.

Elevation of serum matrix metalloproteinase-3 as a predictive marker for the long-term disability of rheumatoid arthritis patients in a prospective observational cohort IORRA.

Matrix metalloproteinases (MMPs) are the proteases responsible for the destruction of cartilage in rheumatoid arthritis (RA) patients; especially the role of MMP-3 in RA has been highlighted from both pathophysiological studies and clinical studies. However, the role of serum MMP-3 in a large observational cohort of RA patients has not been well demonstrated. In a large observational cohort of RA patients in our Institute (IORRA, October 2000-October 2005, n=3834-5049/phase), disease activity and functional status were routinely assessed biannually. In October 2001, serum MMP-3 was measured in 1265 patients in this cohort, and the data of these patients in the subsequent 4 years were analyzed. The functional status of disability was assessed by JHAQ, the verified Japanese version of HAQ. A cut-off point of 121.0 ng/ml (men) and 59.7 ng/ml (women) was used for MMP-3 positive/negative categorization. The baseline data of these 1265 patients include 81.5% women, mean age 57.9, mean duration 11.1 years, and 71.7% of patients were rheumatoid factor (RF)-positive. Serum MMP-3 levels at the baseline (195.1+227.9 ng/ml) were weakly correlated with C-reactive protein (CRP), but qualitative elevation of serum MMP-3 using cut-off points correlated significantly with corticosteroids use, DAS28, CRP, erythrocyte sedimentation rate, JHAQ, or other markers for the disease activity, but not with age or the disease duration. Thus, elevation of serum MMP-3 level represents the disease activity of RA patients regardless of age or the disease duration. In the longitudinal analysis, the slope of JHAQ progression in patients with MMP-3 positive and RF positive, MMP-3 positive and RF negative, MMP-3 negative and RF positive and MMP-3 negative and RF negative were 0.0179, 0.0162, 0.0156, and 0.0119, respectively, indicating that JHAQ increased most progressively in RA patients with MMP-3 positive and RF positive patients, although statistically apparent differences were not identified. In 502 female patients without talking corticosteroid, patients with MMP-3 positive and RF positive were statistically more progressive in the disability than patients with MMP-3 negative and RF negative. In conclusion, elevation of serum MMP-3 in RA patients is an indicator of inflammation, and together with RF, elevation of serum MMP-3 is a predictive marker for the progression in disability especially in female patients without corticosteroid.

A case of Castleman's disease associated with diffuse idiopathic skeletal hyperostosis and ossification of the posterior longitudinal ligament of the spine.

Castleman's disease (CD), diffuse idiopathic skeletal hyperostosis (DISH), and ossification of the posterior longitudinal ligament of the spine (OPLL) are three different entities. Castleman's disease displaying a variety of calcifications in the abdomen and/or pelvis has been reported in some papers. However, there were no reports suggesting an association between CD and ossification/calcification in spine and joints. So far, there has been no case report regarding the coexistence of these diseases in the literature. Herein, we detail a 75-year-old man suffering from CD who demonstrated the features of DISH with coexisting features of OPLL. The cardinal symptoms such as fatigue, high fever, and swollen glands in this case were reduced by corticosteroid therapy. However, it is possible to produce actual symptoms of ossifying/calcified diathesis of entheses and ligaments as a consequence, like the pathology of calcification found in the region of the spleen. In this paper, we describe this patient in order to discuss the association of these diseases.

A role of monocyte chemoattractant protein-4 (MCP-4)/CCL13 from chondrocytes in rheumatoid arthritis.

We studied the role of monocyte chemoattractant (MCP)-4/CCL13 in the pathogenesis of rheumatoid arthritis (RA). MCP-4 was highly expressed in cartilage from RA patients. Interferon-gamma significantly stimulated MCP-4/CCL13 production in human chondrocytes, and this effect was enhanced in combination with interleukin-1beta or tumor necrosis factor-alpha. MCP-4/CCL13 induces the phosphorylation of extracellular signal-regulated kinase in fibroblast-like synoviocytes and activates cell proliferation, and PD98059 completely inhibits these effects. These data suggest that interferon-gamma in combination with interleukin-1beta/tumor necrosis factor-alpha activates the production of MCP-4/CCL13 from chondrocytes in RA joints, and that secreted MCP-4/CCL13 enhances fibroblast-like synoviocyte proliferation by activating the extracellular signal-regulated kinase mitogen-activated protein kinase cascade.

Improvement of disease activity of rheumatoid arthritis patients from 2000 to 2006 in a large observational cohort study IORRA in Japan.

The objective of this study was to show whether the disease activity of rheumatoid arthritis (RA) patients had improved in Japan, and whether the improvement of disease activity had resulted in a better outcome of patients. In a single-institute-based prospective observational cohort of RA patients (Institute of Rheumatology, Rheumatoid Arthritis, IORRA), a total of 7512 patients were enrolled, and their information was collected biannually. A cross-sectional data set A that included all patients in each phase was analyzed. From October 2000 to April 2006, disease activity score DAS28 significantly improved from 4.15 to 3.63, and the frequency of patients in remission (DAS28 < 2.6) increased from 8.5% to 21.5%. During this period, the frequency of methotrexate users increased from 33.9% to 58.7% and the average dosage of methotrexate also increased from 5.59 mg/week to 6.94 mg/week; on the other hand, there was no increase in any adverse reaction among the methotrexate users. To investigate the relationship between longitudinal disease control and progression of disability, a longitudinal data set B that included 712 patients who completed all phases of the study from 2000 to 2006 was selected and was analyzed. The disability index JHAQ of a poorly controlled group (average DAS > 5.1) increased (+34.8%), that of a moderately controlled group (average DAS 3.2-5.1) also increased (+14.0%), but that of a well-controlled group (average DAS < 3.2) decreased (-13.0%). In conclusion, by using a prospective observational cohort IORRA in Japan, we demonstrate that RA disease activity improved from 2000 to 2006, which correlates with an increased use of methotrexate. The suppression of disease activity resulted in a better outcome for patients.

Disturbances of the symphysis pubis in rheumatoid arthritis: report of two cases.

We present two rheumatoid arthritis (RA) patients suffering from disturbances of the symphysis pubis. Radiography revealed one with pelvic ring disruption with symphysis pubis diastasis, and the other with osteolysis at both pubic rami and disruption of the superior aspect of the symphysis pubis. Both cases had received long-term corticosteroid therapy, including pulse therapy. We recommend reducing the corticosteroid dose to prevent disturbances of the symphysis pubis especially in RA patients on long-term steroid therapy.