News Category: General

Dr. Felson offers us a new paradigm to understand what goes wrong to cause osteoarthritis (OA). A paradigm is a pattern or model for something. A paradigm shift occurs when traditional thinking changes about something like OA.

The new way to look at OA is through risk factors that affect joint protectors. Joint protectors include the cartilage, muscles, tendons, and mechanoreceptors. Mechanoreceptors are nerves that tell the muscles, tendons, ligaments, and capsule to get ready for the load or movement. All the soft tissues assume a position of protection. They keep the joint from moving too far, and they spread out the load.

Aging, muscle weakness, and genetics play a role in causing joint protectors to fail. Alignment problems and joint deformities are also risk factors. Also important are factors that affect the load on the joint, such as obesity and some physical activities.

Injury to the joint puts it at risk for OA. Anything that can cause failure of joint protectors can be a problem. Increased load or overload added to this kind of failure can lead to OA. In this article, the author discusses each of the risk factors and brings us up to date about each one.

Ultrasound (US) has been thought to delay wound healing in fractures. But new studies show that US may, in fact, help broken bones heal faster. The key is the intensity of the sound wave. Low-intensity ultrasound speeds up healing time in animals and humans. Are doctors and physical therapists aware of this? They see more patients with fractures than anyone else.

In this study, doctors and therapists were asked three sets of questions:

Swedish scientists report a decrease in strength of healing tendons when patients use COX-2 inhibitors during the early post-operative period. The “patients” in this study were rats divided into groups. All rats had a small piece of the Achilles tendon surgically removed.

Some rats were given saline injections for the first five days after surgery. Others got parecoxib, a COX-2 inhibitor. COX-2 inhibitors are used to reduce inflammation without causing bleeding stomach ulcers. The researchers also studied two other groups of rats. Saline or parecoxib were used from day six until day 14. In a rat’s short life, this is equal to giving them COX-2 inhibitors during the later phase of healing.

Studies show that inflammation in the first few days after trauma is good. It seems to help normal repair of damaged tissue. Later in the healing process, the tissues start to remodel and form cross-links needed for strength. The authors of this study say that inflammation should be stopped in this remodeling phase. COX-2 inhibitors taken in the later phase may be helpful.

These researchers aren’t sure how to translate this information from rats to humans. Rats live a much shorter time compared to humans. A week in the life of a rat is equal to a month in humans. It’s unclear if the phases of inflammation, healing, and remodeling are the same in rats and humans.

It may be necessary to avoid COX-2 inhibitors during the first 10 days of tendon healing in humans. More study is needed to find out how these drugs affect humans in the early period after tendon injury.

This is a single case report of a 27-year-old male naval fighter pilot with a nerve injury affecting his right shoulder blade. Paralysis of the serratus anterior muscle caused the shoulder blade to stick out, a position called winging of the scapula. The patient also had arm weakness and neck and shoulder pain.

The patient couldn’t figure out what caused the problem. He hadn’t hurt himself and wasn’t doing too much weight lifting. No one in his family had ever had anything like this. There was no history of viral infection. Doctors ruled out a cartilage tear in the shoulder. MRI tests showed he hadn’t torn the rotator cuff, either.

A steroid injection to the right shoulder gave him pain relief for about an hour. However, there was no change in his weakness. EMG studies of the muscles showed a nerve palsy of the long thoracic nerve on the right side, causing the weakness of the serratus anterior muscle.

There are many possible causes of long thoracic nerve injury. Heavy packs or a sudden arm injury are the most common causes in the military. In this case, the doctors think pressure injured the pilot’s nerve during 18 consecutive takeoffs and landings in his aircraft. Pressure was put on the nerve each time the plane went from zero to 175 knots in three seconds during takeoff, or from 175 to zero in three seconds during landing. This force equals three times the gravitational pull of the earth.

It’s likely that more naval pilots have this problem. They may not report it for fear of being grounded. This case could help the military prevent and treat early any future cases of long thoracic nerve injury.

Sometimes neck and shoulder pain occurs, but there’s nothing wrong with the neck or shoulder. Heart attack, bleeding ulcers, and lung cancer are just a few problems that can cause pain in the neck and shoulder. Other symptoms can occur as well. These “extra” symptoms occur in situations when the tumors go beyond the lungs. The tumors then put pressure on the nearby nerves, ribs, diaphragm, or vertebrae.

In this report doctors show how standard chest and neck X-rays can be used to find Pancoast tumors early. Pancoast tumors occur in the upper part of the lung lobes. This form of lung cancer is hard to detect early. Patients often have vague symptoms that are mistaken for arthritis of the neck and shoulder or a frozen shoulder of unknown cause.

Even when an X-ray is taken, the doctor may not see early changes on X-rays unless he or she is aware of this problem. The authors of this report point out an important X-ray finding of Pancoast tumor: air in the lungs being separated from the first rib. There’s also a higher pulmonary air density seen around the tumor.

This is the first report to show the importance of X-rays in finding Pancoast tumors. Doctors must know what to look for and screen neck and shoulder pain patients appropriately.

In 1995 the American College of Sports Medicine (ACSM) wrote a position stand on Osteoporosis and Exercise. This new report on Physical Activity and Bone Health replaces the old report.

The ACSM reminds us that regular physical activity can help keep bones healthy in adults. The risk of bone fracture is also reduced, and it doesn’t take vigorous activity to do it!

To build bone in children and teens, physical activities that include running and jumping may be best. Exercise is advised at least three days a week for 10 to 20 minutes.

To prevent bone loss in adults, weight-bearing and resistance activities are best. These activities include walking alternating with jogging, stair climbing, tennis, and weight lifting. Moderate to high intensity is needed to apply enough force to the bones to stimulate bone growth and repair.

Exercise for adults should be 30 to 60 minutes long. Weight-bearing activities should be done three to five times each week. Weight lifting should be done two to three times each week. All major muscle groups should be exercised.

This report gives a prescription of exercise to help build up bone density in children and preserve bone density in adults. Type of exercise, intensity, frequency, and duration are all discussed. The needs of much older adults are also addressed. The ACSM advises older adults to exercise to preserve their bones and keep their balance. The goal is to prevent falls and fractures.

Can you rub your belly and pat your head at the same time? How about walk and talk at the same time? Being able to talk while exercising is a simple way to make sure you get all the benefits of the program without the risks. So say researchers at the University of Wisconsin-La Crosse.

Sixteen healthy volunteers (men and women) were tested on a treadmill and a bike. Heart rate and breathing metabolism were measured. All subjects were asked to exercise at a comfortable level, so that they could talk at the same time. This is called the Talk Test.

Using the Talk Test as a measure of exercise intensity, the researchers found that subjects used the same amount of oxygen on the bike and the treadmill. They conclude that the Talk Test is a good way to prescribe the right level of exercise in a variety of settings.

The Talk Test is a good tool to find the best level of exercise intensity when expensive exercise testing isn’t possible.

Recovery after hip or knee replacement varies from patient to patient. Some can go from the hospital directly home. Others need some extra time in the hospital with help from the physical therapist. And a few will need extended rehab.

Knowing the outcome ahead of time could help family members prepare better for the patient’s care. There’s a new tool used to help measure risk and predict where the patient will end up. It’s called the risk assessment and prediction tool (RAPT). Risk is based on age, gender, and ability to get around without help.

Older females who are housebound and need someone to care for them after the operation are at greatest risk. Younger men who don’t rely on walking aids and don’t need meals on wheels or live-in care after the operation have the lowest risk.

This study shows that using the RAPT before surgery works well to find patients who will need the most help after hip or knee joint replacement. Patients with low risk went directly home while patients with greater risk were treated with in-hospital physical therapy.

Hospital records over time showed that more patients went directly home when the RAPT was used. There was no increase in the number of patients who were readmitted to the hospital later. The authors conclude that use of the RAPT can help reduce health care costs associated with hip or knee joint replacements.

Pain after surgery can be a big problem. In this study, doctors used a small, portable pump after surgery for three children. The pump allowed the patients to go home with good pain control. It also made it possible for the children to complete their physical therapy (PT) sessions.

Until now, patient-controlled analgesia (PCA) was only used for adults. The pump was large and heavy, with very advanced technology. The unit used in this study was lightweight and fit easily inside a small pouch. It was battery operated. Parents could change the program at home with instructions from the doctor.

The main goal in getting such good pain control was to complete the PT program everyday. The PCA was used for the first three days. No other pain medication was needed during that time. PT was carried out with little to no pain. Rehab is very important in the success of many operations.

The authors point out that in-home use of PCA is experimental at this time. Routine use can’t be prescribed until safe doses can be determined.

True or false: Stretching should always be done before exercising. False! Stretching has generally been advised to improve physical performance. But new studies show that stretching may actually decrease muscle force and power, leading to worse physical performance.

This is the first study to look at the effects of acute stretching on balance, joint position sense, and movement time. Sixteen young, healthy male college students were studied. The stretching program under review included stretches of three muscle groups in the legs. The muscles stretched were the quadriceps, hamstrings, and calf muscles. Everyone rode a bicycle for five minutes to warm up. Then they stretched each muscle for 45 seconds. Each stretch was done three times.

The results showed stretching to the point of discomfort decreases the muscle’s ability to respond when needed. Balance, recovery from loss of balance, and speed of movement were all decreased after stretching. This study agrees with other studies that show warm-up exercise has a better effect on performance than stretching.

Improving balance and reaction time can help the athlete as well as the aging adult at risk for fractures from falls. It may be better to do general and more specific warm-ups related to the activity than to stretch first. Stretching is still important but shouldn’t be done right before athletic events or other activities.

Many Americans are using supplements of all kinds to treat or prevent various illnesses and diseases. Some products are used to improve memory, immune function, and joint lubrication. Others are thought to prevent depression and colds. In this report, two pharmacists review 10 of the most common herbal products. They present the effects these herbs have on patients planning to have orthopedic surgery.

Most herbal supplements have some possible problems when used around the time a patient is having surgery. For example, gingko biloba is used to improve memory. But it can also increase the risk for bleeding. The gingko keeps platelets from clumping together so they can’t form a clot.

Ginseng is used to prevent the effects of aging. It’s also reported to increase energy. This is another herb that can prevent blood clotting. It also lowers blood glucose levels after eating. This leaves a person at risk for low energy and falls.

Most doctors tell patients to stop using herbs or supplements at least two weeks before surgery. Some products can be used up to 48 hours before an operation. Others must be stopped slowly to prevent withdrawal. Doctors will be able to set more specific times as information about these herbs becomes available.

These pharmacists suggest that patients always tell their doctors all drugs, medications, and herbs they are using before having surgery. Doctors must know the effects of each product and advise patients about using or avoiding these herbs.

Low back pain (LBP) from a disc problem occurs in patients no matter what insurance coverage they have. But diagnosis and treatment may be based on their insurance coverage.

This study compares patients with LBP in two groups. One group had been in a car accident. They could see any doctor they chose under a personal injury program (PIP). The second group had a work-related injury. They were managed under a worker’s compensation (WC) program. The WC group sent patients to a group of approved doctors.

In the PIP group, treatment and reimbursement depends on getting approval for treatment in advance. This is called preauthorization. In cases of lumbar disc problems, this approval often depends on the patient having a positive straight leg raise (SLR) test. The SLR test is a reliable test. A positive SLR test on one side is called unilateral SLR. A positive SLR test on both sides is a bilateral SLR.

A review of 200 patient charts was done. A higher percentage of people with a positive SLR was seen in people covered by a PIP than by WC. Here are the results:

This article gives some important reminders about treating the older adult with bone and joint problems. Age-related changes in how the body functions are reviewed. Special problems in older adults are noted. A few simple rules are offered to prevent these problems.

Blood pressure goes up. Body temperature goes down. Skin gets thinner and bruises easier. Changes in vision and hearing occur. All these factors put the older adult at increased risk for problems after an operation.

The older adult is more likely to be taking drugs for various problems. Often patients over 65 years old are taking multiple drugs. They may be taking over-the-counter drugs and herbal remedies, too. This report offers doctors guidelines for how to adjust doses for many drugs used to treat older adults. A general rule in giving drugs to older patients is to “start low and go slow.”

Delirium is a common problem during a hospital stay for hip fracture. This problem can be prevented. The article offers some easy-to-follow advice. Keep a calendar and a clock in the patient’s room. Make sure the room is well lit during the day, with nightlights during dark hours. Prevent dehydration. Make sure patients have their eyeglasses and hearing aids.

The patient’s rights are also reviewed. Patients must be given choices. They shouldn’t be forced to choose treatment they don’t want. Advice from family members, a team approach, and using a living will help patients decide what care they do want.

The author suggests taking extra time with the older adult needing medical care. Ways to prevent, treat, and manage problems are reviewed in this report.

Osteoporosis affects women four times more often than men. Still, there are two million men in the United States with this disease. And this figure is expected to increase as men live longer. This article reviews osteoporosis in men.

New research shows that estrogen is needed by both men and women to keep bone mass. Without good bone density, adults are at risk for fractures, especially hip fractures. In this report, doctors discuss the role of hormones, genetics, and treatment for osteoporosis in men compared to women.

Scientists aren’t sure yet exactly how hormones work in men. It’s not clear what goes wrong. Maybe there is an imbalance of hormones. This can cause an increase in bone loss after the bone is formed. Or perhaps not having the right hormones keeps the bone from forming in the first place.

Genetics also plays a role in male osteoporosis. Men with osteoporosis are likely to have other male relatives with this disease.

Treatment begins with prevention. Bone density must be built in young boys through calcium intake and physical activity. Men at risk for osteoporosis must be identified. Risk factors for osteoporosis such as smoking, inactivity, and poor diet can be changed. Alcoholism, low calcium, and low vitamin D are also risk factors for low bone mineral density. Vitamin D comes from sunshine.

Drug treatment is another option for men with osteoporosis. One option is a drug called Alendronate. It used to prevent bone loss once the bone is already formed. Low doses of parathyroid hormone (PTH) can be given off and on. PTH is a bone-forming drug. Fluoride may be useful to boost bone growth, too. Researchers are studying this closely.

The authors conclude that osteoporosis occurs in men slowly over time. Bone loss is highest in men with low levels of hormones such as testosterone and estrogen. Clear guidelines for screening men for osteoporosis aren’t ready yet. This report suggests that screening should begin with men who have already had bone fractures. Screening should also be done for men over 75 and men who are alcoholics.

Many patients could use a joint replacement. Often they refuse to even think about it. What’s the hold up? That’s what researchers in Canada set out to discover. This study focused on 17 adults with moderate to severe arthritis. All were good candidates for joint replacement. All were unwilling to consider it.

The patients were interviewed and asked questions in two key areas. The first was about the information they had received about the operation. Questions were also included to find out what kind of support patients expected if they had the surgery. The second area addressed the needs and desires that were important to the patients. These questions focused on arthritis management and care after joint replacement.

The researchers used the patients’ answers to understand what decision-making process is used. Did the individuals weigh the risks and benefits of joint replacement? Did they compare all treatment options?

The authors report that no one single event made people decide about joint replacement. It’s more likely that a slow increase in pain and loss of function are the key factors. Patients are less likely to think about a joint implant if the pain comes and goes. The same is true if they have some function and can get around despite the pain.

The decision to have a joint replacement is complex. For many patients it’s more than just looking at the pros and cons. People consider many factors and use information from many sources. For example, even with severe pain and disability, many patients don’t think their situation is bad enough for surgery. Or they’ve heard there’s even more pain after the operation. Some don’t see the value given their own limited life span.

Most patients rely on their friends and peers to tell them about the operation. The authors of this report suggest this means patients may not get accurate information about their own case. Understanding how patients make this decision may help doctors guide patients in their treatment.

The topic of this report is how and why joint trauma leads to arthritis. Arthritis that develops after an injury is called posttraumatic arthritis. The authors review what is already known on this topic. They ask: Is this type of arthritis brought on by joint instability or joint incongruity?

Incongruity occurs when two sides of the bone or joint don’t line up smoothly and evenly. Incongruity can be caused by a bone fracture or an injury to the joint. Instability means the joint is free to move too far in one or more directions. Many studies show that patients do pretty well when the joint is stable, even if there is a lot of incongruity. On the other hand, even a small amount of incongruity causes problems when the joint isn’t stable.

Is there a link between joint incongruity and posttraumatic arthritis? Here’s what we know so far:

Chronic groin pain during exercise can be hard to diagnose. This report sheds some light on sports hernia as the most common cause of groin pain among athletes. A hernia is defined as a weakness of the abdominal wall. Part of the bowel pushes through an opening in the weak area, forming the hernia.

Sports hernia refers to a particular kind of hernia and the fact that pain occurs during sports activities. The exact problem isn’t clear and may differ from player to player. Doctors say weakness of the tissues around the inguinal canal leads to tears and separation of the tissues. The inguinal canal is formed by fascia to the abdominal muscles on one side and the internal oblique abdominal muscle on the other. Inside the canal is the spermatic cord in men and the round ligament in women.

In this study, 14 players had undiagnosed groin pain for three months or more. Rest and conservative treatment didn’t help. The pain kept the athletes from their sport, work, or exerting themselves. Other symptoms included only local tenderness. There was no swelling.

X-rays and imaging studies failed to show the cause of the problem. Doctors did surgery to look inside the abdomen. The doctors used an endoscope, a special tool with a light on the end, to look inside the abdomen. In all but three cases, the patients had a sports hernia. The three other patients had a fatty tumor called a lipoma. Surgery was done to repair the hernia or remove the tumor.

The authors report that 13 patients were able to return to full activity. All 13 were able to return to their sporting activity within three months. The researchers recommend an endoscopic exam in any athlete with groin pain of unknown cause. During the endoscopy any damage found can also be repaired at the same time, saving time and money.

In the past the success of total hip and total knee replacements was measured by how many complications occurred after surgery or by how long the patient lived. Today there have been many improvements in the materials and methods used for joint replacement. Patient quality of life (QOL) has become a new way to measure success.

In this report, researchers reviewed studies done over the past 23 years that focused on QOL as the main measure of success. QOL is measured using patient surveys. QOL includes such things as personal satisfaction or social effects of surgery on daily living.

The authors report on how these studies were done, the measures taken, and the results. The time frame for each study ranged from seven days to seven years. Here’s what the authors found:

Doctors report that healing tissue may be helped or hurt by nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are used to reduce pain and swelling. If a broken bone is painful, an NSAID taken for pain may reduce or delay bone healing.

Likewise, bone growth in and around a joint implant can be affected by the newer NSAIDS called COX-2 inhibitors. COX-2s are used to reduce inflammation without causing stomach upset.

In this study doctors reviewed the results of many animal and human studies. They report that indomethacin, aspirin, and ibuprofen all decrease the amount of bone growth around joint implants. They also show how spinal fusion is affected by NSAIDs. Studies show that the fusion rate can drop by as much as half in patients who take NSAIDs for more than three months after spinal fusion surgery. Patients who smoke have an even greater risk of nonunion when using NSAIDs.

On the other hand, COX-2s may have a positive effect on soft tissue and ligament healing. Some studies show that NSAIDs work well for sprains and strains. Patients have less pain when taking these drugs. Injured athletes can train at a higher level when taking them.

More research is needed to study the effects of COX-2 inhibitors on sports-related tendon or ligament injuries. In the meantime, these authors advise doctors to avoid NSAID use when fracture healing or bone fusion is needed.

Sometimes after a leg fracture or surgery the doctor tells the patient to put only part of his or her weight on that leg. Using a bathroom scale to test the limits is a common practice. But does this method really work? The authors of this study say that using a bathroom scale to practice partial weight bearing isn’t accurate.

Two groups of people were tested. One group of 23 patients was compared with a control group of six healthy people. The patients either had a leg fracture or surgery. The six people in the control group were put in a cast. Everyone in the control group was trained to put 20 to 40 percent of his or her body weight on the leg. The patients were given a limit by their doctors depending on their condition.

A physical therapist trained each person to use a bathroom scale to help determine how much weight to bear. Crutches were used to help during walking. Later in the week both groups walked on a special force platform that measures how much weight is applied through the foot.

All the members of the control group used more or less than the required body weight. No one was accurate. Almost all of the patients used more than the prescribed amount of weight. Two patients used less than required. Overall the control group did better than the patients. No one in either group could actually use the amount of weight they had trained with.

The authors conclude that partial weight bearing is hard to learn. Bathroom scales aren’t a good way to teach patients how to use partial weight bearing when walking. The type of force platform used in this study to measure actual force is 2.7 times more accurate than other methods. A force platform should be used for the best results and when it is especially important not to overload the injured leg.