News Category: General

As the incidence of obesity, hypertension, and metabolic syndrome
grow, so too do gout and pseudogout. This rise in prevalence is not
only a byproduct of people living longer lives, but also the result of
a change in diet. The consumption of alcohol, fructose-sweetened soft
drinks, and high-protein foods have all been found to increase uric
acid levels and cause gout. As such, new developments are needed to
combat this growing trend. This article examines recent advances made in the diagnosis and treatment of gout and psuedogout.

Gout, sometimes referred to as “the unwalkable disease,” is caused by
an excess of uric acid in the body. This excess causes needle-shaped
crystals to form in the synovial fluid responsible for lubricating
one’s joints. As the immune system tries to rid the body of these
crystals, inflammation develops, causing joint pain and swelling.

One of the difficulties surrounding diagnosis lies in differentiating
between the unique crystal deposits associated with an onset of Gout
from those associated with Pseudogout. However, the prospect of a new
form of imaging, musculoskeletal ultrasonography (MSUS), offers
doctors the ability to efficiently distinguish between both kind of
crystal deposits according to each disease’s distinctive formation.
Although further research is needed, MSUS may potentially preclude the
need for synovial fluid analysis and enhance both the efficiency and
accuracy of Gout and Psuedogout diagnosis.

The treatment of acute attacks of Gout and Psuedogout relies on many
of the same medications to promote relief. Non-steroidal
anti-inflammatory drugs are typically used as the first line of
defense in such cases. However, those individuals who suffer from
impaired liver or kidney function, gastric or peptic ulcer disease, or
decompensated congestive heart failure, or those taking
anticoagulation medication will require an alternative solution.
Colchicine is one such alternative for patients to NSAIDs. Side
effects include nausea, vomiting abdominal pain, and particularly
diahrrhea. Corticosteroids have proven particularly useful in patients
suffering from liver and kidney dysfunction. The medication has been
noted to cause hyperglycemia, gastritis, and isomnia. If a patient’s
acute gout attack fails to respond to these medications, anakinra may
be used.

While chronic Gout cannot be cured, it can be successfully treated.
Lifestyle changes can be effective in long-term management. It might
be suggested that one lose weight, quit drinking alcohol, avoid
fructose-rich soft drinks as wells as high-purine meats and shellfish.
Further, serum uric acid-lowering (SUA) medications have been shown to
reduce the risk of occurrence. One of these medications, Febuxostat,
recently approved by the FDA, has proven useful for patients with mild
to moderate kidney disease.

The treatment of Pseudogout has also experienced new developments.
Early testing has suggested the potential of Hydroxychloroquine or
Methotrexate to significantly decrease pain severity and the frequency
of attack and inflammation. No significant adverse effects have been
reported.

With the increasing numbers of those affected by gout and pseudogout,
innovations in diagnosis and treatment are required. Developments such
as these are rising to meet this growing need.

Heart disease and diabetes have taken front and center stage for media attention these days. But osteoporosis should be right up there, too. With more than 10 million Americans affected and another 34 million close behind (at risk), the costs of treating associated fractures is in the billions of dollars. What can be done about this problem? Two experts in bone health bring us up-to-date on the prevention, diagnosis, and treatment of osteoporosis. Recommendations for screening, monitoring, and managing this condition are presented.

What exactly is osteoporosis? Simply stated, it is decreased bone density. But that might not mean anything to you. Does the phrase brittle bones help? Because that is quite literally what osteoporosis is. To understand this a bit more from a biologic point of view, consider that bone strength comes from two things: bone density and bone quality. Bone density refers to how many bone cells are present in a square inch. That measure also reflects how close together the bone cells are.

But density isn’t the only component of bone strength. There’s also bone quality. Bone quality reflects the health of the bone cells present. Quality of the collagen cells that make up bone, thickness of the bone, and architecture of the bone all make up this entity we call bone quality. Bone quality reflects the condition of the supportive structure of bone.

Bone loss occurs in a predictable fashion with aging. Women are affected more often before men around the time of menopause when the menstrual cycle stops and the woman can no longer get pregnant or give birth to children. A significant reduction in the hormone estrogen at that time contributes to the development of osteoporosis. But men are also affected — about 10 years later than women as age-related changes cause microarchitectural deterioration. In both men and women, the bone becomes fragile. Fractures can occur without trauma or injury. These are called fragility fractures.

The risk of fracture, loss of independence, and even death associated with osteoporosis is what makes the prevention of this condition so important. It’s not just quantity of life; it’s also quality of life that’s at stake. So what can be done? First of all, build up the bones in the early years of life. That’s the equivalent of putting money in the bone bank, so-to-speak. Getting enough calcium, good nutrition, and exercise in childhood and the teen years increases peak bone mass, an essential ingredient in strong, healthy bones to last a lifetime.

Recent studies have shown that vitamin D is as important as calcium for bone health. Without it, the body doesn’t absorb and process the calcium needed to support bone health. How do we get vitamin D? How much is needed? Sunshine is one way to boost vitamin D levels in the body. But many people don’t get out much. And many people live far enough north that the sunrays aren’t strong enough to really benefit. Then there’s the risk of skin cancer with too much sun exposure. Using sun block decreases the absorption needed to produce vitamin D.

Experts recommend taking vitamin D supplements to make sure everyone is getting enough vitamin D. How much to take depends on your age, ethnic background (light versus dark skin), risk factors, body mass index, and general health. Each person should consult with his or her doctor to find out what’s best. At the same time, your doctor will counsel you about reducing your risks by not smoking, losing weight if you are overweight, and reducing consumption of alcohol and caffeine. Weight-bearing exercises and resistance training are both osteoporosis-preventive.

Hopefully, you won’t find out you have osteoporosis because of a sudden bone fracture. So, how can you find out if you have osteopenia (bone mineral density is lower than normal but not osteoporotic yet) or osteoporosis? You can get tested. Not everyone needs to be tested. If you are a peri-menopausal or menopausal woman of any age or a male age 50 or older, testing for bone density is a good idea. There are several different ways to be tested. Again, your doctor will advise you as to what’s best for you given your own characteristics and risk factors.

The most commonly used measure of bone density is the DXA scan (Dual-energy X-ray absorption). The National Osteoporosis Foundation (NOF) advises all women 65 and older and men 70 years old and older to have a DXA test done. Anyone with other risk factors will also be advised by their doctor when it’s time to be tested. FRAX (fracture risk assessment tool) analysis can determine your 10-year risk of fracture if you have osteopenia.

The FRAX is a questionnaire that asks about age, sex, height and weight, history of fractures, current health, and lifestyle choices (smoking, drinking). Once the answers are completed, a score is calculated that gives your 10-year probability of fracture. Anyone with high risk of fractures should get busy and reduce or eliminate any risk factors that can be changed. There’s not much you can do about your age or gender (male or female). But your lifestyle choices can be drastically modified to reduce the risk of bone loss and fragility fractures.

What else can you do if your DXA scan or FRAX analysis shows there’s a problem? Get enough daily calcium, vitamin D, and exercise. Your doctor will advise you if you need medications called bisphosphonates known to slow bone loss. Stay in regular contact with your physician. You may need to be monitored to make sure you are getting the results you need. Nonresponse is a fancy way to say you are still losing bone, in danger of fracture, or already had a fracture despite treatment. Patient compliance (cooperation, following recommended suggestions) with treatment is an important way to ensure success. Lack of compliance is often a hidden risk factor.

If you are doing everything you’ve been told to do to stop bone loss but the DXA scan shows continued progression of the disease, then your physician will do some more testing to see if there’s some other reason for the problem. Most people are very successful in turning around the negative effects of osteoporosis and prevent fractures that can be so devastating.

What do you think is the number one cause of pain and disability in older adults around the world? If you said arthritis, you would be right. Areas affected most often include the hip and knee, but other joints such as the spine, shoulders, elbows, wrists, and ankles can be affected. Small joints of the hands can also cause pain, stiffness, and loss of motion and function from osteoarthritis. With so many adults affected, health care providers have tried to conduct research and report results in an organized way that includes evidence-based treatment guidelines.

In this article, current practice guidelines published by the Osteoarthritis Research Society International (OARSI) are presented and reviewed by three experts on this topic. The most recent OARSI guidelines were put out in 2007. A group of experts on a committee reviewed high-quality studies in putting together the treatment guidelines. The evidence covers pharmacologic (drug therapy), nonpharmacologic (nondrug therapy), and surgical treatment of osteoarthritis. They also incorporated expert opinion in saying what works best for patients with this condition.

You might think this sounds like a pretty easy task. To use a popular expression today: not so much. The committee members found over 100 ways to treat this problem. They tried to stick with the results of high-quality studies, but they also incorporated patient opinions, preferences, and values. Not too surprising, no one single treatment approach was recommended. Using a combination of drug therapies along with other conservative (nonoperative) approaches was preferred and most effective for the majority of patients.

The bottom-line is to find a cost-effective way to reduce pain and manage other symptoms that accompany osteoarthritis. The more patients understand the disease, the better able they are to manage their own condition. So patient education is a key component of any successful treatment program. Finding ways to take pressure off the affected joints is a central feature of any successful program. For some patients, this means some lifestyle modifications, exercise, weight loss, and using supportive devices when needed. Studies show that combining exercise with weight loss works much better than just exercise or just weight loss alone.

Physical therapy can be very helpful to get a patient headed in the right direction and set up with an individual program that works best for each one. The therapist can provide exercises to help with strengthening muscles that support and offload the joints while also using exercise to help the patient lose weight without aggravating joints and increasing pain and stiffness. The therapist can provide a postural assessment and advice or suggestions about ways to improve posture to reduce stress on the joints.

The therapist may advise changes in footwear or sleeping habits that help manage symptoms. In some cases, the therapist has a role in providing appropriate braces insoles or walking aids to help improve patient function. When symptoms are at their worst, modalities such as heat or electrical stimulation may be used to get control of symptoms before moving forward with the rest of the program.

Pharmacologic approaches with drug therapy usually start with a simple pain reliever such as acetaminophen (Tylenol). This medication only reduces painful symptoms. Patients often have to rely on ibuprofen or other antiinflammatories to relieve stiffness and aching that puts a damper on daily and social activities. For patients with more severe inflammation and swelling, steroid injections offer quick, short-term relief but no long-lasting effects. Likewise, the use of an injection called hyaluronic acid (hyaluronate) can help restore some of the slippery joint surface needed for sliding and gliding during joint movement. One to three injections seem to help with immediate relief of symptoms that lasts longer than steroid injections.

When everything else has been tried and fails to provide symptom relief needed to cope and move through each day, then surgery may be the only answer. Joint debridement (scraping bone spurs away and smoothing the joint), osteotomy (cutting a wedge of bone out to help realign the weight-bearing surfaces), and joint replacement are the three main surgical options. If a joint replacement fails, then fusion of the joint remains the last choice. Fusion is not ideal because motion is lost and therefore, function is reduced.

The authors mention that there are 25 treatment guidelines proposed in the 2007 OARSI document but they were not reprinted in this article. The authors say that the guidelines are flexible and can be adapted and used in many different health care settings. Cost, patient preferences, and availability of resources are all important factors in putting any of the guidelines to good use. As with any condition-specific guidelines, evidence-based research is required. And that means that as new findings are published, the guidelines may change periodically to reflect new data and information.

Having legs that are uneven is not that uncommon, as there are several reasons why this could be. Some people may be born with a dislocated hip that causes the unevenness, develop an infection or tumor, or perhaps they may fracture the hip. And, another category of people who may have uneven leg length is those who have had hip replacements. Having a shorter leg after a hip replacement isn’t necessarily a given, it also isn’t an unusual outcome.

Studies of hip replacements have shown that some people end up with a leg length difference of more than 10 millimeters in three to 29 percent of patients, or 10 to 15 mm difference in 32 percent of patients. While the difference may not be bothersome for some people, it is for others. Uneven legs can cause other problems, including strain on the other hip and back pain. The solution for many is to put a lift on to the shoe for the shorter leg, but this can be difficult, depending on the style shoe to be adapted and it can be quite expensive, particularly if you own several types of shoes.

The authors of this article present a technique to adjust footwear that is not specifically meant for adaptation, giving people more options as to what shoes to wear. Their technique takes shoes with a very thick sole, similar to the shoes that were popular in the 1970s. These shoes are again becoming popular. By taking off height, rather than putting on height, you are eliminating the need for specialized shoe repair and adding parts to the shoe that shouldn’t really be there by design.

There are three steps to the process:

One: Wrap the shoe on the toe end with a towel or protective sheet to protect it. Use this part, the toe that is now protected, to mount the shoe into a vice. This is needed to keep the shoe from moving when you cut it.

Two: Mark the shoe for the desired thickness. Rather than measuring what it to come off, you want to measure what is staying.

Three: Using a serrated blade, the authors recommend the Ginsu variety, cut down from the heel to halfway to the toe. At this point, take the shoe out of the vice to continue cutting. Be careful to cut away from you to prevent injury.

Once you have removed the excess part of the sole, you can trim the bottom part with a Dremel rotary tool to engrave a grip or pattern similar to the other shoe. Rinse off any debris before trying this.

The authors offer this technique because it allows people with leg length differences, particularly women, to adapt their shoes with a minimum of cost.

If you watch any of the medical drama shows on television like ER or Grey’s Anatomy, you know Hollywood’s version of Emergency Department drama and trauma. But, in fact, much of what you see is based on real life situations. For example, when a person has a high-energy traumatic leg injury resulting in a bone fracture and an open wound, getting to a trauma center and getting treatment is a real emergency. In real life, emergency doctors and staff need to know what are the results of delayed treatment for injuries of this type? Does timing matter? And which time period is most important: injury to hospital? Admission to surgery? First surgery to second surgery?

With open fractures, the risk of deep infection is a big problem. Multiple surgeries are often needed. The first procedure is to clean the wound, a process called irrigation and debridement. This should be done within the first six hours after the injury. The bone is set back in place and then the next step is to close the wound. Sometimes there’s so much damage to the skin and soft tissue, the surgeon can’t just close the wound. Another operation is needed called soft tissue coverage.

Getting treatment in the first six hours seems like a no-brainer. But these patients often have multiple other life-threatening injuries that demand more immediate attention. And they may live in a rural setting or need to be transported from one hospital to a trauma center. All of that takes time and attention away from the leg injury. It’s clear that urgent treatment is needed. But how soon? What’s the optimum time for best results? These are the questions a study group tried to answer with this study.

They reviewed the charts of 315 patients who had high-energy leg injuries and who were treated at one of eight trauma centers. They collected a variety of data and information from the patients’ medical records. Type of injury, time periods (in hours), and treatment administered were recorded. Patient characteristics such as age, gender, and other injuries were also noted. The patients were divided into two groups depending on whether they were admitted directly to the trauma center (direct group) or had to be transferred from another hospital (transfer group).

Patients ranged in ages from 16 to 69. Certain patients were not included in the study. Patients excluded were those who were in a coma or had a spinal cord injury, burn patients, or military personnel. Anyone who was admitted or transferred to the trauma center more than 24 hours after the injury was also left out of this study. The direct group was all admitted within the first eight hours after injury. Half of the transfer group made it to the trauma center within the first three hours. The remaining transfer patients arrived in equal numbers between four and 10 hours and 11 and 24 hours.

The number of patients in each group who developed infections was compared. Two types of infection were targeted: wound infection and osteomyelitis (bone infection). Only infections involving the injury site that started during the first three months after the injury were counted. And then this information was analyzed based on the time periods and other patient factors listed. They were trying to see if any particular factor or group of factors combined together might predict who was most likely to develop infection. Of course, the eventual goal is to reduce and/or eliminate infections altogether. This might be possible if any of the predictive risk factors can be changed up front.

Their findings can be divided into two lists: those factors that made a significant difference on infection rates and those that didn’t. First, the factors associated with an increased risk of major infection:

Patients who were delayed in getting to a trauma center (either directly or via transfer) by more than two hours had five times the risk of infection compared to those who arrived within two hours of their injuries. Once the patient made it to the trauma center, the timing of other events didn’t seem to reach significant levels according to statistical analysis.

Factors that did not seem to contribute to the risk of infection included:

What’s the take home message here? It’s mostly for friends, family, and emergency medical personnel transporting patients but surgeons will find the conclusions useful, too. First, severe traumatic leg injuries should be treated at a trauma center whenever possible to avoid the risk of infection and other complications. Instead of going to a local hospital, it may be better to go directly to the trauma center even if it’s further away. Of course, it depends on the condition of the patient. If life saving measures are needed, hospital admission with delayed transfer to trauma center may be unavoidable. All things considered, admission to a trauma center within two hours of the injury significantly reduces the risk of infection later.

The treatment standard of operative debridement for these injuries within six hours of the traumatic event is still advised. But it appears that preventing infection is more dependent on getting the patient to the trauma center than on how soon the debridement is done. That’s likely because the patient is given antibiotics right away and stabilized — two important ways of preventing complications like infection.

The authors suggest a follow-up study looking at the timing of prophylactic (preventive) antibiotics after severe leg injuries and the risk of infection. The information from such a study could help surgeons prioritize which aspects of treatment (and the timing of each) are most important: antibiotics, debridement, fracture stabilization, soft-tissue coverage, or limb-salvage procedures.

Non-white racial groups suffer from more than just a lack of housing, employment, and justice in the criminal system. They also receive unequal health care. In this review, researchers take a look at one specific area of health care inequalities among minority groups: pain. Whether it’s acute pain, chronic pain, cancer pain, arthritis pain, or pain after surgery, it is suspected that all people are not treated alike when it comes to pain management.

The U.S. Department of Health and Human Services set up a group of goals to improve the health of all Americans by 2010. As 2009 comes to a close and the year 2010 is upon us, how well are we doing in this area of pain assessment, treatment, and outcomes for ALL Americans? How far along are we in meeting the goal or reducing and even getting rid of any differences in the treatment of minorities who are suffering from painful conditions? Minorities include African Americans (blacks), Hispanics, Asians, Alaskan Natives, and native Hawaiians or other Pacific islanders.

What do these inequalities look like in a clinical sense? Take for example, care in the emergency room. It is often the case that Hispanic and African American patients are not given any pain medication for broken bones. This is true for Hispanics even when English is their main language and they have adequate health insurance. When it comes to the treatment of disabling pain from headaches or back problems, minorities are less likely to be given opioid (narcotic) medications. Only children (under age 18) are more likely to be treated adequately. But there have been some reports of withholding treatment in the emergency department (and other health care settings) for minority children.

Studies assessing control of postoperative pain report varied results. There may be a trend for better postop pain control in a descending order: Caucasians are offered the highest dose of opioids, then blacks, Hispanics, and Asian Americans last with the lowest dose for the same level of pain. And there’s been some data to show that this is true even when other factors are equal such as insurance coverage, type of surgical procedure, and number of days in the hospital.

Cancer is a big topic in the news these days. With known statistics that one out of every two men and one of every three women will develop cancer sometime in their lifespan, cancer is becoming an important focus of health care. Minorities are less likely to receive screening or preventive care, so the diagnosis is made later. A delayed diagnosis often means more advanced disease and more painful symptoms. And despite increasing awareness of unequal screening and treatment, this trend has not changed in the last 20 years.

The statistics aren’t much different for minorities with chronic noncancer pain from arthritis, headaches, fibromyalgia, multiple sclerosis, or other chronic condition. Health care providers underestimate pain levels for minorities with chronic diseases. Minority women are less likely to have a complete medical workup or have surgery offered as a treatment option compared with all other groups including men of the same ethnic or racial background.

Under treatment of pain from any cause is compounded by the fact that studies show minorities start with a poorer quality of health and lower quality of life. These two factors may contribute to greater perception of pain and/or higher levels of pain compared with Caucasians who have the same underlying condition.

The authors conclude after reviewing studies over the last 10 years and comparing them to previous studies that there are continued inequities in the way minorities are treated for pain. Minorities are less likely to receive specialty care and more likely to experience delays in diagnosis and treatment. They start out with a lower quality of life and poorer function due to health problems. Pain added on top of those conditions further diminishes their health status.

What can be done about this? Clearly, we don’t need more studies to show there are inequities. There is plenty of proof that the problem exists. But there may be a variety of factors affecting how minorities present themselves and are perceived and treated. On the flip side of the coin, there may be important factors among health care providers affecting how they view patients differently based on age, gender, and ethnicity. Health care providers have their own beliefs and expectations. And the health care system as it is set up today with lack of insurance or under insurance limiting resources available to patients is a barrier to pain management all of its own.

Sometimes there are language barriers that make it more difficult to assess patient pain levels. In other cases, there are differing patient beliefs, cultural beliefs, attitudes, and coping strategies that affect how patients are evaluated and treated. Researchers are starting to take a closer look at these kinds of factors. They are also investigating genetic factors, differences in pain sensitivity among minorities, and even how different ethnic groups respond differently to pain medications at a biologic level.

Back to the question of what can be done to reduce these kinds of inequities. The authors identify three ways to approach this problem: through the patient, the provider, and the health care system. Educating health care providers may be one approach. If providers can be taught to assess and treat everyone the same, outcomes may improve. Evidence-based treatment guidelines for pain associated with different causes are needed to help providers give the care that patients need.

Availability and affordability of prescribed medications must be addressed through health care reform. Money is needed to fund pain research with a goal of providing practical health care policies around the treatment of pain. Public health must include a focus on the well-documented causes and results of racial and ethnic disparities in the treatment (or lack of treatment) of pain.

Pilates has become synonymous with core training but it is much more than that. For those of you who have never taken a Pilates class, it is a form of exercise that focuses on the core postural muscles of the trunk and abdomen. Pilates exercises teach awareness of breath and alignment of the spine. They are designed to strengthen the deep torso muscles and protect the back from injury. Breathing is coordinated with movement with a general goal of improved flexibility and health. The developer of this physical fitness system was Joseph Pilates from Germany. He died in 1967 before seeing the tremendous success of his program.

Today, this method of exercise is used around the world but it has especially caught on in the United States. There are an estimated 11 million people who practice Pilates and over 14,000 trained instructors. And it isn’t just for hard-core athletes and those who love to exercise. As the results of this study show, it can benefit people with chronic musculoskeletal conditions like fibromyalgia.

Fibromyalgia syndrome (FMS) is a chronic pain problem with widespread tender points and muscle pain throughout the body. Most patients with fibromyalgia also list many other symptoms that seem to be part of this condition. Those symptoms range from depression to fatigue to decreased sexual function and difficulty sleeping. Finding one treatment to alleviate all of the many symptoms isn’t always possible. Sometimes finding ANY treatment that helps seems impossible.

The results of this study may help some people with this condition. Fifty (50) women diagnosed with fibromyalgia participated in an exercise program three times a week for 12 weeks. The women were divided into two separate exercise groups. One group was instructed and supervised in doing a Pilates program. The instructor was a certified Pilates trainer. The second (control) group did a home program of relaxation and stretching for the same 12-week time period. The participants ranged in age from 24 to 63 years old. Except for the fibromyalgia diagnosis, these women were in good health without evidence of diabetes, high blood pressure, or other significant health problems.

Each participant was tested before and right after the study to measure pain levels, function, and quality of life. Additional testing was done at 24 weeks, giving everyone a 12-week break after completing the program before taking the final outcome measures. The authors used the Visual Analog Scale to measure their pain and the Fibromyalgia Impact Questionnaire (FIQ) to measure function, health, and quality of life.

They found significant improvements in the Pilates group that were not present in the control group. The Pilates group had fewer painful, tender points usually present with fibromyalgia. The women in the Pilates group reported better sleep, improved function and activity, and better quality of life. But the improvements didn’t last. All measures for the two groups were the same at the end of the 24-week period.

Pilates provides effective and safe short-term results — more so than following a program of stretching and relaxation. Pilates has a built-in feature that avoids putting excess demand on muscles, which is important in a syndrome like fibromyalgia that is characterized by muscle fatigue. With less pain and better physical function, the women were able to do more of the daily activities they enjoyed. This contributed to an overall improved quality of life. With such positive results, they may be more likely to continue exercising in order to maintain those benefits.

This study shows that Pilates exercise isn’t just for the fit and able. People with chronic health problems appear to benefit, too. Previous studies have shown that exercise lessens the pain and dysfunction that accompanies fibromyalgia. But exactly what type of exercise to do and for how long hasn’t been established.

This study goes a long way in helping put some evidence behind just what does work for these patients. Finding a program like Pilates that doesn’t make fatigue worse is a boon for individuals with fibromyalgia. Pilates belief that this fitness program strengthened body and mind may prove to be as effective as a combined exercise and cognitive-behavioral program.

If you were born between 1946 and 1964, then you are one of the 75 million Baby Boomers in the United States. And most likely when you look in the mirror you see a few wrinkles and gray hair you didn’t have 20 years ago. But there’s something else there that you might not see and that’s osteoporosis. Osteoporosis is a loss of bone density that can cause weak, brittle bones that tend to break easily. And think about this: 50 per cent of the women in this group and 30 per cent of the men will develop an osteoporosis-related fracture sometime during their older years.

Hang on — there’s a bit more you need to know. Disability and death are close companions of these fragility fractures. If you break a hip, you could end up in a nursing home, you most likely won’t get back to normal, and death is a reality for one out of every four patients with fragility hip fractures.

So where’s the good news in all this? If you have osteoporosis, if you are at risk for osteoporosis, or if you have already had an osteoporosis-related fracture, there are steps you can take for a better outcome. And even better than that — doctors are receiving training specific to this problem so they can help you avoid such problems. What can you expect from your physician? As the authors of this article point out, understanding who is at risk, why osteoporosis develops, and what to do to prevent (or treat) this disease is the orthopedic surgeon’s highest priority for this age group.

First, physicians recognize that menopausal women are affected most often but men should not be neglected. Men develop osteoporosis later in life than women but the effects can be just as devastating. Osteoporosis occurs when more bone cells die than are replaced by new, healthy bone cells. This process of tearing down old bone cells and building up new ones is called bone remodeling. Unfortunately, with age (and for women, a loss of the hormone estrogen), bone remodeling slows down or becomes lopsided with too many old cells and not enough new ones.

That’s where a prevention plan of vitamin and mineral supplementation along with exercise and lifestyle changes come in. Taking calcium with vitamin D, getting some sun exposure (an excellent source of vitamin D), and quitting smoking (or other tobacco use) is a good place to start. A lifestyle of daily exercise to challenge balance, build strength, and stimulate bone growth is essential starting from childhood when bone is forming and continuing throughout the lifespan.

Your physician will check for any hormonal abnormalities that can affect bone and prescribe medications that can restore a correct chemical balance within your body. Usually some blood tests are needed to check this out. If you are a candidate for one of the antiresorptive drugs called bisphosphonates like Boniva or Fosamax, then your doctor will prescribe those for you. Your doctor will also do a risk factor assessment to look for any other risk factors that might increase your chances for developing osteoporosis.

Getting older, having a family history of osteoporosis, being of the Caucasian (white) race, and having a previous history of fracture yourself are nonmodifiable risks. Nothing you can do to change any of those. What you really want to focus on are those modifiable risk factors (things you can do something about). Tobacco use was already mentioned. Other modifiable risk factors include being underweight, drinking too much alcohol, being a couch potato or otherwise inactive, and not taking your calcium and vitamins.

Your physician can also measure your bone density in order to calculate your risk of a fracture using special X-ray tests called Dual X-ray Absorptiometry (DXA scan). Another useful test is the FRAX Risk Assessment Tool put out by the World Health Organization (WHO). This tool calculates your 10-year risk of fracture. You can even access this tool on-line yourself, but you’ll need the results of your DXA scan to complete the calculations (http://www.shef.ac.uk/FRAX). These tests are recommended for women aged 65 and older, men 70 and older, and anyone over 50 who has significant risk factors for osteoporosis.

A physical therapist can also help you. The therapist can prescribe a specific exercise program proven to help improve bone strength. All exercise is good for your health, but not all exercise targets the bones. The therapist can also conduct a falls assessment to find out what your risk is for a fall and then develop a falls prevention plan designed for your unique risk factors.

You can help yourself. Don’t wait until you fall and break a bone. Studies show that preventive measures do make a significant difference. Ask your physician now to measure your bone density and to calculate your risk of falls and fractures. If your physician prescribes calcium and vitamin D, take them as directed! If your physician refers you to an endocrinologist (specialist in hormones and bones), make the appointment and go! Don’t put it off.

Ask your physical therapist to inspect your home for any safety tips and ideas on how to prevent falls. And if you have already had a fragility fracture and you haven’t been told any of these things about vitamins and exercise and home fall prevention programs, then walk (don’t run) to the phone right now and make yourself an appointment for some proactive help today. See your primary care physician or orthopedic surgeon for the kind of comprehensive care you’ll need to keep your bones health and strong and avoid osteoporosis, fractures, and falls that can change your life forever.

Fibromyalgia has a range of symptoms, from pain to fatigue to difficulty sleeping, among others. This wide variety in how it presents can make fibromyalgia a difficult-to-treat illness as there is no treatment for the illness itself, only the signs and symptoms. In addition, there are other problems that are not uncommon among people with fibromyalgia, including irritable bowel disorder and anxiety disorders.

Doctors have tried treating fibromyalgia with different types of medications and have been seeing some success with gabapentin and pregabalin. These medications, originally for treating seizures, also have pain relieving and anti-anxiety properties. The authors of this article found that there were not many reviews of studies that looked at gabapentin and pregabalin, so they did their own systematic review and meta-analysis of the literature to find what has been studied and how relevant the study findings were.

Researchers found 127 randomized controlled trials that evaluated the effects of the medications on fibromyalgia symptoms. After excluding studies that did not meet their criteria, the researchers were left with six to review. The studies used an 11-point rating scale so patients could indicate their levels of pain. Fatigue was also measured, in four of the studies using a scale called the Multidimensional Assessment of Fatigue (MAF). Sleep, assessed in all studies, was measured by the Medical Outcomes Study, while depressed and anxious mood was measured by the Hospital Anxiety and Depression Scale (HADS) and the Montomery Asberg Depression Rating Rating Scale (MADRS). Health Related Quality of Life (HRQOL) was assessed using the Fibromyalgia Impact Questionnaire or the Short Form Health Survey F-36.

In the end, the researchers determined from the studies that pain was relieved in many cases and that patients reported an improved quality of life, but there was some conflicting evidence here. Depression and fatigue did not seem to be helped in many cases, but there was some relief from fatigue – sleep disturbances were lessened. The doses of medications did not seem to have an effect on pain relief for either medication.

Side effects of the medications resulted in patients withdrawing from the studies happened more often with the medications than with placebos. Side effects included dizziness, drowsiness, weight gain, peripheral edema (swelling of the body tissues, most often in the hands or feet), and neurological effects.

The studies that were reviewed were limited for a variety of reasons, from small groups to limited after-study follow up. Only two studies reported any other illnesses that the patients may have had at the time, which could affect the final outcome. The authors concluded that the two medications may have a role to play in treating fibromyalgia but other illnesses and patient preference should be taken into account before prescribing one or the other medication. They suggest “the usage of gabapentin and pregabalin can be considered for the treatment of pain and sleep disturbances in FMS patients.”

The authors also wrote that further testing of the two medications should include if fibromyalgia symptoms continue after treatment has stopped and if treatment reduces the overall cost of fibromyalgia.

Haven’t heard of platelet-rich plasma (PRP) to treat sports injuries? Listen up! You’re not alone. Patients calling their doctors asking about this treatment for tennis elbow or other muscle or tendon injuries may be surprised when their physician has never heard of it. That’s because it is relatively new, and it hasn’t been tested fully to prove its effectiveness. So, there aren’t many studies being published just yet. Most of the studies presented so far have been with animals or small numbers of people.

That’s why orthopedic surgeons from the New York University Hospital for Joint Diseases wrote this article offering general information on the technique. First of all, what is platelet-rich plasma? Platelets are part of the blood that circulate around the body ready to help with blood clotting should you have a cut, broken bone, injury that bleeds internally, or any other type of injury. Besides containing clotting factors, the platelets release growth factors that help start the healing sequence. Plasma is the clear portion of the blood in which all the other blood particles such as platelets, red blood cells, and white blood cells travel.

So platelet-rich plasma refers to a sample of plasma that has more than the normal amount of platelets. To get this substance, a portion of the blood is removed from a patient and placed in a machine called a centrifuge. The centrifuge spins the blood fast enough to separate it into layers based on weight. Heavier parts (e.g., red blood cells) stay on the bottom. Platelets and white blood cells spin out just above the red blood cell layer. Lighter particles (plasma without platelets or blood cells) make up the top layer in the test tube.

The platelet-rich portion of the plasma is then injected into the damaged area (e.g., tendon, joint). This treatment technique isn’t entirely new — just new to the realm of sports medicine. It’s been used for years after plastic surgery and surgery on the mouth, jaw, and neck. It seems to promote bone graft healing and wound healing. Researchers have found a way to combine this substance with other chemicals to make it into a putty or gel that can be painted on a surgical site to speed up healing.

The benefits of this treatment have brought it to the attention of others who have tried it for spinal fusions, bone fractures, and chronic conditions like tennis elbow. Platelet-rich plasma has also been used with positive results for patients with degenerative conditions such as osteoarthritis that result in joint damage from wear and tear.

As with any new treatment, the usual questions arise. For example, how much is needed to get a positive healing response? How many injections are needed and over what period of time? One week? One month? What’s the optimal ratio of plasma to platelets for the desired accelerated healing? At first, surgeons used a mixture that contained four times the normal amount of platelets. But over time, scientists have found that less can be used with the same good results. Patients considering this treatment may wonder about the cost. New treatment techniques are often expensive and this is no different. Each injection costs about $150.00 out-of-pocket (insurance doesn’t cover treatments considered experimental).

What’s the evidence so far that this treatment works? Studies have been done both on animals and on humans. After using the platelet-rich plasma (PRP), tendon cells (called tenocytes) removed from the treated area have been examined. Growth factors that help build new blood supply to the area have been found along with an increased number of type I collagen fibers. Type I collagen makes up the base structure of tendon tissue. Some studies have shown increased strength of the new tissue while others show no difference in tendon strength between those who got the PRP treatment and those who didn’t.

There is no clear direction on when, how, or why PRP should be used. In this experimental phase, surgeons have used it for patients who failed conservative (nonoperative) care for chronic tennis elbow and chronic patellar tendinosis (knee tendon damage). There was one study where it was used for acute (recent) muscle injuries in professional athletes. The results of that study really made the rounds: these high-level athletes recovered in half the expected time and with no bad side effects and no scar tissue or adhesions.

Similar findings have been observed when PRP was used during surgery to repair ruptured Achilles tendons and rotator cuff tears in a small number of patients participating in a pilot study. Once again, wound healing was much faster with fewer problems and less scar tissue. And the list of improvements with this treatment continues: patients use less pain medication, patients gain greater joint motion over a shorter period of time, patients get back to regular daily activities with greater speed and ease, and so on.

A larger study of more than 100 patients using PRP for anterior cruciate ligament (ACL) reconstruction didn’t find that the use of PRP enhanced tendon graft healing despite early signs that the maturation process was faster at first. Six months later, MRIs showed no significant effects of this treatment.

Despite these early results, there are more questions than answers about platelet-rich plasma treatment of musculoskeletal problems. But you can expect to see an increase in studies reporting results over the next months to years. Right now, there are clinical trials being carried out in a number of places with a wide range of conditions. While that’s being sorted out, physical therapists are turning their attention to the proper rehab protocol to follow for these patients. Developing optimal tendon healing and muscle strength, especially in high-level professional athletes who are eager to get back into the game will be a priority.

Fibromyalgia is a medical term for a condition of aches and pains all over the body along with a laundry list of other symptoms. Is it a real problem? Is there any way to treat this condition successfully? And how can you tell if this is what you have instead of other similar problems such as Lyme disease, Epstein-Barr virus, multiple sclerosis, or arthritis?

The authors of this review article on the topic of fibromyalgia attempt to answer all of these questions and more. They provide a quick summary of how to recognize this problem, what might be causing it, and then focus more intently on how to treat or manage it.

Because there is no classic clinical presentation for fibromyalgia, recognizing it as the patient’s underlying medical condition can be very difficult. Symptoms like fatigue, stiffness, sore muscles, and difficulty sleeping just don’t make a diagnosis. Medical testing such as X-rays, urinalysis, or blood testing often come back normal and are not diagnostic either.

The physician must rely on the patient’s report of symptoms (especially body pain and tender points) to make the diagnosis. Chronic widespread body pain that lasts more than three months with specific tender points make the most definitive diagnosis. The American College of Rheumatology (ACR) criteria includes 11 out of 18 points of pain as a positive test for fibromyalgia. These tender points are located in specific locations along the neck, chest, shoulders, back, hips, elbows, and knees.

Understanding what causes fibromyalgia is another challenge. All evidence so far points to some kind of mistake within the nervous system in how it recognizes and transmits pain messages. Somehow, the nervous system seems to think even the simplest touch is a noxious (painful) stimuli. It’s like a ten-alarm fire signal is sent to the brain when a breeze blows by the barn. Pain as an entity is being studied very carefully and especially chronic pain as it is experienced in conditions like fibromyalgia. Nervous system dysregulation of this type is likely caused by biochemical abnormalities, altered brain blood flow, and problems with the pain processing mechanisms.

Until the exact pathologic pathways are understood, treatment will be more of a management approach. There isn’t one magic pill patients can take to wipe away the pain, improve sleep, or restore energy. Instead, a wide range of medications are available that can act on the nervous system in a variety of ways. These include tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), selective serotonin-norepinephrine reuptake inhibitors (SSNRIs), and anticonvulsants.

Finding the right drugs and the right mix or combination of those medications can take some time. And medication only offers small comfort in the big picture of things. Only about a third of the patients are helped and only about a third of their symptoms are improved by this means.

Many patients find nonpharmacologic treatment works best for them. This means they try to manage the pain, symptoms, and loss of function through the use of exercise, counseling, and alternative care such as hypnosis, acupuncture, or biofeedback/relaxation therapy. Clearly, all of the research so far confirms the need to treat this problem with a multidisciplinary approach. A multidisciplinary team of professionals includes doctors, nurses, physical therapists, psychologists, pharmacists, and other practitioners in the healing arts.

Patients must learn as much as they can both about this condition as well as about themselves and what works best for them. That’s easier said than done. Many times the pain and fatigue keep patients from getting the exercise they need. They become deconditioned and weak, which adds to their pain and loss of function.

In the ideal plan, the patient is really the manager who consults with these other experts to formulate the most effective plan. Reducing and managing symptoms, improving quality of life, and decreasing distress are reasonable goals. But the patient must understand that at the present time, there is no cure for fibromyalgia.

Did you think gout was an old disease no longer prevalent in the U.S. population? Think again! The rate of this crystal-induced arthritis is on the rise — along with obesity, metabolic syndrome, and cardiovascular disease, which are closely linked with gout. So say rheumatologists (doctors who specialize in treating arthritic conditions) in this review article on gout.

What is gout? Basically, it’s a problem with the breakdown of uric acid, a compound that forms when purine is metabolized and passed out of the body through urine. Purines are found in high concentration in meat and meat products, especially internal organs such as liver and kidney as well as some fish products. The increased intake of fructose-sweetened soft drinks has also been linked with an increased risk of gout. Plant based foods such as vegetables are generally low in purines and even eating vegetables with purine content does not contribute to this problem.

Food does account for about one-third of the body’s daily uric acid load. The rest comes from mechanisms within the body that produce this compound. When it is not passed out of the body through the kidneys and intestines, just the right conditions in the body result in the formation of uric acid crystals called tophus.

It’s these crystals that form in the joints causing attacks of joint pain, swelling, and even oozing of crystals from the affected joint. The big toe is a common target for crystal formation in gout, but the ear and elbow are also common sites for crystal formation. Without visible formation of crystals, doctors diagnose this problem by examining fluid taken from inflamed joints. The crystals are clearly seen when the fluid is observed under a special polarized light microscope.

Examination of the synovial (joint) fluid helps differentiate gout from pseudogout. Both conditions are types of crystal-induced arthritis. But pseudogout is not caused by improper purine metabolism. The types of crystals involved differ and the joints affected are different, too. Whereas, gout attacks the big toe most often, pseudogout shows up in the knees, wrists, and ankles and rarely affects the great toe. The diagnosis must rule out the presence of infection, which can be a hidden problem along with gout or pseudogout.

X-rays are not usually helpful in diagnosing gout. But ultrasound has been shown diagnostic as the shape of the crystals form what looks like rosary beads inside the hyaline cartilage and this is seen in the ultrasound pictures. Hyaline cartilage is one of several layers of cartilage. This layer coats the ends of the bones and is separate from the articular cartilage. Articular cartilage forms the layer that meets joint-to-joint and allows the joints to slide and glide against each other. Ultrasound studies do not replace fluid removal and examination under a microscope because ultrasound does not confirm infection.

Once the problem has been diagnosed, treatment of the acute attack is with medications such as nonsteroidal antiinflammatories (NSAIDs), colchicine, corticosteroids, and biologic therapy. Chronic cases of gout are treated using a management model that involves lifestyle changes in diet, weight loss, and exercise. Control through the use of medications such as allopurinol, febuxostat, uricosuric drugs, and/or uricases is advised.

Most likely with the exception of nonsteroidal antiinflammatories (e.g., aspirin, ibuprofen), you haven’t heard of these other medications. Because they are an important part of the treatment of this condition, if you are reading this because you or someone you know has gout, a brief description might be helpful.

This first set of drugs is used in the acute phase to prevent or control damaging joint inflammation. Colchicine is actually from the autumn crocus flower. It acts to prevent inflammation in the early stages of a gouty attack. There are some side effects such as nausea, vomiting, diarrhea, and stomach pain, so it’s not for everyone.

Corticosteroids are used when patients can’t tolerate the colchicine or nonsteroidal antiinflammatories (NSAIDs). Anyone with compromised kidney or liver function may need to use corticosteroids for control of joint symptoms instead. These steroids can be taken by pill (oral dose) but if only one or two joints are affected, injection directly into the joint(s) can be done instead.

Patients who don’t respond to these first-line drug treatments might be tried on biologic therapy (also known as biotherapy). Anti-tumor necrosis factor therapy is one form of biotherapy. But it is expensive and hasn’t been studied fully, so its use is fairly limited. It is used on a case-by-case basis when all else fails.

For patients with chronic gout, medications are used to lower urate levels in the body. This treatment is called serum uric acid (SUA)-lowering therapy. It is used until the crystals dissolve. For some patients, ongoing use of these medications is necessary to maintain acceptable levels of uric acid and thereby prevent the deposit of these crystals. Allopurinol is the most commonly used SUA-lowering drug. It works by inhibiting a substance called xanthine oxidase, which then reduces the production of urate. As with all drugs, there are some patients who can’t tolerate allopurinol. They develop an itchy skin rash, severe diarrhea, and fever.

Those patients who are sensitive to allopurinol can try a new SUA-lowering drug called febuxostat. This medication also inhibits xanthine oxidase but does so through a different route than allopurinol. Another class of SUA-lowering drugs called uricosuric drugs includes probenecid, sulfinpyrazone, and benzbromarone. These drugs block the transportation of urate forcing them to be spilled out in the urine. Benzbromarone isn’t available everywhere as concerns about liver toxicity have resulted in the drug being removed from the market in some countries (including the United States).

And a final alternative to SUA-lowering drugs is the use of uricases. Uricases transform uric acid into something else (a molecule called allantoin) that doesn’t form crystals. This drug can only be given intravenously and is used for severe cases of gout because the body makes antibodies against the uricase.

The authors conclude that both gout and pseudogout have been with us for a very long time. The first report of this crystal-linked joint disease was recorded in 2640 BC. Once called the arthritis of the rich because of diet and lifestyle, its link with obesity and sugar intake today remains an important one. Even with newer medications available, the problem has not been cured or removed and an increased number of adults now have this condition because of similar lifestyle factors.

If you have watched any health-related news on TV or read the health section of your newspaper, you know that getting enough calcium for strong bones isn’t enough. Now studies show that low levels of Vitamin D (deficiency) is just as important. Without sufficient vitamin D, the liver and kidneys can’t help the body absorb calcium needed for bone and muscle function. How do you know you’re getting enough vitamin D? That’s the focus of this article in which five patient cases are highlighted.

Unless you develop bone pain, muscle weakness, a fracture, or start to fall, you may not know you suffer from vitamin D deficiency. A blood test will help confirm the diagnosis. Less then 30 ng/mL of vitamin D in the blood is the medical definition of vitamin D deficiency. And according to the National Health and Nutrition Examination Survey, three-fourths of American adults age 20 years old or older falls into this category. That’s a shocking figure.

Who’s at risk? Known risk factors include not getting enough of the right kind of sunshine, having dark colored skin, living with chronic kidney disease, and taking anticonvulsant medications for any reason. Low body weight, especially as a result of an eating disorder can increase the risk of poor vitamin D absorption, decreased intestinal calcium absorption, and low bone mass density. That was the case in the first patient reviewed. She experienced a spontaneous snap in her groin that turned out to be a hip fracture. Her medical history included long-term anorexia and a seizure disorder treated with phenytoin, an anticonvulsant drug.

Most people don’t develop decreased bone mass over night. There are often signs and symptoms that there’s a problem. Muscle pain, muscle weakness, a change in posture or gait (walking) pattern are often telltale signs if you know what to look for. The take home message from this article is for for everyone. All adults (even healthy adults) and health care professionals caring for patients should be on the lookout for such symptoms. Spinal deformities such as scoliosis (spinal curvature), kyphosis (increased forward spinal curve causing a hunchback appearance), leg bowing, or other bone deformities are additional signs of a problem.

Preventing vitamin D deficiency in the face of skin cancer has become quite a challenge. With the rising rates of skin cancer, the use of sunblock has limited the amount of sun exposure some people get. And for those with dark skin or who live in areas where the sun’s rays don’t reach a level sufficient to provide enough vitamin D, bone health is an issue. That’s why current recommendations are for adults to supplement their diet with calcium and vitamin D (foods rich in vitamin D and calcium along with vitamin/calcium pills).

For individuals who have chronic health problems like cystic fibrosis or kidney disease, the challenge of getting enough vitamin D can be difficult. Research is underway trying to determine how much vitamin D and how often this product should be taken by people with these kinds of problems in order to ensure a safe blood level and absorption. These recommendations may vary depending on where the person lives and how much sunshine he or she gets at that geographical latitude.

For the patient in the second case reviewed (a 41-year-old man with cystic fibrosis), the lack of pancreatic enzymes needed to absorb vitamin D resulted in low levels of bone density. He was advised to increase his sun exposure and take at least 50,000 IU/day of vitamin D for two weeks. Retesting showed an improvement but not enough to be out of the danger zone. His vitamin D2 was bumped up to 100,000 IU/d for 30 days and then back down to a maintenance level of 50,000 IU/d once a week. He eventually responded well to this approach.

Some people who suffer low vitamin D levels have unusual health circumstances. In the third case examined during this study, a 41-year-old woman with chronic pancreatitis ended up with muscle weakness and falls as the first sign that something was wrong. With this condition, there is poor fat absorption. Vitamin K is a fat-soluble vitamin, which means it is absorbed by fat cells and used when needed. Without proper fat metabolism, vitamin D levels decline.

In this case, the patient was advised to go to a tanning booth twice a week to get the needed UV B rays. She was under the supervision of a dermatologist who prescribed the UV B therapy. The use of tanning booths is not normally recommended because of the increased risk of deep, long-term skin damage and skin cancer. Studies are needed to determine the safety and effectiveness of this treatment approach for vitamin D deficiency.

Case number four was an older adult (92 years old) with kidney disease. Just turning over in bed caused two very painful vertebral bone compression fractures, which tells you how weak his bones were. Hyperparathyroidism, a result of having chronic kidney disease is also a risk factor for vitamin D deficiency. The longer the patient has had chronic kidney disease and the more progressed the disease is, the greater the risk is for vitamin D depletion and bone loss.

The final case study presented was a middle-aged male (45 years-old) with osteoporosis and a serious seizure disorder that required chronic use of an anticonvulsant. Medications of this type seem to be able to inactivate vitamin D in the body. Taking supplemental doses helps but the exact dosage needed varies and must be determined on a case-by-case basis. Anyone taking vitamin D depleting medications should be tested every year for vitamin D blood levels and bone density. For anyone with vitamin D deficiency, active measures must be taken to correct the problem through diet, supplementation, and supervised sun exposure (or UV-B therapy).

People who suffer from chronic pain syndromes like fibromyalgia, irritable bowel syndrome, temporomandibular disease (jaw pain), or pelvic pain may have more in common than doctors once believed. Recent research has uncovered some new understanding about the way pain develops and is perceived by the affected individual that may link these conditions together. In this review article, pain scientists present the latest information about one condition in particular: fibromyalgia.

Coming up with a definition for fibromyalgia hasn’t been easy. Scientists want to describe it by what they know of the underlying pain mechanism. You might read that it is neurohormonal mediated chronic pain syndrome. That simply means it is believed that the nervous system and the endocrine (hormone) system are somehow both involved in creating the pain signals that don’t seem to get turned off or even turned down.

But if you ever talk to someone with fibromyalgia or you yourself are a fibromyalgia sufferer, then you know the best way to describe it is pain everywhere. The muscles are stiff, sore, and tender. The joints ache. There are headaches, difficulty sleeping, numbness and tingling, and problems with bowel and bladder function. In fact, up to 50 or more other distressing symptoms have been reported in association with fibromyalgia.

One thing scientists agree on about chronic pain of this type: it is centrally mediated. What does that mean? It means the problem isn’t coming from the muscles, joints, skin, or other soft tissues. It is originating within the systems and most likely the central nervous system (brain and spinal cord) with effects on all the peripheral tissues. Since most of these patients experience pain with input or stimuli that isn’t usually painful, it is suspected that there’s a problem with pain or sensory processing, rather than some disease, inflammation, or impairment of the area that actually hurts (e.g., the back, the hips, the wrists).

New information is now available on chronic pain mechanisms because of advances in technology (e.g., functional imaging), genetics, and experimental pain testing. Although there is a link between brain function and somatic (body) illnesses like fibromyalgia, this condition is no longer considered a psychiatric (mental) illness like it was in the past.

Functional brain imaging shows areas of the brain that light up when pressure is applied to painful areas of the body. All indications are that once the central pain mechanisms get turned on, they wind up until there’s pain even when the stimulus (e.g., pressure, heat, cold, electrical impulses) is no longer there. This phenomenon is called sensory augmentation. There is some evidence that people with fibromyalgia have a decrease in their reactivity threshold. In other words, with a low threshold, it only takes a small amount of stimuli before the pain switch gets turned on.

We still don’t know why this happens. Many theories are being tested. It looks like the area of the brain that is in charge of sensory integration (taking in, processing, and making sense of all sensory stimuli) is hyperactive. Instead of properly processing the messages, it amplifies (turns up the volume) on them. Several studies using Single-Photon-Emission Computed Tomography (SPECT) have shown changes in the blood flow to certain areas of the brain. In some places of the brain, there was increased blood flow, while in other areas, the tests showed decreased blood flow. These altered patterns of blood circulation could be part of the problem.

MRIs of the brain have confirmed that patients with fibromyalgia process pain in the same areas of the brain as individuals without fibromyalgia. The difference is again with the amount of stimuli needed to activate those pain mechanisms. People with fibromyalgia have a narrow range of pain tolerance. And because women are affected much more often than men, it is suspected that the endocrine (hormone) system must be involved somehow.

What about other factors that are suspected such as genetics or environmental stressors? Since fibromyalgia (and other chronic pain syndromes) tend to run in families, it’s natural to think there might be an inherited component. This hasn’t been proven yet but scientists are actively studying specific genes, receptors for pain and other neurotransmitters, and chemicals involved in stress responses. Fibromyalgia seems to be triggered (or started) as a result of stress or trauma. Many different environmental stressors have been identified as triggers including physical injury from a car accident (or other type of accident), infections such as Epstein-Barr virus or Lyme disease, thyroid disorders, and post-traumatic stress disorder (PTSD) linked with abuse, torture, or war.

By studying the biochemical pathways of patients with fibromyalgia, scientists have been able to identify ways to treat this problem with medications. They discovered that opioid-based (narcotics) don’t work but serotonin (a neurotransmitter that regulates mood, appetite, and muscle contraction) does. Along with pharmaceutical treatment for fibromyalgia, cognitive behavioral therapy (CBT) is advised. Working with a psychologist or counselor trained in pain management techniques helps the affected individual learn to minimize responses to pain and alter the perception that pain controls their life. In this way, they can stay as functional as possible until scientists fully unravel the pain mechanisms and find ways to control them.

Because there are so many variables and factors involved in chronic pain syndromes like fibromyalgia, treatment has evolved over time to become multidisciplinary. Besides medication and cognitive behavioral therapy, patients are also encouraged to stay active and exercise. Studies now show that exercise can be as helpful as medications for chronic pain conditions. Aerobic or cardiovascular training seems to be the most helpful. Low-impact activities like walking or biking, or even better, nonimpact exercise such as swimming are advised. Patients seem to do best when they progress slowly but gradually.

In summary, the authors show how our thinking about fibromyalgia and other chronic pain syndromes has shifted from seeing these conditions as coming from the affected areas and more toward an understanding of the central (systems-wide) mechanisms. This new understanding has changed treatment approaches more toward a multidisciplinary model. Evidence supports finding the right combination of medications along with modifying thoughts and actions. Recent breakthroughs in understanding of pain, brain function, and the details of chemical and biologic responses in patients with fibromyalgia suggest better treatments are on the horizon — perhaps even a cure for or prevention of this painful condition.

Sports injuries command a lot of attention in the orthopedic world. Keeping athletes in tip top shape and in playing or competitive mode is a top priority for sports medicine specialists. Toward that end, researchers are trying to understand what causes tendon problems (called tendinopathies) in this group of individuals. If we can understand how and why tendon disorders develop, then maybe we can prevent them from occurring in the first place. The authors of this review article on tendinopathies offer some perspective on how these injuries occur and what can be done to prevent them as well as how to manage tendon disorders when they do occur.

Research has clearly shown that chronic overuse tendon disorders affecting the knee (patellar tendon), ankle (Achilles tendon), shoulder (rotator cuff), and thigh (adductor tendons) are common. In the past, it was assumed that these were acute, inflammatory injuries. But studies of cells from the affected areas show minimal or no inflammation. That’s not to say there aren’t changes seen. But these changes are at the cellular level and point more to what is now referred to as a failed healing response.

There may be an inflammatory response at first but it doesn’t last. Instead, the local cells expand and the individual collagen fibers start to spread out. Exactly why this failed healing response happens or even why it leads to tendon problems remains a mystery. Some experts have wondered why tendons don’t hold up under stress and strain — after all, that’s what they are built for. But evidently, the design of most tendons isn’t meant for repeated loading as occurs with competitive athletes who practice daily and perform or compete regularly. The tendons are exposed to more load or mechanical overload than they can handle.

That’s the extent of what we know about the cause and underlying pathology of tendon injuries. From here on, it’s just theory about what might be happening. In the mechanical theory of tendinopathy, the tendon gets weak after too much load over too much time. At first, it’s a problem at the microscopic level, but with repetitive microtrauma, eventually repeated stress causes enough tendon breakdown to result in painful symptoms. There really isn’t a single event or specific injury — it’s more of an accumulation of tiny traumas occurring over and over.

There are some problems with this theory. For one thing, soft tissues and bone normally respond to stress by building up of the tissues, resulting in a strengthening of the muscle or bone. So, why don’t the ligaments respond the same way? Perhaps it’s because the ligaments don’t have a rich blood supply naturally. Heavy training or overload might compress the tendon, cutting off blood supply even more. This is called the vascular insufficiency theory.

Here again, there are some holes in this theory. Microscopic examination of the tendons has shown an even and full blood supply even in tendons exhibiting tendinopathies. There just isn’t enough evidence to show there’s a loss of blood supply to the area so this theory hasn’t been confirmed. Okay, then — maybe all that exercise is creating a local heat response in the tissues. This is the exercise-induced localized hyperthermia theory. The theory suggests it’s not so much a lack of blood supply to the cells as it is too much heat building up inside the tissues and threatening tenocyte (tendon cell) survival.

Two more theories of how and why tendinopathies develop include the neural theory and the underuse theory. The neural theory proposes that the nervous system is somehow at the center of these injuries. A finger has been pointed to the role of pain-producing chemicals such as substance P, glutamate, and calcitonin gene-related peptide. Each of these substances has been found in higher levels than normal in affected tendons. But the fact that not everyone with tendinopathy has pain leaves scientists scratching their heads and going back to the drawing board over this theory.

The underuse theory suggests that there are some tenocytes that don’t get stimulated enough and remain underdeveloped. That idea might not make sense at first when we are talking about overuse or overloading injuries in athletes. But a closer look at where in the tendon the problem is developing has suggested that not all tendinopathies affect the same area. Some disorders appear to affect the main body of the tendon, while others occur where the tendon inserts into the bone. Tendon insertion is called the enthesis or the osteotendinous junction. Stimulation may differ depending on the type of activity involved in each sport. For example, soccer players seem to be at increased risk for Achilles and patellar tendon injuries. Is this because of functional overload or underload?

Whatever theory proves right in the end, a few risk factors have been identified. Older age, gender (female) with hormonal links, and decreased joint motion and tendon/muscular flexibility seem to contribute to the problem. Achilles tendon ruptures have been reported with the use of a particular family of antibiotics (the quinolones) and with prolonged use of steroids. Running or training on concrete surfaces will also increase the risk of tendon problems, especially of the patellar (knee) tendon. Being aware of risk factors and reducing or eliminating as many as possible may be able to prevent the start of tendinopathies. If a tendon injury does occur, preventing a recurrence is also important.

That leaves us with one final area to review: the management of tendinopathies. Since we don’t exactly know what’s going on, the first approach in caring for the individual with tendinopathy is to control the pain. Conservative measures have been tried such as taping, rest, exercise, cold packs, and nonsteroidal antiinflammatory drugs (NSAIDs) with varying success. Correcting any training errors and flexibility or biomechanical problems is advised.

Exercise is quickly becoming a central focus of rehab for tendinopathies. Researchers have been able to show that eccentric muscle contractions seem to help normalize tendons. With eccentric exercise, the affected body part is moved through a range of motion that begins with the at-risk tendon fully contracted and under some load. The muscle is slowly lengthened back to its normal resting position.

The best example of this is eccentric loading of the gastrocnemius (calf) muscle. The patient stands on a stair (facing the stair as if going up stairs) with just the toes in contact with the stair. From a position up on raised toes (shortened or contracted calf muscle), the person slowly lowers the heel down past the edge of the stair. The knee is kept straight throughout the first set of exercises. The exercise is repeated keeping the knee bent throughout the raising and lowering motion.

Surgery remains a last resort when all attempts at nonoperative care have failed. Almost one-third of all patients with chronic tendinopathies end up having surgery. This is true despite the fact that there is no evidence to support this approach or show which surgical procedure works best. Surgical options include removing scar tissue and adhesions, repairing tendon tears, removing areas of obvious tendon degeneration, and tenotomy (cutting the tendon). If a large portion of the tendon is removed, it may be necessary to transfer a tendon from some other area of the body to the affected site. Surgical options vary according to which tendon is the problem.

When it’s all said and done, the athlete may or may not achieve healing or full recovery. Strength may still be limited. As a result, scientists are turning their attention to other types of treatment. In the future, it may be possible to fully repair tendons with growth factors or stem cells. Finding ways to manipulate the biologic process of healing at the cellular level may be our only hope of complete regeneration of damaged tendons.

Elbow, wrist, thumb, and hand problems are fairly common — and they affect people of all ages from young to old. Many are the result of overuse syndromes. Overuse syndromes refers to pain, tenderness, and dysfunction from tissue damage caused by repetitive, prolonged, or forceful use of the thumb, hand, wrist, or elbow. Additionally, assuming awkward positions repeatedly can also contribute to the problem.

Athletes participating in sports activities come to mind first, but half of all repetitive overuse injuries actually occur in workers. Dentists, phlebotomists, nurses, musicians, keyboard operators, grocery store checkers, even short order cooks are just a few of the people affected. In this updated review, Dr. A.C. Rettig, an orthopedic specialist in upper extremity disorders offers tips for the diagnosis and management of several hand and wrist and elbow conditions.

Most people are familiar with carpal tunnel syndrome (CTS), a nerve entrapment syndrome affecting the median nerve as it passes through a tunnel formed by the wrist bones. Before a treatment plan can be determined, the cause of the problem must be identified. That’s because carpal tunnel syndrome can be caused by overuse (repetitive movements). But it can also develop when there is an underlying pathologic problem. Diabetes, pregnancy, cancer, and rheumatoid arthritis are just a few of the possible systemic causes of carpal tunnel syndrome.

Treating the systemic problem is the first-line of treatment for carpal tunnel syndrome of this type. But when it’s forceful, repetitive, loading motions that cause compression of the nerve leading to carpal tunnel syndrome, then treatment is aimed at reducing the symptoms of pain, parenthesis, and loss of strength. Evidence supports the use of oral antiinflammatories and injections of cortisone for repetitive overuse, musculoskeletal causes of carpal tunnel syndrome. Splinting, exercise, and vitamin B6 are often prescribed as well. Research has not been able to prove that vitamin B6 is helpful. Splinting offers short-term results. Exercise is still being investigated as an effective treatment tool for carpal tunnel syndrome.

Two other common causes of wrist pain include scapolunate ligament insufficiency and dorsal wrist syndrome. Both involve the middle of the wrist joint felt as pain on the back of the wrist. Two wrist bones are affected: the scaphoid and the lunate. These two bones are held together by the scapholunate ligament. Injury of the ligament is the underlying problem. In cases of ligament insufficiency, enough damage has been done to the ligament that it no longer holds the bones together in a stable position.

The examiner making the diagnosis can perform a test called the scaphoid shift or Watson test. Without an intact ligament, the scaphoid bone can be moved up and down as the wrist moves back and forth (when it should hold steady). A positive test is a sign that there is scapholunate insufficiency. With dorsal wrist syndrome, pain along the back of the wrist as the patient bends or dorsiflexes the wrist points to injury of the scaphoid bone.

There are several other wrist problems that might develop as a result of repetitive use of the wrist and hand. Tendonitis, ulnar impaction syndrome, and intersection syndrome must be considered as potential causes. Depending on the type of work and repetitive motion required, wrist tendonitis can affect a couple of different tendons at the wrist, such as the extensor carpi ulnaris or flexor carpi radialis. Conservative care is always advised first before ever considering surgery. Rest, modifying activities, icing, and stretching seem to help the most with wrist tendonitis. If there are no results or insufficient response with these efforts, then splinting and steroid injection may be tried next.

Ulnar impaction syndrome occurs when a person is born with one forearm bone (ulna) longer than the other (radius). This might not pose a problem until the affected individual injures the wrist or engages in repetitive wrist motions. The extra load on the ulnar side of the wrist can tear the ligaments and cartilage on that side of the wrist. X-rays are needed to make the diagnosis. If changing the way the person uses the wrist and hand doesn’t help, surgery may be needed to even the bones out and take the stress off the ulnar side of the wrist.

You may not have heard of intersection syndrome but it’s actually fairly common. It occurs when tendons in the forearm cross over tendons in the wrist and rub against them causing inflammation and of course, pain. The problem affects manual laborers and athletes who bend and/or extend the wrist over and over. Sometimes you can hear a crunching or snapping sound called crepitus as the wrist moves creating friction between the soft tissues. A program of conservative care works best with rest, splinting, and steroid injection when needed.

Some less common problems such as stress fractures of the wrist complete the discussion of overuse syndromes of the wrist. Golfers, tennis players, and baseball players share this problem. What do they have in common? The golf club, tennis racket, and baseball bat all come in contact with the fat pad along the base of the wrist on the little finger side. A bone underneath that area (the hamate) can develop a tiny fracture from the chronic impact at that point. The player ends up with pain and can’t grip his or her club, racket, or bat. Stress reactions don’t show up on X-rays during the acute phase, so CT or bone scans are needed to confirm the diagnosis.

That takes us to thumb pain. Most of the time, thumb pain from overuse syndromes develops at the base of the thumb. This could be caused by damage to the joint called arthrosis, tendon lining inflammation called de Quervain syndrome, or trigger thumb when thickening of the tendon in the palm area catches the tendon as it moves through its channel. The tendon gets stuck and thumb remains in a permanently flexed position. As you can imagine, without being able to extend the thumb, hand function can become severely affected. Treatment for all three of these problems begins with a hand therapist and moves to surgery only if conservative care is unsuccessful in restoring motion and strength without pain.

And finally, the author turned his attention to overuse syndromes of the elbow. The most commonly reported problem is elbow tendonitis called epicondylitis. Tendons on the inside of the elbow (medial epicondylitis or tennis elbow) can be affected or the lateral (outside) elbow (lateral epicondylitis or golfer’s elbow).

Elbow tendinitis has been around for a long time. Management begins with ice, stretching, and splinting at night when needed. Activity modification is a key to successful treatment but often takes months up to even a year to recover. That’s not usually very satisfactory to an avid golfer or professional tennis player. Steroid injections are not recommended. Although there is short-term relief of symptoms, as soon as the player goes back to the game, the symptoms often come back. Research efforts are being made to find better, faster ways to treat elbow tendonitis more effectively.

The one time injections are especially useful is in diagnosing the specific soft tissues (nerves, muscles, tendons, ligaments) that are being pinched, compressed, or overloaded. If injecting a numbing agent at the suspected site of dysfunction reduces or eliminates the pain, then the diagnosis is often confirmed. Although there are some diagnostic tests for each of the conditions discussed, the results aren’t always reliable. Diagnostic injections have fewer false positive or false negative responses compared to other more subjective tests.

Since the last time the author reviewed overuse syndromes five years ago, there has been an increase in the number of children affected. Increased participation in organized sports seems to be at the center of this phenomenon. Primary care physicians report that up to half of the sports injuries they see in children and adolescents are from overuse. Keeping up with common problems and evidence-based solutions remains the focus of review articles like this one.

As parents, we have all watched our children who participate in sports with a bit of fear and worry about injuries. And for parents of athletes who have already injured themselves, there’s always a niggling concern that it might happen again. Researchers at the Center for Injury Research and Policy at the Ohio State University have made this area of interest a top priority.

They took data collected on high school sports injuries for a three-year period of time (2005-2008) and analyzed it looking for patterns that might help guide prevention strategies. With more and more students participating in organized sports, injury prevention and especially preventing repeat or recurring injuries is important.

Just to give you an idea of how common sports participation is — there are over seven million high school students involved in athletics each year in the United States. And two million injuries each year as well. About one in 10 of those injuries is really a repeat or recurrent injury.

And as you might imagine, the second injury is usually worse than the first. For example, if a muscle or tendon was partially torn the first time, it ruptures fully the next. A second (or even third) concussion can lead to more severe symptoms and can even result in death. Recurrent concussions resulting in a life-threatening condition are called second-impact syndrome. Disability or death from second-impact syndrome is certainly a good reason to find ways to prevent sports injuries.

There’s always the question of which sport has the most injuries. And in the case of this study, which sport is linked with the most recurrent injuries. The authors looked at nine sports from this perspective. They used information reported to the National High School Sports-Related Injury Surveillance System to gather their information. This is an on-line database into which 100 high schools selected randomly deposited (recorded) information about their athletes’ injuries. Participants from football, soccer, volleyball, basketball, wrestling, baseball, and softball were included.

Everyone who participated was trained to define injuries and recurrent injuries in the same way. This helped make sure the information collected was consistent from school to school and athlete to athlete. For recurrent injuries, there had to be a repeat injury of the same area on the body. The first injury occurred in either the last school year or the current academic year. Details of the injury were reported along with information on the athlete such as their age, height, weight, and sport played. After analyzing all the data, here’s what they found:

The average baseball pitch takes less than five seconds. To the outside observer, the actions occur so quickly, it’s impossible to see much more than a flurry of activity. The leg comes up, the pitcher strides forward as the pitching arm cranks back, the trunk tilts forward, and the ball is released. Sounds simple, doesn’t it? But the accuracy and speed of the pitch depend on many, many actions such as the foot position and orientation (turned out/turned in), shoulder and pelvis rotation, knee extension, and trunk motion and position.

All of these movements together form a concept of biomechanics referred to as kinematics. Athletes such as baseball pitchers are very interested in the kinematics of pitching. They want to increase the ball velocity and improve their performance without adding stress to the pitching arm or ending up with an injury. The authors of this article reviewed all publications between 1994 and 2008 looking for information on kinematics (biomechanics) and kinetics (movement) to aid pitchers in this way.

All of the information found from various studies was summarized under five basic groups: 1) kinematics and ball velocity, 2) kinematics, kinetics, and injury, 3) fatigue, 4) development of the pitcher, and 5) pitch types. Since there has been a lot of new information over the last 10 to 20 years about pitching biomechanics and movement, the intent of this article is to help pitchers, trainers, and coaches focus on improving performance without causing injury. Let’s take a closer look at what they found.

1) Ball velocity. Pitching speed isn’t just about the pitching arm. The entire body (arms, legs, trunk) is involved. The legs are really the foundational support for every pitch and should be the first place to start in improving ball velocity. For example, the force of the push-off of the throwing leg is directly linked with wrist velocity. Too short of a stride length can actually slow down the forward momentum of a ball. Studies show that pelvis and trunk rotation must be coordinated together to improve ball velocity. Greater pelvic rotation is needed to improve ball speed.

The lower body and trunk create the power that is channeled up the kinetic chain to the pitching arm. Each pitcher must work to find his or her own unique rhythm of movement, joint positions, and coordinated motion to produce an explosive pitch. They must do so without injuring themselves. That is a difficult task.

2) Kinematics, Kinetics, and Injury. Studies show that injuries are most likely to occur as a result of force on vulnerable soft tissues from repetitive pitches. And it’s the moment of transition from one position to another, one movement to another that should be the focus of training and practice.

For example, when the pitching foot leads off, is it pointed straight, turned out, or turned in? Even the smallest degrees of motion can make a difference. The foot position causes rotation of the pelvis. Too much rotation, too soon can slow the ball and ruin a pitch. And believe it or not, the foot position transfers energy through the pelvis to the arm affecting force at the elbow and shoulder.

Some pitchers lead with the elbow, a well-known movement pattern that compensates for a weak ulnar collateral ligament along the inside of the elbow. The net result is to put more strain on the shoulder, resulting in elbow-derived shoulder injuries. All shoulder injuries should be examined for pathologic elbow kinematics as a contributing factor.

3) Fatigue. It’s clear now to sports professionals that pitching every inning of every game is no longer a good idea. But that’s how it was done in the early days of baseball and for many years after. Fatigue (no matter how strong the athlete is) can lead to injury. Researchers have studied this problem trying to determine a formula whereby a pitcher would be able to calculate exactly how many pitches would be safe.

Younger, less developed pitchers are especially at risk for pain and injury from over-pitching. High-pitch counts (more than 75 per game or more than 600 per season) are to be avoided. Pitching when the arm is fatigued is also a no-no. Children must be trained from early on to let the coach know when he or she is tired. They must be taught that a fatigue-related injury can be prevented. They may think one more pitch is going to win the game, but in the long-run, they are not helping the team out if they end up injured. This can be a difficult concept for any athlete, especially young ones.

The coaches must also take it upon themselves to monitor their pitchers. Loss of pitch speed and pitching inaccuracies are clear signals of fatigue. Counting pitches and staying under the evidence-based guidelines determined by research is an easy and effective way to prevent injuries. And pitchers don’t just injure their elbows and shoulders. Pitchers are also at increased risk for groin injuries, abdominal muscle strain, and knee and back soreness.

4) Developing the pitcher. You may think some people are natural-born pitchers. But even children with natural pitching ability must develop strength and skill. Those skills are developed over time, starting from the very earliest pitches thrown. Even professionals continue to train after years of pitching thousands of balls. No one should think that they can’t improve. One way to improve is to analyze the pitch from the first pitch of the game to the last. Researchers using slow speed videotaping have been able to document how pitching kinematics changes over time (usually because of fatigue).

Some other useful tools in helping the young pitcher develop include using lightweight (instead of standard-weight) baseballs when practicing pitches and re-evaluating pitch mechanics during growth phases. Growing bones and increasing height during puberty can alter the biomechanics of movement and pitching. Growth plates at the ends of growing bones are especially vulnerable to injury during growth spurts. This is another reason to limit pitches as described.

5) Types of Pitches. As the pitcher trains and develops, he or she will advance from one type of pitch to another. There are many pitch types to learn such as fastballs, cutters, curves, sliders, sinkers, changeups, and knuckleballs. But it’s always advised that young pitchers learn the fundamentals of fastballs first, then changeups and third, curveballs. Each pitch type requires its own unique combination of movements to achieve speed and accuracy.

Researchers are working to understand the biomechanical requirements of each pitch type. Forces and torques on each joint are being measured and analyzed for each pitch type in an effort to reduce injuries. Young pitchers can benefit from the knowledge gained so far by following this order of pitch development.

In summary, there are many biomechanical factors in pitching that rely on one other to create ball velocity and accuracy. Flexibility, strength, body size, and joint motion all combine together to define a great pitcher. Each link of the kinetic chain from head-to-toe (or for pitchers, from toe-to-head) is important in the development of a young pitcher’s skill. Proper timing and sequencing of movement and rotations must be developed with years of practice. Performance can be improved without increasing injuries by following guidelines determined by diligent sports researchers. Coaches, parents, and players must put aside personal desires and abide by these rules for the sake of the player and the team.

Circus performers have wow’ed audiences for years with flying trapeze artists, elephant tricks, lion tamers, and clown acts. But the circus has taken on a distinct difference in the last 25 years with the athletic gymnastics routines performed by modern circus artists without animals. Cirque du Soleil is a large circus company of this type entertaining audiences around the world.

But those amazing feats of flexibility don’t come without some problems. This report from McGill University in Canada, Center for Sports Medicine in San Francisco, and Stanford University describes the kinds of injuries sustained by Cirque du Soleil artists. Injury pattern and injury rates during practices and performances were gathered over a two-year period of time.

Cirque du Soleil performers are really athletes of the highest caliber. They train in diving, juggling, swimming, martial art, dance, and Chinese acrobatic maneuvers. They perform hundreds of times every year — not just in large theatres but at schools and festivals as well. The time they put into practice and performances adds up to 1000s of hours.

An internal electronic database was available for use in this study. Internal means the records were kept by the Cirque du Soleil organization. Physical therapists and athletic trainers working with Cirque du Soleil performers kept track of injuries (location, type), treatment and number of treatments for the injury, and number of practices/shows missed.

Separate analysis was done based on whether the performer was male, female, a musician vs. acrobat, and whether the injury occurred during practice or performance. They found men were twice as likely to be injured as women. Most injuries were relatively minor affecting only one area of the body. Musicians were more likely to injure the head/neck or arms. Acrobats were more likely to suffer injuries of the lower extremities (e.g., knee, ankle, foot).

Types of injuries included sprains, strains, fractures, and ligament or muscle tears. Running on and off the stage actually generated the largest proportion of injuries in both musicians and nonmusicians alike. The performers were back on their feet in one or two sessions and rarely missed a show due to injuries. Overall, the rate of circus-related injuries was far lower than for most men’s and women’s athletic events (e.g., soccer, field hockey, basketball, wrestling, football).

Given all that they found, the authors made a couple of suggestions to help prevent modern circus-related injuries. First, injury prevention programs should target the shoulder, knee, and ankle for all performers and the hip/groin for female artists. Prevention begins with purchasing the highest quality equipment designed for circus performers and then carefully maintaining that equipment.

Work schedules should be reviewed and managed for each artist to avoid excessive workload without adequate rest periods. All performers should be encouraged to report any and all injuries, no matter how minor. Quickly addressing the problem, providing appropriate rehab, and restoring strength and conditioning are key factors to successfully minimizing the impact of injuries.

This is the first report of its type detailing and analyzing circus-related injuries. Despite the fact that circus performers are extremely physically active, combining athleticism and acrobatics/gymnastics, the overall injury rate is much lower than for any other group of athletes.

These performers are called upon to perform multiple physical activities in a single show — probably far more than the average sports performer. Perhaps they have something to offer athletes that might reduce injuries on the playing field or on the court. This was the first study of its type. More research is needed and planned to look at this type of data more carefully and in the near future.

What surgeons consider a complication of surgery and what patients view as a complication are often very different. And since differing opinions can lead to unrealistic patient expectations, there’s a need to clear this misunderstanding up right from the start. The authors of this article hope to lend a hand with that task.

They point out that the first problem is defining what is and what isn’t a complication. And secondly, there is a need to decide whether that complication is a major or minor problem. The goal is to improve communication between surgeon and patients before surgery takes place. A secondary goal is to create some basic ways to define and report on complications in order to conduct studies in the future that can be compared to one another.

In this study, a survey was developed and sent to practicing and spine surgeons. Most were orthopedic surgeons with more than five years experience performing hundreds of spine surgeons every year. The survey presented 11 different patient cases to the surgeon to decide: 1) Was there a complication? and 2) Was it major or minor?

The same set of patient stories was also given to a group of patients who came to the spine clinic for evaluation but had not had surgery yet. The cases were rewritten slightly for the average (nonmedical) person. They answered the same two questions. The opinions of the two groups were compared for the complication scenarios.

In general, they found that patients were much more likely than surgeons to consider a problem as a complication and to see it as more serious (major) than the physician. For example, a temporary problem swallowing was considered major by patients but minor by surgeons. The same was true for blood loss during surgery. In both cases, the surgeons knowledge that these problems were short-term and not life-threatening influenced their choice in placing these complications in the minor category.

On the other hand, some complications (e.g., heart attack, blood clot, nerve palsy) were viewed as major by both patients and doctors. In a few instances, the surgeon recognized a problem (usually some kind of infection), as being major when the patient classified it as minor. Again, knowing that such complications can lead to serious health problems (even death) probably aided the surgeon in choosing to label that problem as major.

There are no previous studies like this one comparing surgeons’ perceptions with patients’ opinions about surgical complications. This is the first attempt to solve the problem of reporting and comparing complications after spine surgery. Once the definitions for severe (major) complications and minor (adverse) events are determined, then further research can be done.

With the new direction toward evidence-based medicine and the need to show that the benefit of an operation outweighs the risk/adverse effects, future research will need to incorporate measuring sticks of this type.

Patient satisfaction (now considered a valid measure of a successful outcome) may depend on better communication between doctor and patient. It’s easier for a physician to allay patients’ fears about possible complications if they know what it is the patients fear the most or consider a major problem. Surgeons can also tell patients how likely it is that each complication might occur to help prepare them for surgery and formulate their own expectations about what might happen.

The authors conclude by saying that they will continue working with this concept. They will make some additional changes in their research method and improve the design of future studies. They will also improve the validity of their assessment tool to judge complications for use in other studies as well. Building consensus in the literature around the concept of perioperative and postoperative complications will be the final outcome of their work.