News Category: General

Many people engaged in repetitive tasks such as supermarket cashiers, assembly-line workers, and workers in the food or meat packing industry develop work-related upper extremity musculoskeletal disorders (UEMS). Symptoms include shoulder, elbow wrist, and/or hand pain and dysfunction. The natural history or clinical course (what is likely to happen) for UEMS is unknown. Giving a patient an idea of a prognosis is difficult.

The authors of this study tried to put this condition into perspective. They looked at a three-year period of time and described patient outcomes when they were exposed to highly repetitive work. They gave 700 workers a survey to fill out.

The survey had a variety of questions about pain, discomfort, ache, and other symptoms. The workers reported areas(s) affected and symptoms present. Information about the workers was also collected (e.g., age, gender, work satisfaction, changes in work tasks, previous surgery or other treatment).

Everyone was also examined by an occupational physician at the start of the study. From the information gathered between the survey and the exam, they were able to classify patients into one of three groups.

Group 1 had a clear diagnosis of upper extremity musculoskeletal disorder (UEMS). Group 2 had a diagnosis of UEMS, which was made before by a specialist or had been present in the last six months. With group 3, it was a little less clear what was going on. Workers in this group didn’t have any active symptoms of UEMS, but they had a history of UEMS in the recent past (last six months). To simplify the names given each group, group 1 had a proven UEMS, group 2 had a suspected UEMS, and group 3 had a prior UEMS.

In the natural history of a condition, we find out what happens over time. Does the problem get better and go away? Does it get worse? Does it stay the same? What are the risk factors for a poor prognosis? What are the predictive factors for a good prognosis?

The answers to these questions would be very helpful for physicians and workers when the worker first develops this problem. Together, they can develop a plan of care that might include time off from work or a change in workload or work tasks. Type of treatment (conservative care versus surgery) can be anticipated as well.

According to the results of this study, the recovery rate actually depends on the site of the disorder (not on which group the patient was in). Elbow pain and dysfunction had the best prognosis for recovery, whereas problems in more than one area were less likely to clear up. Recovery rates for neck, shoulder, wrist, and hand fell somewhere between the results for elbow and the outcomes for multisite disorders.

Workers with multiple UEMS disorders were more likely to have persistent problems or recurrent symptoms compared with workers who had single-site involvement. Those with multiple UEMS had more pain that lasted longer. Older workers (defined in this study as over 30 years of age) were more likely to fall into the category of multiple UEMS compared with younger patients (under 30 years).

The original thought in dividing the patients into three separate diagnostic categories was to see if the results varied based on that classification scheme. In other words, workers with active symptoms were expected to have a worse prognosis. Workers with a past history but no current symptoms would do better.

There was some truth to that idea. Workers with symptoms but no previously diagnosed UEMS disorder did end up having a better prognosis when compared with workers who already had a known or diagnosed condition. But the authors felt there needs to be more research in sorting out differences in outcomes over time between the groups. This was especially true for those workers who had single site problems. It was clear that multiple site injuries came out the worst in all cases.

Physical therapists are often called upon to help determine when an older adult is ready to go home after being in the hospital. Or when it’s time to move from an independent living situation to an assisted living or skilled nursing care facility. These judgments are made with the assistance of standardized tests that measure physical performance.

In this study, a group of therapists from the Department of Human Movement Sciences at the University of Wisconsin in Milwaukee asked the question: are the results of physical performance tests really a reliable way to predict function at home?

They tested a group of adults (ages 55 and older) who were living in a continuing care retirement community (CCRC). Only adults in the independent living and assisted living sections of the CCRCs were included. They had to be able to walk to participate in the study. Tests used included the Mini-Mental State Examination (MMSE), Physical Activity Scale for the Elderly (PASE), and the Six-Minute Walk Test (6MWT).

The PASE is a self-reported survey. It is usually filled out by people still living at home. The person taking the test answers questions about him or herself regarding exercise activity, work or volunteer activities, and daily household-related activity. The 6MWT was done inside the retirement facility. Each adult was asked to walk for six-minutes. Distance covered in that amount of time is recorded. Blood pressure, heart rate, and ratings of perceived exertion (e.g., no fatigue, moderate fatigue, most fatigue ever experienced) were collected.

After completing these tests, a special device called the StepWatch Activity Monitor (SAM) was attached to the ankle. The SAM was used to count the total number of steps each person took each day for a period of seven days. The device is designed to be used with people who have different walking patterns, speeds, and limps. It can be used by anyone with an assistive device such as a walker or cane. And the SAM can be used in water for those who participate in a pool-exercise program of any kind.

The authors report that the tests used did not really measure actual functioning of older adults living in a senior community. Most of the people tested had much higher physical function than was reflected by the formal testing. It appears that people living in continuing care retirement communities (CCRC) are more active than seniors living independently but not in a CCRC.

That was a surprise because the seniors in the CCRC appeared more physically limited than those living home on their own. The difference may be in the level of activity that goes on in the senior-designed environments. The facilities are set up so that the residents have to walk short distances many times during the day to get their meals, pick up the mail, or participate in any of the many activities available each day.

Several suggestions were made for physical therapists using these common clinical tests. First, be aware that the 6MWT and the PASE tests may not be good predictors of daily physical activity in this population/environment. Caution must be used in looking at the test results and predicting what a senior can or can’t do at home (home including a CCRC type setting).

The SAM device may be a better tool to use when measuring daily physical activity. It is easy to use and gives both objective and accurate information about daily physical activity. The only disadvantage in using the SAM is that it may overcount the number of steps taken. That could make it look like the person is engaged in more activity than is really the case.

The results of this study may be a true testimony as to the benefit of living in a retirement community. The environment is designed to meet the needs of older adults with some physical limitations. Short bouts of walking activity at the person’s own pace carried out daily and consistently over time seem to be the key to achieving higher physical function. The result is to minimize the impact of physical limitations on daily function for these seniors. That could mean improved quality of life with fewer health problems and greater independence.

Gunshot wounds are not your everyday ordinary problems. But they do occur with some regularity in the United States. In fact, there are a reported 80,000 nonfatal gunshot wounds every year. The average orthopedic surgeon won’t see a steady flow of these patients, but still must be prepared for any that do show up.

In this instructional course, orthopedic surgeons from the Henry Ford Hospital in Detroit, Michigan review musculoskeletal injuries from gunshot wounds. In particular, joint injuries affecting the shoulder, wrist, hip, and ankle are discussed. A separate section is included with a discussion of long-bone fractures affecting the humerus (upper arm bone), forearm, femur (thigh bone), and tibia (lower leg bone).

All of the patients treated were admitted to the hospital with at least one gunshot-related bone fracture. Frequently, the joint nearest the fracture was affected. For example, fractures of the humerus often involved the scapula (shoulder blade) and/or the clavicle (collar bone). Gunshot wounds to the femur or tibia often involved the knee joint.

Penetration to the joint isn’t always obvious, so surgeons are advised to examine patients carefully. Any sign of air or blood in the joint is a suspicious clue. Likewise, fractures affecting the joint (called intraarticular fractures) raise a red flag pointing to joint penetration.

Once the damaged area has been cleaned up and all debris removed, then it’s possible to look at the joint more carefully before stabilizing the bone fracture. Bullets and bullet fragments must be removed to prevent lead toxicity from developing. Any foreign body left in the joint can interfere with normal joint mechanical movement. Over time, this can lead to arthritis.

Surgery often requires a multiteam approach with orthopedic surgeons, vascular and microvascular specialists, and plastic surgeons on hand. Severe injuries involving muscles, tendons, ligaments, bones, and joint cartilage take the skill of all those individuals to stabilize and repair so much damage.

Small bone and/or bullet fragments will be removed. Large pieces of shattered bone or cartilage are more likely to be reattached or reconstructed. Arthroscopic techniques work well for minor, stable injuries, but an open-incision approach is needed for patients with more extensive damage. Some joints have so much destruction, they can’t be repaired. In such cases, reconstruction with a joint replacement may be needed.

Gunshot wounds of the elbow can be especially difficult to treat. Nerve and blood vessel injuries compromise recovery. The bones are small enough that it may be necessary to use external fixation to stabilize the area. This means there are pins and metal plates holding things together. There’s also a rod or device on the outside of the skin to support and hold the forearm in place until healing can occur.

The extent of damage may be determined by the type of gunshot wound (low- versus high-velocity). Low-velocity gunshot wounds occur when the speed of the bullet is less than 1.5 meters per second. The amount of energy transferred to and through the body at the time of impact determines whether the gunshot wound is a low- or high-velocity injury. Soft tissue defects caused by high-energy gunshot wounds may be severe enough to need skin grafts.

The specific areas affected must be determined using advanced imaging techniques. X-rays help identify the location and severity of bone fractures. But sometimes the view isn’t clear enough and additional imaging is needed. Arthrograms of the joint, CT scans, and MRIs may be needed before a surgical treatment plan can be finalized. Gunshot wounds to the buttock area can compromise the abdomen and bladder. Advanced imaging is needed before transabdominal surgery is performed.

Complications of gunshot wounds are many and varied. Infection, the formation of a fistula (pocket of blood and/or pus), fractures that don’t heal, and loss of blood circulation resulting in osteonecrosis (death of bone) are the main concerns early on. Anyone with a significant positive health history for diabetes, heart disease, peripheral vascular disease, or alcohol abuse is at increased risk for delayed wound healing and impaired recovery.

Nerve injuries take a long time to heal. Recovery is slow as the nerve regenerates. Unstable fractures that don’t heal increase the risk of a second surgery later on. In some cases, amputation becomes the final treatment required. This is especially likely when blood vessels have been damaged and blood loss to the area causes necrosis (death of soft tissues).

The authors offer details about each type of bone fracture and what to expect. Common patterns of soft tissue involvement for each fracture type are discussed. Treatment approaches such as open vs- closed surgery, internal vs. external fixation, and wound care for war wounds are also discussed at length.

Stable fractures are relatively easier to handle than displaced fractures or fractures associated with multiple soft tissue injuries. The need for long range planning based on treatment approach and presence of any complications is also presented for the readers’ consideration. It may be necessary to complete the surgical reconstruction in stages. The need for bone and/or skin grafts complicates the picture. Many times, additional surgeries are needed because of the destructive effects of infection.

Besides surgery, fracture bracing is an important topic. After surgery, the affected area (arm, leg, wrist, ankle) is put in a cast to allow the bones to knit together. After the cast is removed, a brace is prescribed. Some gunshot fractures take months to heal completely. Bracing allows for increased function while still off-loading the area enough to promote healing.

Studies are being done to help determine what kind of approach works best to speed up healing and recovery. Of course, this type of research is difficult because there are so many different variables to consider. Severity of injury, development of complications, and persistent wound drainage are just three of the many factors that can affect results.

There isn’t consensus on how to treat every type of gunshot wound. But some experts recommend following these guidelines for gunshot wounds affecting the long-bones:

Almost 30 million adults in the United States have diagnosed osteoarthritis (OA) in one or more joints. With another 1.3 million affected by rheumatoid arthritis that makes arthritis the second most common musculoskeletal disease in America.

It’s actually a little more complex than that. There are more than 100 diseases that fall under the category of arthritis and other related conditions or AORC. Besides osteoarthritis and rheumatoid arthritis, there are conditions such as gout, lupus, psoriatic arthritis, ankylosing spondylitis, and many others.

All added together, one-fifth of the adult population in the United States has some form of arthritis. That’s almost 50 million people. And it’s not just older adults who are affected. Two-thirds of these individuals are under the age of 65. Men and women are both affected, although women tend to be the larger group of patients diagnosed with arthritis of some type.

Why does it matter if so many people are affected by this group of diseases? From the affected person’s point-of-view: it can be a painful and disabling condition. There is treatment with medications, physical therapy, and joint replacement. That means with more people affected each year, more procedures and more medical costs are mounting up.

In one year alone, over 281 billion dollars is spent on the medical care of arthritis and joint pain. That price has doubled in the last 10 years and is expected to continue to increase in the next 10 years. Hospital costs for joint replacements alone totaled 30 billion dollars in 2004. And those figures don’t include the indirect costs to the patient such as lost wages.

So who’s keeping track of all these expenses and how will this information help us? First a little bit about the who. There is a large group of orthopedic surgeons and other medical doctors who have banded together to focus on the burden of musculoskeletal diseases in the United States. They are collecting data on the prevalence of arthritis and other related conditions. Prevalence refers to how many people on any given day have this disease. They are also looking at the societal and economic cost of this group of diseases.

This research is a joint project of the American Academy of Orthopaedic Surgeons, the American Academy of Physical Medicine and Rehabilitation, the American College of Rheumatology, the American Society for Bone and Mineral Research, the Arthritis Foundation, the National University of Health Sciences, the Orthopaedic Research Society, the Scoliosis Research Society, and the U.S. Bone and Joint Decade.

So you can see, it has grabbed the attention of thousands of doctors across multiple disciplines. Readers can find out more about their work on this project available on-line at www.boneandjointburden.org. And as for the what of how this information will help us — in the immediate period, there is a need to improve joint implants for joint replacements. The goal is to produce better designs that last longer for an active, aging group of adults.

Backing up a bit, there is a need to prevent these problems from developing in the first place. Testing and research efforts centered on prevention are looking for risk factors that could be modified to prevent or delay the onset of any of these arthritic conditions.

There is also a focus on the development of safe and effective medications as the first-line of treatment. Early diagnosis and treatment may be able to prevent damage to the joints and hold off the need for surgery.

More and more, efforts are being directed toward patient education. Reducing the burden of arthritis requires a better understanding of the disease and its natural course. This knowledge may help people manage their own condition. Weight loss, physical activity, and exercise are extremely important for everyone with musculoskeletal disorders but especially those who suffer from any joint problems such as arthritis.

Workers with chronic musculoskeletal disorders (MSDs) are often unable to return-to-work (RTW) at the full capacity required by the job. A multidisciplinary approach to rehab is often helpful. Physical therapists use a special test called Functional Capacity Evaluation (FCE) to figure out what form of therapy is best.

FCE is a group of 25 standardized tests including lifting weights, bending, and carrying objects. This battery of tests is designed to assess an individual’s capacity to work. For example, does the person have the physical strength and mobility to do the job? Does the job have to be modified for the worker? Does the worker need lifting or weight restrictions?

The main question addressed by this study was: can the Isernhagen Work System Functional Capacity Evaluation (ISW-FCE) be used to predict who will be able to get back to work? The Isernhagen Work System FCE was developed, tested, and standardized by a physical therapist. It is a widely known and accepted FCE test around the world.

The ISW-FCE can assess functional capacity and guide therapists in setting up rehab programs. The target group consists of workers with chronic musculoskeletal disorders. But can the ISW-FCE be used to predict return-to-work (RTW) status? Right now, studies have shown that patients self-report of pain intensity and expected disability in the job are pretty good predictors of success in returning to work. The authors asked, if those two factors were taken out of the FCE, would the battery of tests given really add any additional information about the worker’s likelihood to return-to-work?

A total of 145 blue-collar workers from northern Germany with musculoskeletal disorders (MSDs) were involved in this study. Each one filled out a survey that measured their general health and the effect of MSD on general health. The survey was done before and after FCE testing or rehab. Each person was followed for one full year using these measures.

The therapists administering the ISW-FCE compared each worker’s functional capacity with the demand of their individual jobs. The data was also compared to self-report measures usually used to predict the estimated time until the patient’s successful return-to-work. Successful return-to-work was defined as full-time employment by a worker in good health who had used low levels of sick leave because of pain from musculoskeletal disorders. Low levels of sick leave use was considered six weeks or less off work in a one-year period of time.

One year after the FCE testing and rehab there were slightly less than two-thirds of the 145 workers (62.1 per cent) successfully back on the job. For the remaining 37.9 per cent, the FCE results showed a lower work capacity and higher level of work-related deficits. The more tests failed on the FCE, the less likely it was that the worker would return-to-work. Five or more failed tests in the FCE battery were significant.

Despite that information, the FCE really didn’t add any additional information to predict a worker’s return-to-work that couldn’t be obtained from the already successful method of assessing pain levels and workers’ own predictions about work-related disability. However, the information from this study did help the researchers identify and then test a clinical prediction rule (CPR).

CPRs are a popular and effective way to take results from a study like this and put together a formula that can be used to categorize patients. In the case of blue-collar workers with musculoskeletal disorders, the CPR was used to identify people who were likely to be returners and those who would be nonreturners.

The CPR was defined as follows: returners would be patients who had low rates of sick leave before entering rehab. They also had a positive expectation that they could handle the job if they returned. And they failed five or fewer parts of the FCE. Nonreturners were defined by the CPR as having a high rate of musculoskeletal-related sick leave, an expectation of disability at work, and failure of more than five tests on the ISW-FCE.

Applying this CPR to the 145 workers, the authors reported it was possible to accurately predict returners from nonreturners for three out of four workers when the potential status of workers was unclear. Combining the already used and accurate self-report model with the FCE can help improve the success of the clinical prediction rule.

This information may help physical therapists identify patients who won’t make it back to work despite completing a rehab program. The next step in research is to find ways to create a rehab program that would increase the number of workers who do return-to-work successfully.

I hurt all over. I feel like a truck ran over me when I wake up in the morning. These are the most common complaints of patients suffering from a condition known as fibromyalgia. In addition to widespread pain, patients with fibromyalgia also report a wide range of other symptoms such as fatigue, difficulty sleeping, anxiety, depression, stiffness, and mental fog to name just a few.

Patients with fibromyalgia feel sensations like touch and temperature (hot and cold) louder and longer than people who don’t have fibromyalgia. Normal sensations feel uncomfortable or even painful to them. And the awareness of those sensations lasts longer than in other folks.

Twenty years ago, fibromyalgia was recognized by the American College of Rheumatology (ACR) as a real biologic problem and not just an imagined or psychologic disorder. That brought an increased attention to this condition. Since then, many studies have been done to understand the underlying basis for the problem and to find a way to effectively treat it.

In this report, two physicians from the University of Pittsburgh School of Medicine present an in-depth update on the latest findings in the diagnosis and treatment of fibromyalgia. Let’s start with what causes it. In a nutshell, we still don’t know. The pathology has been narrowed down to an abnormal processing of pain signals. It appears that the entire nervous system and its connections to other systems is involved.

Studies have shown there are neuroendocrine, biochemical, and genetic abnormalities. But not all fibromyalgia patients have the same symptoms, responses to pain or other stimuli, genetic links, or altered hormones. So, finding one treatment that will be equally effective for everyone remains a challenge.

Stress seems to have a role in fibromyalgia. Symptoms are certainly aggravated or made worse by emotional, psychologic, or physical stress. There’s some evidence that communication between the hypothalamus, pituitary, and adrenal glands is altered in patients with fibromyalgia. The proper functioning of these three areas is essential to a normal response to stress that doesn’t lead to physiologic dysfunction.

Most experts agree that a combined approach using medications, cognitive and behavioral therapy, exercise, and complementary approaches is best. This mode of treatment is referred to as multidisciplinary or interdisciplinary. Scientists are still working to identify what form of treatment, in what order, and combined with what other treatments results in the most favorable outcomes.

Physicians are advised to listen to the patient’s report of symptoms and choose treatments that will reduce (or eliminate) the most bothersome ones first. So far, studies have shown that exercise is a key therapy for everyone. Too much, too soon can aggravate symptoms. Patients are carefully guided by a physical therapist through a progressive but individualized program of strength training, endurance, and flexibility.

Exercise is combined with medications, cognitive-behavioral therapy, acupuncture or hypnotherapy, and biofeedback/relaxation training. If these methods don’t help (or don’t help enough), then the patient may want to try chiropractic care, massage therapy, or physical therapy modalities such as ultrasound or electrical stimulation.

There are several different types of medications used with fibromyalgia patients. Most of these work at the level of the nervous system to alter pain signals. These include antidepressants, antiepileptics, analgesics (pain relievers), and sometimes muscle relaxants. It may take some time to find the right drug in the most effective dose to calm symptoms without adding unwanted side effects. The use of vitamin supplements, hormones, herbs, and thyroid medication are under investigation.

Whatever treatment approach is taken, patients must be questioned about results to measure a response to treatment. For example, surveys of pain levels (frequency, intensity, and duration) and assessment of tender points are often used to measure outcomes.

Most treatment is by trial and error. If the chosen treatment isn’t having the desired effect(s), then something else can be tried. Any reduction in global pain score and tender points is a step in the right direction. Improved mood, better sleep patterns, fewer headaches, and improved quality of life are all much appreciated by these patients.

Pain from tender points called trigger points (TrPs) is a common feature of many conditions such as headaches; neck, jaw, shoulder, chest or back pain; and carpal tunnel syndrome. When pressed with just the right amount of pressure, these trigger points reproduce the person’s pain pattern. But how reliable is this test to diagnose trigger points? What’s a trigger point and what isn’t?

That’s the question these researchers from the University of Sydney in Australia posed in this study.
To find the answer, they reviewed the studies published so far. They looked for studies that tested whether the commonly used test of digital palpation is really reliable. In other words, would each examiner using the same test on the same patient get the same results?

The current palpatory test is described as using enough pressure from the examiner’s finger to cause the examiner’s own nail bed to blanch (turn white) when pressure is applied to the patient. The pressure is applied to the patient’s muscle over points known (from previous studies) to be tender.

We don’t have any other way to test for trigger points yet. Other research has been done to find a reliable test that could be used. Some of the techniques tested so far have included muscle biopsy, electromyography (EMG), microdialysis, and various imaging techniques. Palpating trigger points remains the most commonly used method of diagnosis.

Studies collected and reviewed investigated the reliability of physical examination (specifically palpation) to identify trigger points. Journals and textbooks were searched and studies reviewed for quality. In each study accepted for inclusion in this study, trigger points were labeled as active or latent.

Active means the affected person was having pain in a pattern typically associated with that particular trigger point. Latent means the pain was present only after the trigger point was pressed. Only patients reporting painful symptoms can have an active TP. Anyone can have (latent) trigger points without knowing it.

The authors report a variety of problems with the different studies included. Some were deficient in research design. Some did not mention if the examiners were blinded to the findings of other examiners. This could influence the results. For example, higher levels of reliability are reported when examiners aren’t blinded to the results of others. They are more likely to be influenced by the results reported by other examiners.

Some studies used expert examiners. This would not really test the reliability when the average clinician used the test. Most of the studies just reported whether or not the trigger point was present or absent. With all of these differences, comparing and interpreting the results of the studies was impossible.

None of the final studies included in this study focused just on reliability of palpatory testing for active trigger points. The kind of statistics needed to answer the question of how accurate is the standard digital palpation test for trigger points just weren’t available. There were too many loose ends in how the research was done and inconsistent reporting techniques.

Reliability was better in studies that used experts to conduct the testing. That suggests this test (digital palpation) isn’t reliable when applied by the typical practitioner.

The authors of this study take their own findings one step further. They point out that it’s one thing to reliably identify trigger points using palpation. It’s another to agree on the location of where trigger points exist. If examiners can’t agree on the exact location of an active trigger point, can treatment applied to trigger points be effective?

The authors conclude that there isn’t a reliable diagnostic test for trigger points — or at least, no study has reported one. They suggest that anyone identifying trigger points using digital palpation should let their patients know the diagnosis is questionable. Treatment based on the diagnosis may not be successful without an accurate diagnosis with specific treatment for that diagnosis.

And, if measuring trigger points before treatment isn’t reliable, then the test can’t be considered reliable for measuring them after treatment either. Evaluating the effectiveness of treatment using the presence (or elimination) of trigger points (via palpation) may not be acceptable either.

Clearly, there is a need for future studies of high quality that will accurately discern the reliability of tests performed in the diagnosis of trigger points. The authors offer several suggestions for how to create and conduct an optimal study of reliability.

Smoking (tobacco use) has been shown to increase pain intensity among patients with chronic pain. Fibromyalgia is one of those conditions with chronic musculoskeletal pain. So, does this association between smoking and pain apply to patients with fibromyalgia? That’s what the authors of this study set out to investigate.

They evaluated patients from the Mayo Clinic Fibromyalgia Treatment program. Those who smoked were placed in one group. Those who did not smoke were in a second group. About 15 per cent of the total group smoked.

Everyone was evaluated first by a registered nurse. Information was collected about their social background. Questions were asked about age, gender, marital status, educational level, and tobacco use.
Then, a physiatrist (rehab specialist) or rheumatologist (arthritis specialist) saw the patients to confirm a diagnosis of fibromyalgia.

Everyone filled out the Fibromyalgia Impact Questionnaire (FIQ). The FIQ measures pain severity and function. The higher the score, the greater the impact of fibromyalgia on the patient’s work and home life. Scores range from zero (no problem) to 100 (severe loss of function; disabled).

The scores on the FIQ were compared between the smokers and nonsmokers. They found one major difference: tobacco users did have much higher pain levels compared with nonsmokers. Other differences included: the tobacco users had higher FIQ scores, indicting a greater effect of the fibromyalgia on their daily function. Smokers were more likely to live alone and to be unemployed. There was also a higher incidence of abuse (history of sexual, physical, or verbal abuse) among the smokers.

They did not find a greater number of tender points in smokers with fibromyalgia compared with nonsmokers. The study could not answer the question of whether tobacco use puts people at greater risk of developing fibromyalgia than people who don’t smoke.

The mechanism by which tobacco increases pain intensity is being studied. Scientists think that tobacco increases substance P in the cerebral spinal fluid. Substance P helps transmit pain signals. At the same time, smokers have lower endorphin levels (natural pain killers). In addition to these two factors, there may be a connection between depression and smoking and between fibromyalgia and personality disorders. When all put together, the impact of these variables on fibromyalgia and pain intensity could be significant.

The results of this study were consistent with other studies linking smoking with pain (e.g., low back pain), more severe symptoms from other musculoskeletal disorders, and loss of function. The smokers with fibromyalgia were also more likely to miss days of work.

There are still many unknowns in the field of fibromyalgia. Do smokers (or tobacco users) respond to treatment for fibromyalgia differently than nonsmokers (faster? with different treatment?)? Do smokers with fibromyalgia have a harder time quitting smoking (or quitting using tobacco)?

Future studies may take a look at some of these questions. For now, the authors conclude that tobacco use is linked with worse symptoms in patients with fibromyalgia. It is always advised that patients should quit smoking. Patients with fibromyalgia should be encouraged to enter a tobacco-cessation program not only to reduce pain but also for their overall better health.

People around the world suffer from the global (many different) symptoms of fibromyalgia. In this report from Spain, the effects of an aquatics program are measured in women with fibromyalgia compared with a healthy women of the same age, weight, education, and physical fitness). No one in the control group had fibromyalgia, symptoms of fibromyalgia, or any other known illness. The goal was to see how exercising in warm water affects the global symptoms of fibromyalgia.

Fibromyalgia or fibromyalgia syndrome (FMS) is a chronic muscle pain syndrome. It is characterized as pain or tender points that is widespread throughout the body. FMS was originally put under the category of rheumatology (arthritic conditions). New understanding of FMS with documented objective biochemical, endocrine, and physiologic abnormalities puts it more in a biologic (organic) category.

It has been described as a disorder associated with neurohormonal dysfunction of the autonomic nervous system (ANS). The autonomic nervous system is the part of your nervous system that controls unconscious functions like breathing, heartbeat, blood pressure, and body temperature.

Many studies have shown that physical activity and exercise are very helpful for patients with fibromyalgia syndrome. They report decreased pain, improved sleep, better quality of life, and even improved cognitive function.

In this study, women in the fibromyalgia group were divided into two groups. One group participated in a three-times-a-week, 16-week exercise therapy program in a pool of chest-high warm water. The program included warm ups, strength exercises, aerobic exercise, and a cool down period. Heart rate was monitored throughout the program. The second group of women with fibromyalgia was told to continue their normal activities but not to add any new activities or exercise.

In addition to looking at the effects of the exercise, the researchers followed the group for a full year to see what kind of adherence there was. Adherence refers to how many women kept participating in a pool therapy program once the study had ended.

Effects of the program were measured using tender point count, health status, physical endurance, anxiety, and cognitive function. Various questionnaires (e.g., State Anxiety Inventory, Pittsburgh Sleep Quality Index, Fibromyalgia Impact Questionnaire) were used to assess each of these areas. Each woman in the study completed the surveys before and after the exercise program.

The authors discuss the difficulty of testing patients with fibromyalgia. Measuring pain using a verbal report of present/absent or giving pain a rating from zero (no pain) to 10 (maximum pain) is not an adequate measure of exercise-induced effects. The results of other studies using these measures reported no observed changes.

At the same time, physical function is limited in patients with fibromyalgia. Testing in any meaningful fashion can result in increased pain and a set back in their health status. The use of a metronome to control the pace of movement while performing a test called the chair-stand test was presented. Patients were instructed to stand up and sit down in time to the beat of the metronome. The ticking of the metronome could be set so that patients got an aerobic effect without compromising the results of the test.

In the pre-testing results, they found that the fibromyalgia group was very deficient in all areas compared to the normal, healthy group. After the 16-week program, there were no changes in the control group (group that did NOT do the pool program). The exercise group did have significant improvement in pain levels, sleep quality, and physical and cognitive function. However, there was no change in anxiety level after exercise.

The authors note that not all of the improvement in health status could be linked with the exercise therapy. The change in season from before (January) and after the program (May) may have had an effect. The beneficial effect of warm weather on fibromyalgia has been pointed out in previous studies.

There was a very low dropout rate from the exercise group. Reasons given were related to problems with transportation and work schedules. And at the end of a year, 79 per cent of the women in the exercise group continued to exercise. Most of the women continued in the pool therapy program. A few others chose a different form of exercise.

The conclusion from this study was that an aquatic program of exercise is beneficial for fibromyalgia patients. There were no negative effects and many positive results of the exercise. And it’s a type of exercise they are likely to continue.

Exercise of any kind can help reduce or minimize deconditioning. Further studies are needed to assess the long-term results (i.e., how long do the exercise-induced changes last?). And the authors suggest looking into other forms of exercise to find the one most likely to encourage patients to maintain an exercise program for life.

Muscle injuries occur on a continuum (range) from mild to severe. They may present as delayed soreness a day or two after overuse. There could be a strain or even a muscle tear. In some cases, contact with another person or object can cause a contusion (bruise). In this article, orthopedic and sports medicine experts update information on two of those possible muscle problems: muscle strains and tears.

Understanding the treatment and management of muscle injuries requires a working knowlege of the anatomy and pathophysiology (what happens on a cellular level after injury). At the microscopic level, muscles are arranged in small units or bundles. They are surrounded by protective layers of tissue and satellite cells. The satellite cells are a type of stem cell that stand by in case of injury. They start the healing response when it’s needed.

Muscle injury occurs when the muscle fibers are stretched too far, too fast. The strain or tear usually starts at the weakest part of the contractile unit. And the injury is most likely to occur during an eccentric contraction.

Eccentric contraction means the muscle is shortened or already contracted and is now lengthening. An example of this is the biceps muscle in the upper arm. Making a fist and bending your elbow as much as possible is a concentric contraction of the biceps muscle. Now, as you lower your hand and straighten the elbow, the biceps muscle is contracting eccentrically (lengthening or stretching out).

The weakest point of the muscle (where a strain is most likely to occur) is at the myotendinous junction. This is the transition zone between the muscle fibers and the tendon that attaches the muscle to the bone. The muscle is soft and pliable. The tendon is more like tough connective tissue and less resistant to sudden force.

Some muscles are more prone to injury because of the location or fiber type. For example, muscles that attach across two different joints are under increased force from different joint angles and movement. The hamstrings behind the thigh cross the hip and knee. The gastrocnemius (calf) muscle crosses the knee and ankle.These are two of the most commonly injured two-joint muscles.

Muscles are made up of two different types of fiber. You can see this most readily in a turkey or chicken by what we refer to as dark meat and white meat. Type I fibers have lots of endurance and resist fatigue (corresponds to what we think of as the white meat). Type II fibers (corresponds to what we think of as dark meat) have fast twitch fibers needed for speed and a quick response. It’s the Type II fibers that are most vulnerable to a muscle stretch injury.

Once an injury has occurred, the body responds quickly. First, it mobilizes inflammatory cells and sends them to the area of injury. That’s when we get pain, swelling, and a warmth or even hot feeling around the injured site. That’s the acute phase (first 24 to 48 hours).

Then, the satellite cells are activated to create new muscle fibers. They help knit the torn area back together over the next six to eight weeks. In the last phase of muscle healing, the body spends some time remodeling the tissue.

Before treatment can begin, the physician must assess the injury and determine where is the patient in the healing process. A careful and thorough history and clinical exam are performed. The physician must rule out other problems such as a compartment syndrome, complete tendon tear, fractures, and infection. Imaging studies such as X-rays, ultrasound, or MRIs may be needed to confirm the diagnosis and perhaps show the extent of the injury.

An early or acute injury is usually managed with the RICE principle (rest, ice, compression, elevation). The goal is to reduce swelling and pain while restoring motion. Over-the-counter drugs such as Tylenol for pain relief or ibuprofen (nonsteroidal anti-inflammatory drug or NSAID) may be presecribed during the early phases of healing and recovery (seven to 10 days).

Long-term use of NSAIDs is no longer advised. Animal studies have shown that muscle force and function can be inhibited with prolonged NSAID use. These drugs may reduce the number of satellite cells available for tissue regeneration.

Resting the injured muscle is a good idea at first but long-term immobilization should be avoided. At first, the pain prevents movement. And during the acute phase, keeping the muscle and joints still helps protect the injured area from further damage. Scar tissue formation is also less likely if the strained muscle is given a short rest from a repeated contract-relax sequence.

Gentle movement should be resumed within 48 hours. Usually, this coincides with a natural decrease in pain and swelling. The task now is to regain motion and eventually full strength. For athletes, a physical therapist or athletic trainer can be very helpful during this phase of rehab and recovery. Sports experts recommend waiting to resume sports activity until the injured side has at least 80 per cent of strength when compared to the uninjured side.

Completing a full rehab program is an important step to avoiding reinjury. Preventing muscles strains from even occurring in the first place may be possible. Athletes with muscle strength imbalances appear to be at increased risk of a primary (first) muscle strain. That’s one reason why a preseason screening program is advised for all competitive athletes.

For older adults who are active in sports or other physical activities, muscle atrophy and loss of tendon flexibility (contractility) are major risk factors. There’s some evidence that stretching before physical activity may help prevent muscle strains. But this is currently a controversial area with some studies showing no preventive effect of stretching before exercising.

It makes sense that warm muscles are more flexible and possibly less prone to strain injury. Warm-up activities and stretching are still advised by some as part of strain injury prevention. Until further studies can clear up confusion around this subject, it can’t hurt to include warm-ups in any training program and it may help.

Methicillin-resistant Staphylococcus aureus (MRSA, pronounced mersa) infection isn’t exactly a household name. But it’s becoming better known as it affects people of all ages, not just older adults in the hospital or a nursing home. It’s even been reported in healthy, young adult athletes.

MRSA is a bacterium responsible for difficult-to-treat staph infections in humans. It’s resistant to a large group of antibiotics including penicillin and cephalosporin drugs. That makes it a dangerous infection that can spread, even causing unexpected deaths in children and young adults. When it’s acquired outside the hospital or institutional setting, it’s referred to as community acquired MRSA or CA-MRSA.

CA-MRSA was first reported in a group of children back in the 1980s. Then the 2003 death of a college football player brought the disease to everyone’s attention. CA-MRSA starts as a simple skin infection. If it’s found early enough, it can be treated successfully with antibiotics. But if it’s undetected or ignored, the infection can become much more serious. Osteomyelitis (bone infection), necrotizing pneumonia (death of lung tissue), and sepsis (blood infection) can develop as a result of MRSA.

Risk factors for CA-MRSA include the overuse of antibiotics, crowded living conditions (including locker rooms), and open skin lesions. Locker rooms aren’t the only crowded areas where people are at risk for CA-MRSA. Prison inmates, soldiers and other military workers, children in day care centers, and any athlete participating in competitive sports are at increased risk for this condition.

CA-MRSA has become so common now that hospital personnel estimate it is present in 50 to 80 per cent of all skin infections seen in the emergency department. That means education and prevention are key factors in reducing the risk of this potentially deadly problem.

Hospital and emergency department staff must evaluate all patients for skin or soft tissue lesions that could be at risk for MRSA. Likewise, athletic trainers, coaches, team physicians, and even the players must know what to look for and how to prevent it.

A few simple steps can be taken in the locker room to reduce the spread of CA-MRSA. Hand washing and the use of hand gels are a must. Special anti-MRSA soaps have been developed. Players should not share (or even ask others to share with them) items such as towels, water bottles, shavers, or other personal items.

There’s no place in this environment for a quick shower. Players should soap down, wash, rinse, and towel dry after each workout. The showers, exercise equipment, and other areas athletes come in contact with must be disinfected on a regular basis. Those in charge of laundry should be instructed to use hot water and a hot dryer when washing the uniforms. There is a risk that the clothes will shrink, but this will help kill bacteria.

Anyone with a skin infection (especially one that is open, oozing, or draining) must have proper wound care and coverage of the site. Any lesions that can’t be covered will put the athlete on the bench until healing occurs.

The team physician must work with the coaching staff and athletes to ensure that antibiotics (when prescribed) are taken in the proper way. The appropriate antibiotic must be chosen. The correct dosage must be prescribed. And the athlete must take the medication as instructed. Many people stop taking the drug as soon as the most recognizable symptoms are gone. This type of drug-taking is one of the main reasons bacteria have become resistant to certain antibiotics.

Anyone who is planning to have surgery is at increased risk of MRSA. Scientists are actively looking for a way to kill off the bacteria before doing surgery. This process is referred to as decolonization. The method involves a decolonization agent. Such a chemical would reduce (or eliminate) the number of bacteria on the skin and keep it from growing again. Studies are ongoing trying to find the perfect agent to do both.

If you have gout (or are at risk for developing gout) do you have to restrict your diet? Is it okay to eat meat? Dairy products? Is protein helpful or harmful? If meat isn’t okay, what about seafood? Can alcohol and leafy green vegetables bring on an attack of gout?

These and other questions about the prevention and treatment of gout are discussed in this update on the condition. For years, dietary restrictions and advice have been at the forefront of managing gout. Studies over the last 30 years are starting to shed some light on the true evidence behind some of these recommendations.

Gout is a disease that involves the build-up of uric acid in the body. Uric acid is a normal chemical in the blood that comes from the breakdown of other chemicals in the body tissues. About 95 percent of gout patients are men. Most men are over 50 when gout first appears. Women generally don’t develop gout until after menopause. But some people develop gout at a young age.

Everyone has some uric acid in his blood. Excess uric acid causes needle-shaped crystals to form in the synovial fluid. As your immune system tries to get rid of the crystals, inflammation develops. For the person with too much uric acid, this inflammation can cause painful arthritis. Gout was the first disease in which researchers recognized that crystals in the synovial fluid could be the cause of joint pain. Synovial fluid is the fluid that the body produces to lubricate the joints.

We know that eating too much meat (especially organ meat) and seafoods high in protein and purine content increases the risk of a gouty attack. But is it the protein or the purine that causes the problem? Studies have confirmed it’s the purine content (not the protein) that’s causing the elevated urate levels in the blood.

On the other hand, dairy products seem to help reduce levels of urate in the blood. In fact, it looks like the combination of high protein and low purine levels in dairy products is what functions as a natural anti-gout diet. And although leafy, green vegetables are high in purine, eating them doesn’t seem to really be linked with an increased risk of gout.

And now for the beverages (alcoholic and nonalcoholic). Beer and hard liquor definitely increase blood levels of uric acid. The more alcohol is consumed, the higher the levels of serum urate, and the greater risk of gout. But there’s been a surprising finding about wine. Wine seems to lower serum urate levels. Whether or not red versus white wine works better and in what amounts remains a mystery for now.

Sugar may also be a key factor in the development of gout. Data supports a rising number of obese patients are developing gout these days. The introduction of high-fructose corn syrup in the 1960s has escalated these findings even faster. Sugar consumption in many and varied forms has increased dramatically in the last 50 years.

Sweeteneners are used now more than ever and in products previously sold without such sweeteners. Scientists have been able to pinpoint the complex mechanism by which fructose stimulates uric acid production. Once again, men seem more susceptible to the effects of beverages containing fructose (e.g., soda pop, sports drinks) as a potential cause of gout.

And finally, the link between caffeine (and especially caffeinated coffee) and gout has been investigated. It appears that coffee actually lowers serum urate levels — but not because it has caffeine in it. Some other chemical or factor is involved. Scientists aren’t sure what that is just yet.

There are drugs to prevent and/or treat painful gouty attacks. But they don’t work for everyone and they often have nasty side effects. And many patients have other health problems (e.g., diabetes, hypertension, kidney disease) that make it impossible to take the current drugs for gout.

So there’s a call for safer, more effective therapy for gout. What’s on the horizon right now? Well, the European Commission (like the U.S. Food and Drug Administration) has approved a new therapy called febuxostat. It lowers uric acid slowly enough to avoid flaring up the gout. It isn’t processed by the kidney, so it’s possible patients with kidney disease may be able to take it. But it is metabolized by the liver. Anyone with a liver problem or who abuses alcohol may not be able to take this drug.

When all else fails, there is a rather expensive ($8,000 per dose), but effective enzyme treatment (pegylated uricase) that may be helpful for rescue therapy. Rescue therapy refers to the patient with extreme, uncontrolled, and very painful gout for whom nothing else has worked. Once the worst of the problem has been treated, the patient can be switched to something else (one of the more standard treatments available).

Scientists continue to explore all avenues of possibility in seeking a way to prevent, treat, and/or manage gout. As new biologic agents are developed for other inflammatory conditions, these will be tried with patients who have gout. The hope is to find something that works quickly in order to offset the high cost of most new drugs.

In this study, researchers at one children’s hospital look back over the years at the incidence of musculoskeletal infections caused by methicillin-resistant Staphylococcus aureus (MRSA, pronounced mersa).

The purpose of the study was to see if they needed to update their treatment guidelines or do anything different at their hospital. This is an important step to take because of the increased number of patients these days needing treatment for MRSA. Not only are there more cases of MRSA-resistant musculoskeletal infections, they are more severe and affect more than one area of the body.

MRSA is a bacterium responsible for difficult-to-treat staph infections in humans. It’s resistant to a large group of antibiotics including penicillin and cephalosporin drugs. That makes it a dangerous infection that can spread.

The most common musculoskeletal problems caused by MRSA in children are highlighted in this article. These include infections of the spine, pelvis, or arms/legs caused by osteomyelitis (bone infection), septic arthritis (joint infection), cellulitis (skin infection), and pyomyositis (muscle infection or abscess). MRSA-related abscess anywhere else in the body were also reported.

The updated study was done by reviewing the medical records of children admitted to the hospital for a musculoskeletal infection. The time period selected was for the years 2002 through 2004. Anyone with a skin, muscle, joint, or bone infection was included. Data was collected on each child to help better understand how things might be different now from when this study was last done in 1982 (20 years ago).

The authors report over 3,000 children were included in the study. One-third of those children had cellulitis treated with an oral (taken by mouth) antibiotic. Another one-third had skin abscesses that required drainage and oral antibiotics. A small number of children needed intravenous antibiotics and hospitalization for abscesses or deep musculoskeletal infections.

They took a closer look at the 554 children with deep musculoskeletal infections. Almost half of the children in this group had osteomyelitis, another group had septic arthritis, a third group had deep abscesses, and the rest had pyomyositis. Antibiotics and surgical drainage were often the course of treatment.

Comparing this to data collected 20 years ago, there were almost three times as many cases of osteomyelitis during the 2002-2004 time period. Staphylococcus aureus was the cause in about half of the cases. Half the children with S. aureus had the kind that was resistant to the antibiotic methicillin (a type of penicillin). Some children had a combination of different infections involving bone, joint, and soft tissues.

There was no change in the number or type of cases of septic arthritis. Twenty children had pyomyositis. Half were resistant to methicillin. Most of the children with deep abscess only had one area of the musculoskeletal system involved. This was usually the groin, thigh, buttock, or foot. In a small number of cases, there were abscesses found in more than one place. Once again, methicillin resistant S. aureus was the major cause of these abscesses.

In this study, the types of musculoskeletal infection were grouped as described (bone, muscle, skin, other soft tissue) for future reference. Looking at the data in groups showed a linear trend. In other words, the severity was based on the location of the infection. This means that the cases involving bone were the most severe. Tissue involvement was the least severe when skin and soft tissue abscesses were present.

In order to make the distinction among these different musculoskeletal infections, careful diagnosis is required. Symptoms are often the same from one condition to the other. The physician must rely on advanced diagnostic imaging to make the final diagnosis and plan the correct treatment. The increased risk of a blood or lung clot with musculoskeletal infections also means the physician must monitor children with musculoskeletal infections carefully.

Twenty years from now, when the next update is done, it will be possible to use these categories to compare changes that have occurred or trends that are developing. The current diagnostic classification replaces the one used in 1982. At that time, everyone was divided into just two groups: osteomyelitis and septic arthritis (bone or joint infection).

The authors suggest that since there are differences in what occurs in one area of the country from another, it’s important that each institution conduct similar research for themselves. Comparing current trends with historical data for the same hospital helps each facility keep up with what’s going on in their own area. This type of research allows physicians to refine current treatment guidelines in their own facilities.

Twenty-five per cent of the American population are Baby Boomers. This means they were born between 1946 and 1964. They are active. They are unwilling to experience pain or disability. They are involved consumers interested in making their own choices. And they want total joint replacements sooner than later.

Many older adults expect to remain engaged in their favorite activities and sports — even after getting a hip or knee replacement. They want little or no pain or discomfort with the surgery and recovery process. They want the new joint to last a long time no matter what kind of abuse they dish out. And they don’t want to be told they can’t do what they want to, when they want to do it.

How realistic are all these expectations? Can seniors getting new joints throw caution to the wind and continue running marathons, engaging in daily activities, or participating in regular sports of their choosing?

In this review of athletic activity after joint replacement, the authors try to give patients and surgeons an idea what the experts are saying about safe and appropriate athletic activity after total joint replacement. They base their comments on information taken from several studies published on athletic activity after hip and knee replacements. They also used surveys of surgeons collected by the Hip and Knee Society.

In general, it looks like there is agreement that patients with total joint replacements CAN participate in demanding sports. Some of the high-demand sports patients were involved in included tennis, jogging, downhill skiing, racquetball or squash, and basketball. But it’s not clear whether or not it is wise to do so. Most surgeons advise avoiding these activities because of the high-impact loading and twisting motions required.

In some cases, patients’ preoperative expectations exceed their actual postoperative actions. Fear of damaging the implant, pain in other parts of the body, and pain at the site of surgery are mentioned as reasons why people don’t pursue their athletic goals. One study from UCLA showed that only about 11 per cent of the patients were engaged in strenuous work or sports after knee replacements.

The rate of return to sports activity is much higher with hip joint resurfacing. Hip resurfacing is a type of hip replacement that replaces the arthritic surface of the joint but removes far less bone than the traditional total hip replacement. The design features of the hip resurfacing may make it possible to be more active. At the present time, there aren’t enough studies to support safe return to high-demand sports activity after hip resurfacing.

Results of the Hip and Knee Society survey break down activities according to whether they are allowed by surgeons, allowed with experience, or not recommended. A separate category exists for activities for which there is no consensus (general agreement). Although this information is considered expert opinion, the authors point out it is not necessarily backed by evidence from published studies.

Experts advise surgeons to educate their patients about the risks of sports activities. Specific risks associated with particular sports should be discussed at length. Patients are encouraged to have fun but keep in mind the need to prevent injury and protect their new joints. Training is especially important. A rehab program under the direction of a physical therapist should include: back, hip, and knee rehab; core strength training; stretching and flexibility; and muscle strengthening.

The trend toward increased activity in the golden years (age 65 and older) may result in changes in joint implants and surgical techniques to meet all the Baby Boomers’ expectations. For now, there is concern about how long the available implants will last — especially when exposed to increased load and bearing surface wear from high levels of activity.

Physical therapists provide rehab and retraining for patients after severe leg injuries. Regaining normal motion and motor control, improving strength, and restoring kinesthetic awareness (sense of position) are some examples of what physical therapy addresses for these patients.

It makes sense that a program of this type is needed for patients with lower-extremity trauma. But what’s the evidence to back this up? In this study, physical therapists compare two groups of patients after severe lower-extremity injuries.

All patients in both groups were recommended for physical therapy. Some patients received physical therapy but others did not. The patients were divided into two groups. The groups were labeled patients with a met need (those who had therapy) and patients with an unmet need (those who did not have therapy). Recommendations for physical therapy were made by either an orthopedic surgeon or a physical therapist. This was done after an interview and evaluation by either of these health care professionals.

The researchers hypothesized that the patients who did indeed receive physical therapy would have improved recovery and better outcomes than the patients who did not receive physical therapy services.

Patients included in the study came from one of eight different level-one trauma centers in the United States. They had an injury to the lower leg (from the knee down). Patients ranged in age from 16 to 69. The injuries included bone fractures, crush injuries of the soft tissues, and injuries severe enough to consider amputation. Anyone with an actual amputation was excluded from the study.

Information collected about each one came from a database already in existence called the Lower Extremity Assessment Project (LEAP) study. Everyone was followed for at least two years. General information collected from the medical record included:

Surgeons beware: it’s up to you to use musculoskeletal allografts safely. Tissue used as grafts during orthopedic surgery from a donor source are called allografts. Almost all allograft tissues recalled for any reason have been musculoskeletal (e.g., tendons, bone, meniscus). The authors of this article investigate and report what’s going on. They provide surgeons with a safety checklist for the use of musculoskeletal allografts.

Tissue grafts are now under the regulation of the U.S. Food and Drug Administration. Before 1993, government regulation of this practice was lacking. Disease transmission through contaminated allografts became enough of a safety issue that something had to be done.

Besides bringing tissue transplants under the regulatory guidance of the FDA, there is also the Current Good Tissue Practice rule to improve and ensure tissue safety in the United States. The Joint Commission on the Accreditation of Hospital Organizations (JCAHO) and the American Association of Tissue Banks (AATB) have also published tissue safety guidelines. Improving public health and maintaining patient safety are the key areas of focus.

But with the one million musculoskeletal tissue grafts provided each year, problems can occur. The Centers for Disease Control and Prevention (CDC) has reported cases of bacterial and viral infections in donor grafts. The risk is small but there is some concern that the number of actual cases reported is less than what really occurs. Serious problems (including death) can occur with infections of allografts.

Using a search method of all databases, the authors of this report compiled a list of all recall reports for bone and soft tissue. Product type, manufacturer, and reason for recall were all categorized. Data from 1994 through the first half of 2007 was analyzed.

The results showed a trend for inadequate or improper donor selection. Processing errors accounted for some tissue recalls. Positive lab tests helped screen out contaminated specimens. Tissues are often processed carefully but they are not sterilized. Many of the tissue banks don’t have what is needed to conduct tissue sterilization.

The authors also made note of the fact that in 2005, less than 20 per cent of the 1,970 registered tissue banks had actually been inspected by the FDA. Other studies have shown an increased rate of infection the longer the time between the donor’s death and the time of tissue recovery from the deceased.

It also appears that the standard practice of using a surface swab to culture donor tissue is not enough. Recovery teams are advised to use techniques that require tissue samples to be extracted and destroyed in the testing process. Safety and accuracy are improved at the risk of losing some tissue.

Confirmed reports of HIV, West Nile Virus, Clostridium infections, and Hepatitis C virus (HCV) in donor tissue have resulted in new FDA guidelines. For example, as of August 2007, nucleic acid testing is required for all new tissue donors. This test will identify musculoskeletal tissues from donor tissue infected with HIV/HCV. The same test will be used to screen donor blood for HIV/HCV and West Nile virus.

What this study points out is that not all donor tissue is safe. Some tissue samples will be processed and make it to the shelf for use but they are still contaminated. Regulatory measures must be taken to ensure that all samples are properly screened, processed, sterilized, stored, and distributed. Sterilization procedures must be investigated and new sterilization techniques developed.

Overall, the regulation of tissue-banking companies is very poor. The FDA doesn’t fund regulation of the industry. Groups like the Joint Commission on the Accreditation of Hospital Organizations (JCAHO) and the American Association of Tissue Banks (AATB) provide guidelines but no regulation.

Therefore, until things improve, surgeons must be on the look out for potential problems. Besides conducting a checklist screening exam, careful surgical technique to avoid contaminating sterile donor tissue in the operating room is important. Here are some additional tips for surgeons:

A diagnosis of osteoarthritis (OA) affects both the patient and his or her partner or spouse. Both individuals face a number of challenges in adjusting to someone in the relationship having chronic, disabling pain.

In this study, self-efficacy for communication about pain for the patient and strain for the spouse is measured. Self-efficacy refers to the person’s confidence to do a specific task, communicate a particular idea, or achieve certain goals. The effect of holding back in discussions about the effect of pain and arthritis-related problems on the relationship was measured.

Patients (and their spouses) included in the study had knee osteoarthritis and attended the Rheumatology Clinic at Duke Medical Center in North Carolina. They all agreed to complete several surveys designed to measure self-efficacy in communication.

Measures used included Lorig’s Scale of Self-Efficacy, Pistrang and Barker’s questionnaire, the Arthritis Impact Measurement Scale (AIMS), Pain Catastrophizing Scale, the Positive and Negative Affect Schedule (PANAS), and the Caregiver Strain Index (CSI).

Each one of these tools measured various aspects of pain, psychologic distress, disability, mood, tendencies to catastrophize (exaggerate pain), and health status. For example, the Scale of Self-Efficacy for pain communication asked about patients’ confidence in telling their partner about their pain. Questions asked included, How certain are you that you can let your partner know how much your pain is bothering you? Or, How certain are you that your partner will respond to your pain in a way that meets your needs?

The questionnaire measuring how much patients and partners hold back in talking about pain-related concerns included 11 areas of interest. Feelings and concerns were measured in relation to pain, other symptoms, body image, fears and emotions, finances, and relationships with family and friends.

The Arthritis Impact Measurement Scale (AIMS) took a look at pain and disability (psychologic and physical disability). Anxiety and depression were measures of psychologic disability. Physical activity (including activities of daily living), movement and mobility, and manual dexterity were assessed when making a determination about physical disability.

The Pain Catastrophizing Scale was used to indicate how often and how much patients’ dwelled on their pain. It was a measure of symptom magnification and feelings of helplessness. At the same time, the partner’s mood (positive or negative) was measured.

The researchers compared self-efficacy with all of these measures looking for correlation or links between different variables. They found that both groups (patients and partners) scored low on self-efficacy. This means they both felt low in their confidence to talk about their adjustment to the patient’s pain and disability. Patients seemed to be able to communicate better than their partners in this regard.

Even though they doubted their own confidence in this area, both groups did not hold back from discussing their concerns with each other. Patients did tend to hold back more than their partners. When they held back, their levels of pain catastrophizing and psychologic distress increased. When the partner held back, their level of strain as a caregiver went up dramatically. And, when the partner held back, the patient experienced greater psychologic distress.

A vicious cycle was present: the lower the patient and partners’ self-efficacy (confidence in communication), the more they held back in talking about their concerns. The lower their self-efficacy and the more patients held back, the greater their pain catastrophizing and psychologic distress became.

Adjusting to a chronic and painful condition like osteoarthritis requires communication on the part of both patient and partner. The patient who can explain their pain well enough for the partner to understand seems to adjust better with lower levels of pain and disability. The adjustment goes even more smoothly when the caregiver is confident in his or her ability to manage the challenge of pain communication and strain in the relationship.

The authors suggest both partners might benefit from treatment aimed at improving communication. Training could help each one find ways to share thoughts and feelings in a non-threatening manner. Setting up shared goals and assisting each partner in responding to the other may help smooth out the adjustment phase. Improving confidence and skills in pain communication may reduce negative outcomes for both patient and partner.

Downhill skiing and snowboarding are popular winter sports in the United States. It’s estimated that there are over five million visits to ski hills and resorts per winter season. Despite the increasing popularity, increased safety awareness has resulted in an overall decrease in ski injuries over the past 50 years. Latest statistics show that the rate dropped from 7.6 injuries for every 1,000 ski days in the 1950s to 3 injuries per 1,000 days now. That being said, arm and shoulder injuries have increased from one in four injuries to one out of every two injuries. So, despite the improvement in injuries to the lower body, not much has changed with the upper body. If we compare snowboarding injuries to skiing injuries, we find that injuries of the arm happen twice as often in snowboarding over skiing.

An earlier study, by Dohjima and colleagues, looked at 2,552 snowboard injuries and 5,048 skiing injuries during one season. They found in snowboarders, the radius (the forearm bone in the innermost part of the arm) was broken in 48 percent of cases, while the humerus (the second forearm bone, more towards the outside of the arm) was broken in 7.7 percent of cases. The clavicle (collar bone) was broken in 15 percent. In skiers, however, the radius was broken only in 5 percent of the accidents.

The authors of this article wanted to investigate the risk factors associated with fractures of the humerus resulting from skiing and snowboarding. Their list of potential risk factors included the gender of the skier/snowboarder, snow conditions, experience in skiing or snowboarding, helmet use, cause of the accident, age, and the conditions of the day.

Patients who participated in the study were injured while skiing or snowboarding and they had been transported or presented themselves to a clinic at a base lodge at the bottom of a major ski area since the 1972/73 season (34 seasons total) for skiers and since 1988/89 for snowboarders (18 seasons). In all, there were almost 7 million skiers and over 700,000 snowboarders during this period. In all, among 18,692 ski injuries and 2,270 snowboard injuries, the researchers identified 327 humerus fractures, 49 snowboarders (2.2 percent of snowboard injuries) and 278 skiers (1.5 percent of ski injuries). However, although the number of snowboarder humerus fractures was smaller in total, they actually happened more frequently, given the shorter period of time (18 years versus 34 years) and the lower number of snowboarders.

Shoulder dislocations were also common. Among the skiers, there were 640 dislocations over the 34 years and 42 of them were associated with fractured humerus. Among the snowboarders, there were 56 dislocations over 18 years, but only one was associated with a fractured humerus.

The researchers analyzed the risk factors and found no differences between males and females in either skiing or snowboarding for fractures of the humerus, although when looking at all injuries, more female skiers than male skiers did get hurt. There wasn’t any difference in snowboarding. After the injuries, the patients were asked about the snow conditions, their skiing level (beginner through to expert), helmet use, cause of accident, age, and whether they were left sided or right sided.

The results showed that more humerus fractures and overall injuries occurred on dry powder/packed powder conditions for both skiers and snowboarders. Being a beginner or novice skier did not increase the risk of a broken humerus but the risk of an overall injury was higher in this group. Snowboarders, however, had a higher risk of both a humerus fracture or an overall injury if they were beginners or novice. Helmets didn’t affect humerus fracture in either group but it did lower the risk of overall injuries.

When looking at the causes of the accidents, there was a significant difference between skiers and snowboarders. Only 5.4 percent of broken humerus were caused by jumps in skiers, while 28.3 percent were caused by jumps among snowboarders. The average age of skiers who fractured the humerus was 37 years compared with the average age of uninjured skiers at 29.7 years. With snowboarders, it was 18.9 years for fractured humerus and 24 for those who had no injury.

The researchers looked at what side the humerus fractures were. Among snowboarders, most (71.4 percent) were on the left side, but only 53.8 percent were on the left side for skiers. Someone who leads with their left foot is considered to be regular footed. Among regular-footed snowboarders, 77.8 percent of the humerus were on the left. Wrist injuries, however, were more likely to happen on the right side of regular footers.

The study showed that snowboarders had a higher rate of humerus fracture than skiers, almost 50 percent higher. The authors of this article suggest that this may have something to do with the apparatus – a snowboarder is locked into the bindings, while a skier can release the bindings quickly. By not being able to get out of the bindings, the only way to break your fall is by putting out your arms. Because the falls are different, between snowboarders and skiers, the breaks are a bit different as well. Skiers tended to have breaks higher up in the arm, while boarders lower down near the wrist. As well, the locked in position and the sideways descent of snowboards contributes to the majority of humerus fractures being on the left, unlike skiers who are facing forward as they move down the hill.

The authors were surprised at the finding that powder/packed snow contributed to a higher risk of a fracture, considering that these fractures usually occur as the result of falling on a hard surface, such as ice. The age differences weren’t as surprising: skiers were generally older than average when injured and snowboarders younger than average when injured. Although they didn’t have data to support their thoughts, the authors feel that the ages could be due to younger snowboarders being inexperienced and more likely to fall, while older skiers may not have the flexibility and strength of the younger skiers.

More than 80 per cent of professional dancers will suffer some type of injury during their career. On any given day, the prevalence of injuries among professional ballet and modern dancers can be as high as 70 per cent. Almost half of all ballet and modern dancers report pain caused by chronic injuries. What can be done to reduce injuries and reinjuries?

In this review article, researchers from Canada take a look at all the articles on dance injuries published between 1966 and 2004. They found 32 studies of acceptable quality to study and analyze in an effort to understand dance injuries. This report called a systematic review is a summary of their findings.

Best-evidence of musculoskeletal injuries and pain in dancers is broken down into categories such as epidemiology, diagnosis, prognosis, treatment, and prevention. Epidemiology refers to characteristics of the dancers including age, gender, type of and dance. Years of dance experience, performance level, personality traits, and work dissatisfaction were also included.

Data on type of injuries, number of injuries, and services sought for care of the injuries was also collected, analyzed, and summarized. Information on hours in rehearsal and performance, stretching and flexibility training, and type of stage (angles or raked) was also collected.

The authors report most injuries are musculoskeletal affecting the soft tissues of the back and legs. Sprains, strains, tendon problems, and stress fractures from overuse are the most common. Most of the injuries are minor and do not require time off. Many dancers suffer from more than one injury at a time. Injuries are not always reported and/or treated.

This systematic review showed the difficulty of collecting data on musculoskeletal injuries and pain in dancers. Many of the articles were of low quality and couldn’t be included. The definition of injury was not the same from one study to another. Some studies didn’t even define injury. The type of dancers can vary widely, too (e.g., ice, modern, ballet, professional, preprofessional, theatrical, and mixed). most of the literature was focused on ballet dancers.

Statistical methods of analyzing factors were not always used. Different study designs provided only weak evidence to identify treatment methods that were effective. Despite all the inconsistencies in published research, there were some noticeable trends in dance medicine.

For example, dancers find the most help for their injuries from physical therapists. But they receive care from other specialists as well. They may see a primary care physician, massage therapist, acupuncturist, chiropractor, or osteopathic physician. Two studies did suggest that injury prevention and management may reduce total number of dance injuries and the related costs. And dance company morale was improved when there were fewer injuries.

Future studies are needed to collect data on the severity of dance injuries, extent of disability from injuries, and prognosis. More studies are needed on dance styles other than ballet. And analysis of many possible risk factors is needed to help identify ways to educate dancers about reducing risk factors to prevent injuries.

Osteoporosis (brittle bones) can be a devastating disease leading to vertebral compression and hip fractures. Postmenopausal women are affected most often. But a second group is also at increased risk. Anyone who takes corticosteroids over a long period of time for chronic conditions is at risk for corticosteroid-induced osteoporosis.

Corticosteroid therapy is a common treatment for asthma, inflammatory bowel disease, and autoimmune disorders. These drugs have adverse side effects that lead to osteoporosis. For example, corticosteroids decrease the amount of calcium available in the bloodstream and decrease the amount of bone formation. They also cause an increased amount of bone to be resorbed by the body.

Early measures to prevent osteoporosis in this group of patients are advised. The physician must assess each patient’s individual risk of fracture. They do this by first looking at the total daily dose of steroids in use. Any amount of steroid used daily is a risk factor for osteoporosis and fractures. But high-doses (over 10 milligrams per day) increase the risk of fracture even more.

How soon do these effects occur? Some studies show that fractures can occur early on when taking corticosteroids. Bone changes occur quickly. Others have found the risk to increase after 90 days of corticosteroid use. Taking daily doses of steroids has a greater impact on fracture risk than intermittent use. But there is a cumulative effect no matter how much or how often these drugs are used.

Some tips for prevention of corticosteroid-induced osteoporosis include: