News Category: General

In this review, two doctors from the Virginia Commonwealth University School of Medicine in Richmond, Virginia give a summary of the latest findings on osteoporosis. In particular, they reviewed the current status of drug treatment for this condition.

Calcium, vitamin D, and bisphosphonates are the most commonly used agents to prevent and/or treat osteoporosis. It appears that using vitamin D along with calcium has the best results. Postmenopausal women who normally have a low (or no) intake of these supplements seem to have the best results.

Taking vitamin D alone is not as good as taking it along with calcium. By itself, it does reduce the risk of falls in healthy older adults. They must be taken daily to improve bone strength and reduce the risk of fracture. It’s important to take enough of these supplements. How much you take depends on your age. For women, whether or not they are postmenopausal also determines how much to take.

A newer class of drugs called bisphosphonates is also available. This drug increases bone density. It also decreases the risk of fracture in adults who already have osteoporosis. Many people are familiar with Fosamax, a commonly prescribed bisphosphonate.

Newer bisphosphonates such as ibandronate and zolendrate are taken much less often. Ibandronate is given orally once a month. It can be given intravenously once every three months. A single dose of zolendrate has been shown to work for up to a year. It’s being tested further for its ability to prevent bone fractures.

There is a downside to these drugs. Studies show the benefit from taking these drugs goes away if the person stops taking it. Some patients have reported heartburn, stomach pain, and diarrhea with bisphosphonates. And recently, there’s been an increase in the number of cases of jaw osteonecrosis with long-term use of bisphosphonate.

Scientists are studying the best way to use drugs to treat osteoporosis. Combining parathyroid hormone (PTH) with bisphosphonates is one option. Using PTH first for a year or two and then taking bisphosphonates is also under investigation. Another method being studied is called cyclical therapy. In this treatment, different drugs are taken in a pattern of three months on, then three months off.

So far, combining drugs in any pattern has not shown to be better than taking one drug long enough to let it do its job. The cost must be considered. Who is more likely to benefit remains to be determined by future studies.

Vitamin D, which we can get from sunshine, some foods, and vitamin supplements, plays a significant role in reducing the risk factors of osteoporosis. Vitamin D is important for the human body because it increases the body’s ability to absorb the necessary calcium and phosphate needed for bone health. If someone is lacking in vitamin D, they can develop hyperparathyroidism and a loss of bone mass. They can also be more prone to fractures. However, calcium and vitamin D intake go hand-in-hand and the two need to taken in the right amounts in order to be absorbed properly.

When discussing how much vitamin D is needed to promote good bone health, there is debate among researchers. Studies have found that lower doses of vitamin D, 400 international units (IU) per day did not reduce the risk of breaking a bone, but higher doses of 700 IU to 800 IU per day did have a positive effect, reducing the risk of hip fractures by 29 percent and other fractures of bones not in the back by 23 percent.

Controversy does remain though in how effective calcium supplements and vitamin D are in reducing the risk of overall fractures. In one study done in Australia, researchers found that there was no significant reduction in fracture risks among women who took calcium supplements of 600 mg twice a day when they were compared with a group of women who took placebos, or sugar pills. In another study, the Women’s Health Initiative, researchers found that women who took 1000 mg of calcium along with 400 IU of vitamin D every day did improve bone density, but there wasn’t any significant decreases in hip fractures when compared with women who took placebos.

When looking more closely at the studies, some of the findings changed a bit. In the Australian study, women who took at least 80 percent of the supplements as they should have did show a reduced risk in fractures. The same sort of results were found in the other study when researchers looked at the women who also took at least 80 percent of the recommended supplements.

Vitamin D and calcium are not the only aspect of maintaining good bone health. A person’s lifestyle that includes not smoking, limiting alcohol intake, participating in weight-bearing exercise, and eating well, also plays a role.

Experts say that the usual recommended intake of vitamin D for healthy people is between 1200 and 1500 mg of calcium per day, and between 800 and 100 IU vitamin D per day.

Patients with osteoporosis who have had a fracture are often treated with medication, but which medication is chosen will depend on the effect desired. Physicians measure the bone mass density (BMD) of patients with osteoporosis to get an idea of how much bone loss has occurred and will also look at other risk factors. BMD is measured with a dual energy x-ray absorptiometry, or DEXA, scan. After the assessments, the physicians determine a t-score that provides the basis for treatment.

There are different guidelines regarding treatment of osteoporosis. The National Osteoporosis Foundation (NOF) and the American Association of Clinical Endocrinologists (AACE) say that at t-score of -1.5 or lower means that the patient should be treated if there are the additional risk factors of having had a fracture and older age. If the patients don’t have those risk factors though, this is where the controversy lies. The NOF guidelines say that people without the extra risk factors should only start treatment if their t-score is -2.0 or lower, while the AACE, and the World Health Organization, say that treatment should only start if the t-score is -2.5 or lower. It is also suggested that physicians look at other factors, such as the patient’s family history and current lifestyle.

When prescribing medication, there are two categories from which to choose: anabolic agents and anticatabolic agents. The first group, the anabolic agents, help increase bone formation while the second group decreases bone resorption (breakdown). There is only one medication, teriparatide, that is approved as an anabolic agent for the treatment of osteoporosis. Patients with Paget’s disease, unexplained high levels of alkaline phosphatase, and other skeletal disorders shouldn’t take this medication.

In the second group of medications, there is more choice. Some medications are for the prevention of osteoporosis, while some are for both prevention and treatment. This group includes a hormone called salmon calcitonin, a drug called raloxifene, and several bisphosphonates. There are side effects associated with bisphosphonates that can make them difficult for some patients to take. If a patient has a history of kidney problem, low calcium, or gastrointestinal disorders, they may not be able to take them.

Studies of all of these medications show promise in helping to prevent and treat osteoporosis. The long-term safety data show that the drugs appear to be safe, although there have been incidences of osteonecrotic jaw, or dead bone in the jaw, but it is rare.

The author concludes that treatment with medication should be started immediately in patients with osteoporosis who have broken a bone. She adds that the DEXA scan isn’t necessary before treatment, but she be done as soon as is possible.

Since 1994, osteoporosis has been diagnosed based on bone density measurements. Treatment is started when the score for bone density drops below -2.5. This score means the person’s peak bone density is two and a half standard deviations below the average peak bone density in young adults.

But new guidelines have been made recently. Studies show that using bone mineral density (BMD) alone may not be enough. Fractures can and do occur in women who have normal BMD. And there may even be more fractures in groups of people with low bone mass. These are men and women who are not yet osteoporotic.

Low bone mass of this type is called osteopenia. The increased number of fractures in adults with osteopenia may occur simply because there are more older adults now than ever before. And more older adults have osteopenia than ever before.

The World Health Organization (WHO) suggests using the BMD along with clinical risk factors to predict the risk of fractures and to guide treatment. The two most important risk factors for bone fracture are age and previous history of bone fracture. Other important risk factors include the use of medications such as corticosteroids, cigarette smoking, and daily alcohol use (more than two drinks per day).

Combining clinical risk factors with BMD may help identify people who are at moderate risk. For regions where BMD testing isn’t available, then the risk factors can be used to guide treatment. In fact, the clinical risk factors can be used to predict the chances of having a hip or other fracture over the next 10 years.

In this article the clinical presentation, natural history, and diagnosis of gout are reviewed. Gout is a disorder of uric acid metabolism. Urate crystals are produced and deposited in the joints. The joints respond with an inflammatory reaction. The size of the deposits can increase until they burst through the skin.

Early diagnosis and treatment have helped reduce the painful joints often associated with gout in the past. Blood test for urate levels and X-rays are the most helpful diagnostic tools. Not everyone with high uric acid levels have signs and symptoms of gout. Treatment is not applied until uric acid is more than nine mg/dL.

There are four stages of gout. Each one is reviewed with X-rays to demonstrate changes seen. The exception is asymptomatic hyperuricemia, which does not show any differences on X-ray.

Acute gouty arthritis is the most common stage. The patient has one or more painful, hot, red joint(s). X-rays show soft-tissue swelling and places where the bone has been eroded. Thinning of the bone can occur. Bits of bone can form inside tendons, a process called calcification.

Some patients have quiet periods called intercritical gout when they don’t have any symptoms. Others enter a phase of chronic gout affecting more than one joint. Bone changes in this phase are very clear on X-ray.

Deposits of urate crystals in the soft tissue called tophi are seen on the X-rays. Overhanging edges of bone from bone erosion are clearly seen. Areas of bone erosion often look like holes punched out of the bone.

The authors provide more than a dozen X-rays with descriptions to help physicians make the diagnosis. They describe how gout looks different on X-ray from other conditions such as osteopenia, osteoporosis, and rheumatoid arthritis.

X-rays aren’t always specific enough during an acute attack. In those cases, the physician relies upon lab values and the patient’s response to treatment.

More and more health groups are advising people to get the right amount of physical activity and exercise. This is set at 30 minutes each day. The activity should be of moderate-intensity. This means it should be intense enough to increase your heart rate. You should break out into a slight sweat.

But what about the weekend warrior? Is it enough to get in four or five hours of activity in one or two days to offset an inactive work week? In this study, researchers from the Centers for Disease Control and Prevention (CDC) take a look at the weekend warriors.

First, they used two national surveys to identify how many people fall into the category of weekend warrior. A weekend warrior was defined as anyone who reported at least 150 minutes of physical activity. That activity is moderate in intensity (or more). And it’s done on one or two days of the week.

They found about one to three per cent of the adults could be called weekend warriors. The age group most commonly in this category was 45 to 64 years old. Men were more likely to be weekend warriors than women. They said juggling families (children and parents) and work requirements just didn’t leave enough time to exercise every day.

The authors expected to find a higher number of people defined as weekend warriors than they did in this study. They reported some major problems with the research methods and advised that further studies should be done.

Future research should focus on identifying any benefits there may be of low-intensity activities compared to more strenuous levels. A survey with more specific questions would be helpful.

During the second half of the 20th century, in many parts of the world the human diet that was generally plant-based became animal-based. The World Health Organization has reported that these alterations in diet have strong effects on human health.

Physicians are trained about the actions of the medications they prescribe, but many don’t have an in-depth knowledge of nutrition. However, if diet is affecting chronic illness or pain, then diet and nutrition may need to play a larger, more prominent role in health care.

This editorial briefly reviews the findings of a few early studies that found certain food groups were affecting study outcomes. In one study, patients with rheumatoid arthritis who fasted for a short while and then ate a vegetarian diet appeared to have clinically relevant improvement in their disease.

It’s known that certain herbs and spices have properties that can affect health, even causing death. One compound, resveratrol, is found in grapes, berries, and peanuts. It has both an anti-inflammatory effect as well as an antioxidant effect. Antioxidants may reduce the chances of developing certain kinds of cancer.

Fruit juice and caffeine are common among many diets. It wasn’t long ago that researchers determined that certain medications were greatly affected if patients took them while drinking grapefruit juice. Some medications were affected to the point that they could be toxic. As a result, there is now a list of medications that should not be taken with grapefruit juice. While other juices don’t seem to have the same effect on medication, one type of orange juice that is made with Seville oranges, may be somewhat similar to grapefruit juice.

Caffeine is found not only in coffee and chocolate, but can also be in tea, soft drinks and some medications. Caffeine can work against the effects of some medications, like methotrexate. On the other hand, caffeine is often put into medications that are for pain relief because of its added benefit.

The author concluded that if dietary interventions are an option in treating of preventing some illnesses, then this could be a promising area for future medical care.

Osteoporosis is a concern for older adults. Osteoporosis is a loss of bone mineral density (BMD). Loss of bone mass increases the risk for fracture. The Surgeon General has said that Tai Chi is a good exercise to maintain bone density and to prevent falls.

In this report, researchers review studies on Tai Chi. They target postmenopausal women with low bone mineral density (BMD). They also offer ideas for future studies to assess the benefits of Tai Chi on BMD.

Tai Chi is an ancient Chinese form of martial arts. It includes breathing, movement, and meditation. Shifting weight from side to side can help with balance and the mechanical load placed on the joints needed for good joint health. Arm movements help improve natural arm swing while walking. Many other benefits of Tai Chi have been reported.

After reviewing the studies of Tai Chi for reducing rates of BMD loss in postmenopausal women, here’s what they found:

In this article, The American Lyme Disease Foundation (ALDF) offers a brief summary of the updated clinical practice guidelines for Lyme disease. These guidelines were developed by the Infectious Diseases Society of America (IDSA). The update was published late in 2006.

The guidelines have the latest information on Lyme disease. An expert panel updated the previously published 2000 guidelines. They based the changes on current evidence-based medicine. The complete guidelines are available on-line at www.idsociety.org.

Some of the new or updated recommendations include:

The transition from active work life to retirement can be a hard time for many
people. Professional athletes, who spend their work days with intense devotion to fitness and competition, may find that transition difficult, particularly if the retirement wasn’t their idea, such as the result of being released from a team, or after being injured.

Researchers wanted to learn of the difficulties encountered by some professional athletes as they moved from active playing to retirement. The
researchers sent out questionnaires to 3377 retired National Football League
players and they received 1617 usable responses.

The survey covered issues such as how the former players had adapted to retired life, if they were experiencing financial or marital problems, if they
received any help, and what or how they would like to receive for assistance if they needed. The questionnaire also measured depression symptoms using the PHQ-9, a nine-item patient health questionnaire.

When the results were interpreted, the former players were split into three groups for causes of retirement: 557 said they were cut from the team, 559 said they chose to retire, and 470 sustained an injury that forced their retirement.

Almost half of respondents (48 percent) reported that they had difficulty with pain after retirement. This complaint was followed by 29 percent who complained of loss of fitness or exercise, 28 percent each of weight gain and trouble sleeping, and 27 percent each of difficulty with getting older and adjusting to life after football. The researchers found that those respondents who reported moderate to severe depression also were the least likely to seek help. Many felt that the help wasn’t available, that family and friends wouldn’t understand or that they would seem weak, or that the issues weren’t as serious as they might be.

There is already a known connection between depression and chronic pain within the general population. These researchers reviewed almost 60 studies about the association of pain and depression, and found that approximately two-thirds of patients with major depressive disorder also reported significant pain. It was also found that around 50 percent of patients who visited chronic pain clinics, also had depression.

Depression scores from the former football players were compared with their pain scores. Of all the respondents, 10.9 percent reported that they had increased scores in both pain and depression; 37.2 percent had an increase in pain but a decrease in depression; 4.0 percent had a decrease in pain and an increase in depression; and 48 percent had a decrease in both pain and depression scores.

The researchers concluded that retired football players may be at higher risk of developing depression and having a difficult time adapting to retirement. The chronic pain, the change in lifestyle and their perceived barriers to seeking help, could contribute to significant disability and maybe even suicide in a small group of ex-players.

They recommend that players be prepared for retirement while they are still
actively playing, allowing them to anticipate what could happen after
retirement and how to seek help if their retirement occurs suddenly and earlier than anticipated.

Physicians often specialize in medicine and even subspecialize. In the field of orthopedics, sports medicine is becoming a subspecialty with certification. In August of 2007, the first ever review course for certification in orthopedic sports medicine will be offered.

In order to prepare for that course and keep up with what’s happening in the field of sports medicine, this article reviews the latest on the topic. The authors reviewed the results of studies presented by over 200 orthopedic surgeons.

The focus was on problems in sports medicine involving the knee, shoulder, elbow, spine, hip, foot, and ankle. In addition to the treatment of sports injuries, injury prevention is also discussed. Special problems faced by female athletes and military recruits gets a brief mention.

Knee injuries are by far the most common sports injuries. Anterior cruciate ligament (ACL) rupture and repair gets a lot of attention. Major topics include choices of tendon graft material and fixation methods. Complications, advantages, and disadvantages of each type of graft remains the main feature of many research studies.

Other knee problems discussed involving ligaments include posterior cruciate ligament and medial collateral ligament injuries. Nonoperative treatment is more common for these injuries. What’s the best thing to do when both the ACL and the medial collateral ligament are torn remains an unanswered question. The timing of ligament reconstruction (early versus late) is a key issue. The authors report there hasn’t been much improvement in treatment outcomes in this area.

Preserving the knee meniscus remains a goal of treatment. Various repair methods are reviewed. Damage to the joint from screws and arrows used to repair the meniscus has led to new, more flexible devices. So far, only short-term results are available but show good outcomes.

Labral tears and rotator cuff problems are the two main shoulder injuries treated in athletes. Improved technology has made it possible to identify the size, shape, and location of these injuries. As a result, surgeons can treat more efficiently.

In other areas the authors report that repair of wrist fibrocartilage tears is on the rise. Treatment of tennis elbow and Achilles’ tendon injuries remains a challenge. Ankle sprains can be reduced with proper balance training. A brief summary of four other articles related to sports medicine was included to help guide surgeons specializing in sports medicine.

In this study, researchers from Johns Hopkins University compare death rates, complications, and costs for three types of joint replacements. Hip, knee, and shoulder arthroplasties were included for patients with osteoarthritis (OA). Arthroplasty is the medical term for joint replacement.

Data was taken from Maryland hospital discharge records for the years 1994 to 2001. More than 500 surgeons from 60 hospitals were included. Types of information collected included age, sex, race and insurance type. Length of stay, in-hospital complications, and in-hospital mortality (death rate) were also compared.

They found most patients were Caucasian (white) with an average age of 69 years. However, patients ranged in age from 24 to 94. Patients having a total shoulder arthroplasty (TSA) were older and less likely to use Medicaid insurance.

There were more problems after total hip arthroplasty (THA) or total knee arthroplasty (TKA) compared with TSA. Patients with complications were more likely to be 65 years of older, male, and nonCaucasian. Patients with other health problems were also more likely to have post-operative complications.

Overall the data showed that TSA was safe with half as many complications as the THA or TKA. With shorter hospital stays, costs were less with TSA as well.

In this review article, orthopedic surgeons describe changes in the way older adults walk and what might be causing these changes. The way we walk is called our gait pattern. How to evaluate a patient with a gait abnormality is described. Common problems seen by the physician are outlined and discussed.

Gait changes occur in older adults, usually by age 65 and increasing by age 85. Sometimes people just slow down and shorten their stride length and speed. For other people, the fear of falling results in a wider base of support.

Muscle weakness of the hip can lead to waddling. Spinal stenosis, a narrowing of the spinal canal where the spinal cord is located, can cause a forward stooped posture during gait. Arthritis, stroke, Parkinson’s disease, and dementia are just a few of the other conditions that can lead to gait changes in the elderly.

Sometimes, but not always, it’s possible to look at how someone walks and recognize what caused the change. However, when the cause is unknown, the physician must rely on the patient history, a physical exam, and imaging studies to identify the underlying problem.

Treatment of gait disorders is the work of a physical therapist. Falls assessment and prevention is a major part of the program. Strength training, balance and sensory training, and making the home safe are important components of the program. Participation in any exercise program but especially tai chi or yoga has been shown to help improve balance and reduce falls.

Medically-induced problems are handled by the physician. Medications known to increase the risk of falling must be evaluated and monitored. Vitamin B12 deficiency can cause gait changes and is easily treated with supplements. Surgery such as hip and knee joint replacement or spine surgery to remove a disc or take pressure off a spinal nerve may be needed for some patients.

In this study, physical therapists from Australia compare two groups of adults with hip or knee osteoarthritis (OA). All participants were at least 50 years or older and had pain, difficulty climbing stairs, and trouble getting in and out of the car. Everyone was assessed before and after treatment.

One group received twice weekly hour-long sessions of aquatic physical therapy for six weeks. An experienced aquatic physical therapist instructed each class. Special attention was paid to posture, muscle contraction, and trunk control.

The second (control) group did not have any pool therapy for the first six weeks. They were offered this option after the study was over. This group was advised to continue their usual daily routines for six weeks. They were asked not to begin any new exercise program or other treatment for OA during this time.

After six weeks, the groups were examined again. Pain on movement, physical function and activity, balance, and muscle strength were measured. Quality of life was also assessed. The difference in results between the two groups was striking.

Three-fourths (75 per cent) of the aquatic group reported improvements. Only 17 per cent of the control group had similar improvements. Pain was reduced and function improved by 33 per cent in the aquatic group. Hip muscle strength and quality of life were also greatly improved in the aquatics group.

The aquatic group was 12 times more likely to report overall improvements compared to the control group. Many of the participants in this group continued with the pool program on their own after the study was over.

Osteoarthritis (OA) of the knee is common in older adults around the world. In this study from Thailand, researchers explore the link between lifelong floor activities and knee OA. Floor activities included squatting, lotus position, side-knee bending, and kneeling. Side-knee bending is sitting on the floor with both knees bent and one leg (hip) turned in and the other rotated out.

Nurses conducted a survey of 288 women and 288 men from southern Thailand who were over the age of 40. Average daily duration of these four floor activities was recorded. Based on the number of minutes per day in each position, the researchers calculated the average lifetime floor activity exposure for each person.

Other data collected included age, body mass index (BMI), and tobacco use (smoking). They found the lotus position was the most common floor activity. Side-knee bending was next. Average time in floor activity each day was about one hour for all subjects.

There was a positive link between lifetime floor activity exposure and knee OA. People who spent the most time in squatting, lotus, and side-knee bending had twice the risk of knee pain and OA. The risk of OA increased with age in women who were overweight.

Using X-rays, the researchers matched the type of arthritic problem with the positions used most often. The effect of these positions appears to be on the entire joint, not just one side or the other.

The authors suggest these finding show that habitual flexed positions of the knees can overload the joint. The result is damage to the meniscus and/or the joint cartilage. All of these changes may lead to OA. Changing or avoiding floor activities may help reduce the risk of knee OA in this group of southeast Asians.

Despite billions of dollars spent every year on the treatment of low back pain (LBP), the cause of that pain remains a mystery. Researchers are actively seeking an understanding of the way the spine works.

In this study, electromyographic (EMG) activity of the muscles was used to compare trunk extension strength before and after an exercise program. The subjects were a group of amateur tennis players with and without LBP. The authors looked at patterns of muscle flexibility, neuromuscular imbalance, and spinal mobility.

The athletes were given daily exercises to do for seven weeks. The exercises included strength, mobilization, coordination, and stretching of the trunk and low back. No weight training or resistance exercises were allowed during this period.

Before the exercise program, 85 per cent of the athletes with LBP had neuromuscular imbalances of the erector spinae (ES) muscle. The ES is a large muscle mass on either side of the spine. Only 25 per cent of the athletes without LBP showed signs of imbalance. And a small number of athletes without LBP tested positive for neuromuscular imbalance.

Both groups had increased extension strength after exercise. Analysis of the data before and after showed that neuromuscular imbalance and trunk extension strength were not linked. Flexibility of the ES was much more important to LBP. There was a strong relationship between neuromuscular imbalance and LBP.

The most important finding from this study was that right-handed players had lower muscle activity in the left ES and vice versa. The authors aren’t sure if these imbalances came before or after the LBP. The good news is that the imbalance can be corrected through a reconditioning exercise program.

Patients with rheumatoid arthritis (RA) are two to four times more likely to have osteoporosis compared to the general population. This means they are also at greater risk of hip and vertebral fractures.

In this report, Dr. Kevin Deane from the Rheumatology Division at the University of Colorado Health Sciences Center (Denver) discusses the topic of osteoporosis in RA. Osteoporosis is a decrease in bone density or mass. Doctors must know how to prevent this problem. It’s also important to recognize when it happens and treat it early.

Patients with RA are often given corticosteroids to reduce inflammation. These drugs cause bone loss leading to osteoporosis. Corticosteroids also weaken bone putting the patient at risk for fracture.

Dual-energy X-ray absorptiometry (DEXA) is still the best way to measure bone density. DEXA scanning should be done in premenopausal women to establish a baseline. Anyone with RA who is planning to go on corticosteroids should also be tested. DEXA scanning of all patients with RA is advised (men and women, with or without corticosteroids).

Steps to prevent OA include: stop all tobacco use, reduce amount of alcohol, and increase weight-bearing exercise. Patients should be on the lowest dose of corticosteroids at all times. Other drugs used to control RA-related inflammation also help reduce bone loss. These include anti-tumor necrosis factor (TNF) and disease modifying antirheumatic drugs (DMARDs).

Doctors should also recommend calcium and vitamin D supplements for all patients with RA. Bisphosphonates are prescribed to prevent bone loss if DEXA scanning shows bone density loss.

For anyone with continued bone loss despite all measures, parathyroid hormone (teriparatide) can be given. Dose and duration of therapy and precautions for use are discussed. Testosterone levels in men with RA and osteoporosis should be checked and treated if low.

Health care professionals often rely on patient report of pain and function to assess their status. Self-report may not be accurate. In this study, physical therapists in Canada measure the validity of four specific tests as a better measure of pain and function in adults with osteoarthritis (OA).

The four performance activities are well-known to physical therapists. They include 1) 40-meter Walk Test (self-paced), 2) Stair Test, 3) Timed Up & Go Test (TUGT), and 4) Six-Minute Walk Test. All patients had either hip or knee OA and were on the waiting list for a joint replacement. After each test, patients reported the amount of pain and level of exertion they felt.

The authors suggest that self-report measures may be less expensive and easier to give but they don’t really measure physical function. Self-report tests are affected by patients’ ability to move around and how they feel (pain, exertion) when moving around. Many patients report higher physical function than they really have.

The results of this study showed that three of the four tests were a better measure of pain and function than self-report. The Stair Test did not help give a distinct measure of pain and function. The authors warn that a patient’s ability to manage stairs is still important and shouldn’t be neglected.

Measuring pain and function in patients with OA is important. The information helps guide treatment. The results give feedback on progress. Insurance companies can use these benchmarks to set a reasonable number of maximum patient visits.

Using self-report alone overestimates patients’ status and may cut off treatment too soon. The Walk Test, TUGT, and Six-Minute Walk Test are valid measures of physical function in adults with OA and should be used along with self-report tests to gain a better view of a patient’s true function.

New and better treatment for rheumatoid arthritis (RA) is on the horizon. In this article, physicians from the New York Hospital for Joint Diseases review current and future drugs used in the treatment of RA.

Research has made it clear that early treatment of RA has the best results. And if the drugs used aren’t working, a switch is advised without delay. A new class of drugs called disease-modifying antirheumatic drugs (DMARDs) has made a big difference in the outcome of this condition.

DMARDs actually slow the disease progression. Treatment improves symptoms and quality of life. Daily activities and function are improved. Even long-term effects are better.

Methotrexate (MTX) was the first DMARD used in the mid-1980s. Then in the late 1990s, tumor necrosis factor (TNF) inhibitors were discovered. TNFs used along with MTX made remission from RA possible.

More recently, new drugs to modify the immune system response to RA have been introduced. Abatacept and Rituximab are two promising medications for RA management.

Other new agents are still in clinical trials. These immune system modifiers include HuMax-CD20, Belimumab, Atacicept, Tocilizumab, Centrolizumab, and Golimumab. The authors of this article discuss the mechanisms by which each of these drugs works. Research results with each one are summarized to date.

Most likely, these newer drugs will help the 10 to 15 per cent of patients who do not get good results from MTX combined with TNF inhibitors. Aggressive treatment is the new standard for RA. Early intervention does reduce long-term problems, including death.

In this article four cases of Lyme disease presenting as a popliteal cyst in children are reviewed. A popliteal cyst is a fluid-filled sac behind the knee. The children all presented with chronic knee swelling but no other signs or symptoms.

This is a rare symptom for Lyme disease. Most patients present with a rash, flu-like illness, headache, or stiff neck. Single joint arthritis is not uncommon. The knee is affected most often. Some, but not all, patients are aware of a tick bite (the cause of Lyme disease). These four children had no awareness of a previous tick bite.

Treatment was with oral antibiotics. Symptoms did not go away for three of the four patients and intravenous antibiotics were needed. One child had a steroid injection when the antibiotics didn’t clear up the joint swelling. Everyone was able to regain full knee motion.

The authors advise other physicians to consider Lyme disease as a possible diagnosis for children with popliteal cysts. This is especially true for children living in areas where Lyme disease occurs. Early diagnosis and treatment are needed to avoid long-term problems that can occur with this disease.