Biomedical subjects
R L Swezey
Publications and source records attributed to R L Swezey.
Fibromyalgia: a risk factor for osteoporosis.
OBJECTIVE: To investigate associations of bone mineral density (BMD) and osteoporosis in patients with fibromyalgia (FM) and healthy controls. METHODS: Twenty-four women meeting the American College of Rheumatology criteria for FM (23 Caucasians, one Asian) were each compared to 2 age (+/-3 years) and ethnically matched controls by bone densitometry of the femoral neck and lumbar spine. The patients' ages were 33 to 60 years. No patient or control used steroids or other bone demineralizing agents. Simple T tests were used to compare hip and lumbar spine BMD of FM cases to controls by 3 decades (31-40, 41-50, 51-60 years). RESULTS: The patients with FM in all 3 decades had a lower mean BMD of the spine (p<0.05). The femoral neck BMD were also lower, but reached significance (p<0.05) only in the 51-60 age group. CONCLUSION: FM in this pilot study was frequently associated with osteoporosis. Early detection and implementation of appropriate nutritional supplementation (calcium/vitamin D), resistive and weight bearing exercise, and specific bone mineral enhancing pharmacological therapy may be indicated in pre, peri, and postmenopausal subjects.
The sacroiliac joint. Nothing is sacred.
One hundred years ago, the sacroiliac joint was considered to be the most common cause of sciatica; over time, however, it became increasingly apparent that the major back enterprise lay in disc extractions. Still, despite the lack of specific clinical tests, the same clinical symptoms suggesting lumbar disc and lumbar facet joint pathology may also justify consideration of the sacroiliac joint as the pain generator. Treatment approaches, including manual therapies, bracing, and exercises, may benefit both the facet and sacroiliac joints as well as intradiscal pathologies. The possibility of utilizing specific local intra-articular steroid injections into the sacroiliac joint may add another useful tool to the armamentarium of back pain relief strategies.
The management of rheumatoid nodules.
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Rehabilitation of the rheumatoid arthritic patient.
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Exercise for osteoporosis--is walking enough? The case for site specificity and resistive exercise.
Historic and clinical references obtained by general literature review and a medlars search from 1984-1994 on the impact of muscle strengthening on bone mineralization were reviewed and analyzed. The efficacy of site-specific resistive exercise on bone mineral enhancement and/or preservation as a supplement to weight-bearing exercise is documented. Previous reports demonstrated that resistive exercises enhance bone mineralization and play an equivalent, or perhaps greater role, than weight-bearing activities in the management of osteoporosis.
Comment on the American College of Rheumatology guidelines for osteoarthritis of the knee and hip.
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Chronic neck pain.
The disorders most commonly seen in rheumatologic practice are acute to chronic cervical disc-related strains, radiculopathies, and degenerative spondylosis. Inflammatory disorders including ankylosing spondylitis and rheumatoid arthritis, although generally rare, are not uncommonly seen in a rheumatologic practice. The pertinent anatomic and pathologic features of cervical disorders are examined in the context of their implications for the hierarchy of specific therapeutic interventions. The basis for the usually favorable prognosis for these conditions, particularly in response to a rational, structured, and phased conservative regimen, is delineated.
Bone densitometry: comparison of dual energy x-ray absorptiometry to radiographic absorptiometry.
OBJECTIVE: To assess the reliability and validity of radiographic absorptiometry of middle phalanges when compared to dual energy x-ray absorptiometry (DEXA) of the spine and hip as an indicator of osteoporosis. METHODS: DEXA readings from the spine and femur were compared with radiographic absorptiometry measurements obtained the same day in a sample of 50 women (average age 63 yrs; range 23-86). RESULTS: Both spine and femur DEXA scores were significantly correlated with radiographic absorptiometry scores (R = 0.70 and 0.68, respectively; approximate standard errors 0.08). DEXA scores were used as the standard, defining moderate fracture risk by a standardized t score < -2 and marked risk by t < -3. Using cutpoints of t < -2 for DEXA and t < -3 for standardized radiographic absorptiometry values, the sensitivity to osteopenia was 0.62 for DEXA of the spine and 0.63 for DEXA of the femur, with specificities of 0.90 and 0.96, respectively, at these cutpoints; the corresponding false positive and false negative rates for our cohort of women were 0.19 and 0.24 (spine) and 0.07 and 0.24 (femur). Receiver operating characteristic (ROC) curves were plotted, varying DEXA measurement site from spine to femur and standardized cutoff from -2 to -3; the areas under the resulting ROC curves ranged from 0.82 to 0.91. CONCLUSIONS: Radiographic absorptiometry holds promise as a practical method for screening for osteoporosis.
Obturator internus bursitis: a common factor in low back pain.
The presence of irritation of the obturator internus bursa (OIB) is identified as a common but thus far overlooked focus of myofascial irritability in association with low back pain. Eighteen of 50 consecutive patients with low back pain (36%) demonstrated the presence of tenderness at the anatomical site of the OIB. OIB was found in 11% of men and 43% of women. Nineteen of the 50 patients had regional myofascial pain; of these, eight (42%) had OIB tenderness. Palpation of the OIB will commonly reveal local tenderness in patients suffering from low back pain. In these patients, conservative treatment of regional myofascial disorders may be made more effective when therapy and/or local steroid injections are appropriately directed to the obturator internus bursa.
Pathophysiology and treatment of intervertebral disk disease.
Back pain is like quality--you know it when you see it--but it is hard to precisely identify and quantify all the factors that are responsible for it. Quality of care in back pain compounds this dilemma. Because we cannot often precisely identify specific causes of back pain (we are usually overwhelmed by an excess of putative factors) and we cannot often assess therapeutic results with precision (double-blind randomized studies of multivaried pathologic and psychologic factors and multiple coexistent therapies and compliance variables), assessment of treatment modes is extremely difficult. Nonetheless, we ultimately must treat the patient. Nihilism is unrealistic. The art and science of medicine must be integrated. Pseudoscience based on high-tech dazzle must be viewed with appropriate skepticism. Treatments must enlist patients' understanding of their options with carefully directed self-care and home therapies augmented when needed by proven safe treatments as well as reasonable, inexpensive, safe remedies still lacking proof of efficacy to help comfort and support the patient during the healing process. Surgical interventions, with a few exceptions, are a last resort and should be employed judiciously and skillfully by experienced surgeons. The surgeon also must be both knowledgeable and experienced in the conservative treatment of low back pain to know when conservative treatment has truly failed. Failure to profit from an investment in a poorly managed business does not mean that the business per se has no value but rather that the business can only prosper with committed qualified management. No less can be asked of conservative rehabilitative therapies before they have been judged a bankrupt failure. Conservative treatment of low back pain is not complicated, but it does require knowledge, skill, and persistence and the ability to recognize when its failure is the result of a lack of response to optimal therapy and when further therapy is procrastination, redundant, and wasteful of time, suffering, and resources.
Ankylosing spondylitis in nonhuman primates: the drill and the siamang.
Nonhuman primates are known to be susceptible to many of the arthritides that afflict humans. Psoriatic like spondyloarthropathies have been reported in gorillas and skeletal hyperostosis in gibbons, rhesus monkeys, and gorillas, and additional cases of both of these conditions occurring in drills (baboons) are noted in this report. One western lowland gorilla and two rhesus monkeys with clinical features consistent with ankylosing spondylitis have been documented previously. Two additional nonhuman primate species with radiographic evidence of ankylosing spondylitis are described. A siamang (gibbon) and two drills (baboons) with the classic radiographic features of ankylosing spondylitis, namely a bamboo spine and sacroiliac joint fusion, are reported.
Non-fibrositic lumbar subcutaneous nodules: prevalence and clinical significance.
Lumbar subcutaneous nodules (LSNs) have been associated with fibrositis but are distinct from painful myalgic trigger points and tender points. One hundred and twenty-six adults (53 males and 73 females) were examined for LSNs. LSNs varied in size from a +/- 3 mm 'corn kernel' (15/47) to +/- 5 mm 'pea' (21/47) to +/- 10 mm, 'grape' (11/47), occurred singly (22/47) and in clusters of two to seven uni- and bilaterally. Eight of 47 LSNs overlying the posterior superior iliac spines (PSIS) were tender. The results of a cross-tabular analysis using disease as the independent variable and presence or absence of LSNs as the dependent, found no differences (chi 2 = 1.06, df = 2). LSNs occur near the PSIS in approximately 25% of white adults, are rarely a cause of back pain, and should seldom require biopsy.
Rheumatoid arthritis: the role of the kinder and gentler therapies.
Rehabilitative therapies, as adjuncts to pharmacological and surgical therapies in rheumatoid arthritis (RA), help minimize pain and inflammation, improve functional capabilities, and, above all, enhance quality of life. The effects of heat, cold, and electrical stimulation on neurohumoral, inflammatory, and immunological mechanisms has been noted, although knowledge about their mode of action is lacking. There is, however, much that these modalities, in addition to splints, bracing, exercise, activities-of-daily-living training, and psychological, social, and vocational counseling can offer to reduce suffering and disability in patients with RA. Far more, however, needs to be learned to provide precise prescriptions and more effective applications.
Low back pain in the elderly: practical management concerns.
Low back pain occurs in 90% of the adult population. Previous episodes of low back pain in young adults predisposes to exacerbations and chronic problems in the elderly. Radiographic abnormalities demonstrating osteoarthrosis of the lumbar spine and facet joints and varying degrees of disk bulge and disk degeneration are the rule in both asymptomatic and symptomatic patients. Therefore, clinical assessments rather than purely morphological assessments are necessary to assess treatment plans and prognosis in elderly low back pain patients. Osteoarthritic changes are more often asymptomatic than symptomatic. CT and MRI demonstrations of spinal stenosis should be correlated with clinical findings to determine appropriate management decisions. Most elderly patients with low back pain with or without sciatica and with only radiographic CT or MRI rather than clinical evidence of spinal stenosis can be successfully managed conservatively.
Low back pain treatment: is a 'Yank' in King Arthur's Court or elsewhere as effective as traction, epidural injections or what else?
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Outpatient treatment of lumbar disc sciatica.
Of 47 patients with lumbar disc disease and sciatic radiculopathy (L-5 or S-1), 39 were successfully managed at home and as outpatients in an ambulatory care facility designed for the treatment of arthritis and back pain. When these patients were evaluated one to three years following discharge, they maintained their maximum level of activity and functional improvement noted at discharge. The average total cost per patient including physician's fees, x-rays, laboratory and therapy was approximately equivalent to the day rate for 1(1/2) days in hospital.
The modern thrust of manipulation and traction therapy.
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