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A consensus development conference sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the European Foundation for Osteoporosis and Bone Disease and the American National Osteoporosis Foundation was held in Copenhagen in October 1990. The consensus statement is presented (also published in Am J Med 1991; 90:107-10).
We present 5 young men who developed acne fulminans. During the acute, febrile illness, all had musculoskeletal symptoms, and X-ray and bone scan examinations revealed that 4 of the patients had osteolytic bone lesions. The disease was resistant to various antibiotics and one patient needed surgical trepanation of the sternum. No evidence of sepsis or bacterial osteomyelitis was found, as all bacteriological cultures proved negative and the tissue reaction was unspecific. The dermatopathogenetic origin of bone lesions in the present patients seems evident, but speculation that the etiology depends on immune mechanisms remains open.
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Magnetic Resonance Imaging (MRI) has had a significant impact on the diagnosis of musculoskeletal conditions. Technologic advances in the last years allowed the development of cost-effective, compact and easy-to-install MR systems. After an early phase to optimize the units, a 14-month multicentric study was performed to define the possible clinical applications of the system. The obtained data are reported by the authors in the present study to assess the diagnostic accuracy of the new MR system for the study of the limbs. The system consists of an 0.2 T permanent unit, weighting 800 Kg, with a built-in radiofrequency shield and 10 mT/m gradients. October, 1992, to February, 1994, 2437 limbs examinations were carried out in patients whose age ranged 5 to 83 years. In 93% of cases, the exam was performed to study one joint, mostly the knee. MR diagnosis was verified in 311 patients, who were subsequently submitted to surgery. Quite satisfying overall results were obtained, particularly in case of knee traumas, comparable to those provided by units with more potentials. The particular structure of the magnet allowed the comfortable management of the pediatric, aged and acute patients. Nevertheless, in 3% of the investigated knee or elbow conditions, the examinations could not be performed due to technical limitations related to magnet size. In addition, the authors believe that a limited field of view (11-16 cm) does not allow accurate staging of the malignant lesions involving soft tissue and bone, which require a wider locoregional staging.
There are many reasons to start an ergonomics program in a health care facility. The cost of injuries and the quality of service are two important justifications. Across all industries successful ergonomics programs have similar elements: management commitment, employee involvement, worksite analysis, hazard prevention and control, medical management, training, and evaluation. While injuries and quality are good ways to justify starting a program, the program ultimately must support the objectives of the administration. Therefore, the program must be planned in advance and measures used to show that the progress in ergonomics is consistent with the goals of the company. As the program expands by individual job and by department, it is important to remember that the goal of the program is to weave the knowledge and application of ergonomics into the fabric of the company culture.
Musculoskeletal diseases are one of the major causes of disability around the world and have been a significant reason for the development of the Bone and Joint Decade. Rheumatoid arthritis, osteoarthritis and back pain are important causes of disability-adjusted-life years in both the developed and developing world. COPCORD studies in over 17 countries around the world have identified back and knee pain as common in the community and are likely to increase with the ageing population. Musculoskeletal conditions are an enormous cost to the community in economic terms, and these figures emphasise how governments need to invest in the future and look at ways of reducing the burden of musculoskeletal diseases by encouraging exercise and obesity prevention campaigns.
Exercise and nutrition represent primary countermeasures used during space flight to maintain or restore maximal aerobic capacity, musculoskeletal structure, and orthostatic function. However, no single exercise, dietary regimen, or combination of prescriptions has proven entirely effective in maintaining or restoring cardiovascular and musculoskeletal functions to preflight levels after prolonged space flight. As human space flight exposures increase in duration, identification, assessment, and development of various effective exercise- and nutrition-based protective procedures will become paramount. The application of adequate dietary intake in combination with effective exercise prescription will be based on identification of basic physiologic stimuli that maintain normal function in terrestrial gravity, and understanding how specific combinations of exercise characteristics (e.g., duration, frequency, intensity, and mode) can be combined with minimal nutritional requirements that mimic the stimuli normally produced by living in Earth's gravity environment. This can be accomplished only with greater emphasis of research on ground-based experiments targeted at understanding the interactions between caloric intake and expenditure during space flight. Future strategies for application of nutrition and exercise countermeasures for long-duration space missions must be directed to minimizing crew time and the impact on life-support resources.
Prophylactic treatment from ages 2 to 18 years could prevent the development of hemophilic arthropathy if the concentration of the patient's deficient factor is kept from falling below 1% of normal. Early treatment is of paramount importance because the immature skeleton is very sensitive to the complications of hemophilia. Major hemarthrosis and chronic hemophilic synovitis should be treated aggressively to prevent hemophilic arthropathy. When advanced hemophilic arthropathy is present with severe disability, the aim should be to restore function while minimizing the risk to the patient. Joint debridement is an effective method to achieve this goal, especially around the elbow or ankle, and can be considered an alternative to knee replacement in the younger age groups. Proximal tibial valgus osteotomy is a reliable treatment method for painful genu varum of the mobile hemophilic knee. Supramalleolar tibial varus osteotomy is an attractive alternative to the more commonly used surgical option of arthrodesis. Finally, joint replacement can usually be relied on to restore both mobility and function in a diseased joint. The potential benefits of joint replacement must always be weighed against the long-term sequelae, however, especially loosening and consequent revision surgery.
Neuroprostheses with the use of functional neuromuscular stimulation (FNS) have the potential to restore elbow and shoulder function lost to paralysis because of spinal cord injury (SCI). The human shoulder is highly flexible and thus provides a large range of motion to the arm and hand, although at the expense of precarious stability of the articulations. The complexity of the shoulder has prevented widespread use of FNS at this joint. However, musculoskeletal modeling of the elbow and shoulder has the potential to significantly speed the development of neuroprostheses by allowing many mechanical issues to be resolved in simulation prior to implementation in human subjects. This paper describes our rationale for the use of musculoskeletal modeling, the model we are using, and several practical applications of the model to study the potential use of shoulder and elbow muscle FNS to restore function following cervical SCI.
Enhanced hepatocyte growth factor (HGF) receptor (Met) signaling has been suggested to play an important role in the development and progression of various epithelial and nonepithelial tumors. N-terminally truncated forms of the HGF receptor have been shown to be constitutively activated and tumorigenic in animal experiments. In the present study, 102 benign and malignant human musculoskeletal tumors were examined for expression of the HGF receptor by Western blotting and/or immunohistochemistry. A clear predominance of HGF receptor expression was seen in malignant as compared to benign tumors (Western blotting, P < 0.001; immunohistochemistry, P < 0.02). For the first time we show HGF receptor expression in the following four tumor types: dermatofibrosarcoma protuberans, clear cell sarcoma of tendons, malignant primitive neuroectodermal tumor, and benign fibrous histiocytoma. In three cases of sarcoma with high HGF receptor expression by Western blotting, we found indications of a short 85-kd N-terminally truncated HGF receptor that was tyrosine phosphorylated and located in the cytoplasm. Although fragments of this length were seen in 18 of 65 tumors, most were not tyrosine-phosphorylated. Northern blotting revealed only the 7.5-kb full-length HGF receptor transcript, suggesting that the 85-kd fragment is generated by an alternative initiation of translation or by proteolytic cleavage. Southern blotting detected no amplification of the Hgfr/Met gene in the 35 tumors examined, in contrast to our recent report of Hgfr/Met gene amplification in 7, 12-dimethylbenz(a)anthracene (DMBA)-induced rat sarcomas. The present data suggest that the locally aggressive and malignant properties of human mesenchymal tumors maybe related, in part, to high levels of full-length HGF receptors, and in some cases to the occurrence of N-terminally truncated HGF receptors, activated independently of HGF.
OBJECTIVE: To investigate the natural history and outcome of fetal talipes diagnosed by routine ultrasound scanning at 18-23 weeks' gestation. PATIENTS AND METHODS: This was a retrospective study of 103 228 pregnancies undergoing routine ultrasound scanning at 18-23 weeks' gestation. A computer search was made to identify all cases of fetal talipes and the records of these patients were examined to determine the incidence of other defects and pregnancy outcome. RESULTS: The incidence of fetal talipes following routine ultrasound examination was 0.10% (107/103 228) and was bilateral in 64 (59.8%) and unilateral in 43 (40.2%) cases. In 52 (48.6%) cases, talipes was of complex etiology, as it was associated with other defects, while, in 55 (51.4%) cases, it was classified as idiopathic. In 19% of cases, an initial diagnosis of idiopathic talipes was changed to complex, because of the subsequent development of associated features. Perinatal death and long-term neurodevelopmental or musculoskeletal problems were significantly more common when the talipes was complex rather than idiopathic (odds ratio, 150; 95% confidence interval, 34-665). Adverse outcomes were also seen more frequently with bilateral compared to unilateral talipes (odds ratio, 3.44; 95% confidence interval, 1.50-7.90). CONCLUSION: The outcome of antenatally detected talipes is mainly dependent on the presence or absence of other defects. A significant proportion of cases, thought to be idiopathic at presentation, will develop associated complex features when reassessed on subsequent scans or postnatally.
Because of the substantial increase of sick listing, reports of work disabilities and early retirement due to the musculoskeletal chronic pain, prevention studies at the work site are greatly needed. The purpose of the present study was to investigate the effects of a cognitive behavioural work site intervention on a group of public health workers judged to be at risk for developing chronic pain. Following baseline measurements, a group of 29 practical nurses with daily pain symptoms working at services for the elderly were randomized into two conditions: an active treatment based on cognitive behaviour therapy and a passive treatment based on traditional symptom alleviation. The two treatment conditions, provided by a registered nurse and a physical therapist, took place 30 min a week each once a week, on an individual basis for 4 weeks at the work site during work time. Results at 4 and 8 weeks and at 6, 12 and 24 month follow-ups showed improvements for those individuals receiving the active treatment with regard to the reduction of use of pain-killers, perception of one's self as being sick and the fear-avoidance response to work-related activities. A preliminary conclusion was that this short-term work site programme for the prevention of chronic pain for individuals at risk may be a promising development in the treatment of pain.
Computer modeling has had an undoubtedly enormous impact on the field of bone research in recent years. Development of advanced computer based models has permitted researchers to explore a vast area of musculoskeletal science from the complex biophysical stimuli at the cellular level to the mechanical behavior of heterogeneous skeletal structures. Furthermore, computer modeling has given significant impetus to the impressive progress of modern bone implant development. With recent advances in computers, faster hardware and increasingly sophisticated software, the prospects for the future of computer-based bone research appear more exciting than ever.
This paper extends the systematic approach described in Winters and Stark (62) for developing muscle models. The underlying motivation is our finding that for larger scale shoulder and head-neck postural systems to be mechanically stable, open-loop muscle properties are often not sufficient. There are three primary contributions. First, the previous muscle mechanical model structure and parameter estimation process of (62) is updated to reflect recent experimental findings. Second, an intrafusal (IF) muscle model is developed that includes a gamma static motoneuron (MN) drive, a Hill muscle model, and a muscle spindle sensor across the IF series element; this provides a more appropriate muscle spindle output signal, especially for studies of posture. Third, the conceptual cut between the neuro-control input and the actuator is raised from just below the MN summing junction to a higher location, allowing a "muscle-reflex actuator" to be defined that satisfies the formal theoretical requirement for possessing passive spring-like behavior when the neurocontrol input is constant, alpha-gamma MN coactivation is assumed, and three types of intrinsic autogenic reflex responses (spindle, Golgi tendon organ, Rhenshaw cell) are developed. Default feedback gains are set based on the criteria that inherent feedback should not sculpt the feedforward excitation drive by more than +/- 10% of maximum. This new actuator model only mildly affects voluntary goal-directed dynamic performance, but enhances spring-like performance around the postural equilibrium state, in line with available animal and human studies and with several theories on postural regulation.
Clinical practice guidelines (CPGs) should consist of treatment recommendations that assist hand therapists in providing high-quality cost-effective care to specific patients based on the highest level of available evidence. This requires CPGs to be developed using a rigorous process based on evidence, appraisal of both original studies and expert opinion, and a process for multiple reviewers to evaluate the draft CPG. This study identified CPGs relevant to hand therapy and then evaluated their quality using the AGREE quality assessment tool. The majority of guidelines were not evidence-based and were of extremely low quality. Two guidelines were produced using a rigorous process that emphasized comparative clinical trials. These were able to provide only a single treatment recommendation, that ultrasound is effective for calcific tendinitis of the shoulder. Hand therapists need to move away from opinion- or clinic-based protocols and toward more evidence-based treatment guidelines. However, the value of treatment guidelines must be tested, not assumed, regardless of the development process.
The efficacy of treatment for orthopedic trauma patients has improved slowly compared to advances in other areas of orthopedics, e.g., poliomyelitis, bone infection, microvascular surgery, and endoprosthetic devices. Further progress will only be possible by reappraising a number of traditional methods and opinions. In this regard, four proposals are noteworthy: (1) a transfer of attention from predominantly clinical to theoretical research; (2) clarification of terminology to enable effective computerization and development of automated search systems; (3) improvement of the quality of clinical research methodology, including the strict adherence to the requirements of statistical analysis; (4) development of quantitative estimates of locomotor system function and anatomy. A problem-oriented automated information search system and a quantitative method for assessing the anatomic and functional state of the locomotor system has been developed.
Horses competing in 3-day, combined-training events develop a metabolic acidosis that is partially compensated for by a respiratory alkalosis immediately after phases B and D. By the end of phase C and 30 minutes to 2 hours after phase D, the acidosis is resolved by the oxidation of lactate, and a metabolic alkalosis prevails. A reduction in TBW and cation content occurs, which often is not replenished 12 to 24 hours after the event, even though the serum or plasma concentration of various constituents may be within normal limits. Hypochloremia and hypocalcemia, however, may persist 12 or more hours after the speed and endurance test. All of the data cited in this article are from horses that successfully completed their respective tests. Nevertheless, some horses developed substantial fluid and cation losses. In horses that are not well conditioned or in competitions in which terrain, footing, or hot environments increase the thermal load or decrease heat loss, greater losses of fluids and electrolytes can be expected. Body weight losses exceeding 5% and cation losses exceeding 4000 mEq/L occur in endurance horses suffering from exhaustion and synchronous diaphragmatic flutter. In one study, two thirds of the Na+ lost during exercise-induced sweating in cool, dry conditions was replenished from salt supplements added to a balanced forage and concentrated diet. Consequently, horses in regular training and competition may benefit from salt supplementation. The composition of the salt supplement and the amount fed should be based on the composition of the horse's diet, degree of work, and environmental conditions. Horses competing in a 3-day, combined-training event may be expected to have persistent losses of weight and cations, particularly if conditions result in heavy sweating. Many horses in the field studies had minimal changes in weight and cation balance compared with pre-event values. The diet and electrolyte supplementation of the horses in the majority of these studies were unknown; consequently, no firm conclusions may be made regarding the degree of weight, water, and cationic losses. It is likely that the horse's large intestine serves as a reservoir for both fluid and electrolytes so that performance is not diminished, despite losses demonstrated consistently in treadmill studies. Horses that are inadequately trained or have other systemic or musculoskeletal problems or those that are competing in hot conditions may develop a variety of metabolic problems. It is hoped that knowledge of the fluid and electrolyte losses may help in treating horses with metabolic problems and, more importantly, in improving management of horses in training and competition to prevent any loss of performance.
We report on the construction and psychometrics of a survey measure of musculoskeletal symptomatology for use with Spanish-speaking immigrant farmworkers. Survey development included focus groups with workers, forward and backward translations, and pilot testing. The final survey includes a body diagram and items about symptom severity, frequency, and duration and about self-treatment, medical care, and job tasks. We report on the initial test of the survey with 213 commercial nursery workers in Southern California. Fifty-five percent of the workers reported pain, with 30% reporting back pain, 21% reporting upper extremity pain, 19% reporting lower extremity pain, and 10% reporting neck and shoulder pain. A composite symptom score exhibited acceptable test-retest reliability (r = 0.41, p < 0.01) over the annual agricultural cycle. Greater symptomatology was associated with greater frequency of self-treatment (r = 0.42, p < 0.01), seeking professional health care (t = 2.49, p < 0.05), and exposure to high-risk jobs (OR = 2.1, p < 0.05, CI = 1.0 to 4.4), supporting the validity of composite score.