Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial

BACKGROUND

There have been few randomized controlled trials evaluating nonoperative treatment of proximal humeral fractures. To investigate shortening the period of dependence, we assessed the feasibility and efficacy of early mobilization of the shoulder (within three days after the fracture) in comparison with those of conventional three-week immobilization followed by physiotherapy.

METHODS

We randomly assigned seventy-four patients with an impacted proximal humeral fracture to receive early passive mobilization or conventional treatment. The primary outcome was the overall shoulder functional status (as measured with the Constant score) at three months. The secondary outcomes were the Constant score at six weeks and at six months, the change in pain (on a visual analog scale), and the active and passive range of motion.

RESULTS

At three months and at six weeks, the early mobilization group had a significantly better Constant score than did the conventional-treatment group (between-group difference, 9.9 [95% confidence interval, 1.9 to 17.8] [p = 0.02] and 10.1 [95% confidence interval, 2.0 to 18.1] [p = 0.02], respectively) and better active mobility in forward elevation (between-group difference, 12.0 [95% confidence interval, 1.7 to 22.4] [p = 0.02] and 28.1 [95% confidence interval, 7.1 to 49.1] [p = 0.01], respectively). At three months, the early mobilization group had significantly reduced pain compared with the conventional-treatment group (between-group difference, 15.7 [95% confidence interval, 0.52 to 30.8] [p = 0.04]). No complications in displacement or nonhealing were noted.

CONCLUSIONS

Early mobilization for impacted nonoperatively treated proximal humeral fractures is safe and is more effective for quickly restoring the physical capability and performance of the injured arm than is conventional immobilization followed by physiotherapy.

Could a simple educational intervention modify beliefs about whiplash? A preliminary study among professionals working in a rehabilitation ward

Could a simple educational intervention modify beliefs about whiplash? A preliminary study among professionals working in a rehabilitation ward.

OBJECTIVE

Whiplash and its consequences remain an alarming clinical and social problem, and psychosocial factors could play a role. We aimed to translate and assess the effects on beliefs of an evidence-based educational booklet on whiplash-associated disorders among professionals who work in a rehabilitation ward.

METHODS

After translation/back-translation of the English version of The Whiplash Book, we undertook a before-and-after prospective study. The main outcome assessment was final score on the whiplash belief questionnaire (WBQ) involving nine questions assessing beliefs and attitudes about the consequences of whiplash rated on a 5-point Likert scale ranging from "completely agree" to "complete disagree." Final scores range from 9 to 45, low scores indicating positive beliefs. Demographic, educational and professional data, as well as personal medical history of neck pain, were recorded. Acceptability of the booklet was rated on a 10-point scale and by open questions.

RESULTS

Among the 50 professionals included in the study, 48 completed the questionnaire. Whiplash beliefs tended to be positive at first assessment (WBQ score 23.37+/-6.45). Reading the whiplash booklet significantly improved beliefs (14.27+/-4.39; P<0.05). Global evaluation of the booklet on a 10-point scale was good (8.13+/-1.05) as was acceptability (8.13+/-1.05).

CONCLUSION

After reading a booklet about whiplash translated into French, beliefs about the consequences of whiplash were changed for the better in this sample of French-speaking healthy professionals working in a rehabilitation ward. This simple educational intervention translated into French could be used for education and for ameliorating beliefs about the consequences of whiplash among health care professionals and the public.

An unusual complication of intra-articular injections of corticosteroids: Tachon syndrome. Two case reports

Local injections of corticosteroids can, in very rare cases, be complicated by Tachon syndrome-intense lumbar and/or dorsal and/or thoracic pain a few minutes after the injection, with rapid regression of the pain. Passing the drug into a vein through a nick made during the procedure could explain the pathophysiology of this disorder. We report two good cases illustrating the typical symptoms of this distressful syndrome. Diagnosis of Tachon syndrome is made by elimination of the usual medical and surgical causes, and physicians performing local injections should be aware of this phenomenon. The patient needs to be reassured of the temporal nature of the syndrome.

Should aggregate scores of the Medical Outcomes Study 36-item Short Form Health Survey be used to assess quality of life in knee and hip osteoarthritis? A national survey in primary care

OBJECTIVE

To assess the relevance of using the aggregate physical component score (PCS) and mental component score (MCS) of the Medical Outcomes Study 36-item Short Form Health Survey (SF-36) for patients with knee and hip osteoarthritis (OA).

METHODS

We conducted a cross-sectional national survey in a primary care setting in France. A total of 1474 general practitioners enrolled 4183 patients with hip or knee OA. Construct validity of PCS and MCS was assessed by convergent and divergent validity and factor analysis.

RESULTS

Records of 4133 patients (98.8%) were analyzed (2540 knee, 1593 hip OA). PCS mean scores were 32.0+/-8.4 and 31.8+/-8.4 and MCS scores 47.1+/-11.0 and 46.8+/-11.1, for knee and hip OA, respectively. Acceptable convergent and divergent validity was observed, and correlation between PCS and MCS mean scores was low (r=0.14). However, factor analysis performed on the eight subscale scores failed to support the use of PCS and MCS aggregate scores. It extracted two factors which were similar for both OA types and differed from the a priori stratification. Scores for two subscales usually attributed to MCS - emotional role and social functioning - were shared between factors, and scores for another subscale - general health perception - usually belonging to the PCS was in the mental component factor.

CONCLUSIONS

Our results suggest that aggregate scores from the PCS and MCS of the SF-36 as they are currently defined may not be optimal for used in hip and knee OA patients to assess health-related quality of life.

Superoxide production and NADPH oxidase expression in human rheumatoid synovial cells: regulation by interleukin-1beta and tumour necrosis factor-alpha

OBJECTIVES

to evaluate the rheumatoid synovial cell capacity to produce superoxide anion in response to interleukin-1beta (IL-1beta) and tumour necrosis factor-alpha (TNF-alpha), and to study the NADPH oxidase involvement in this production.

MATERIAL AND METHODS

Synovial cells obtained from 7 rheumatoid arthritis (RA), 5 osteoarthritic (OA) patients, and dermal fibroblasts, were stimulated (i) with IL-1beta and TNF-alpha, or (ii) with specific oxidase activators and inhibitors, before studying superoxide production; we also studied NADPH oxidase mRNAs and protein expression, and p47-phox phosphorylation.

RESULTS

Constitutive superoxide production by RA cells was increased in comparison to OA cells and dermal fibroblasts, and was stimulated by PMA and ionomycin. This production was increased after cytokine treatment of RA synovial cells. Cytokine-induced superoxide production by RA cells was inhibited by iodonium diphenyl or apocynin, suggesting the involvement of NADPH oxidase. RT-PCR and western blot analysis revealed the presence of p47-phox, gp91-phox and Nox4 in RA and OA cells, and in dermal fibroblasts. P47-phox phosphorylation was enhanced after cytokine-treatment in RA and OA cells, suggesting a PKC-mediated up-regulation of NADPH oxidase.

CONCLUSIONS

NADPH oxidase is involved in the superoxide release by RA synovial cells, constitutively and after cytokine up-regulation. These cells express two different homologues (gp91-phox and Nox4).

Qualitative evaluation of the expectations of low back pain patients with regard to information gained through semi-directed navigation on the Internet

OBJECTIVES

To make a qualitative analysis of the expectations of chronic low back pain (LBP) sufferers with regard to information gained using semi-directed Internet navigation on a sample of French LBP-related websites, and to compare the results with those of physical medicine and rehabilitation (PMR) medical doctors (MD).

MATERIAL AND METHODS

Twenty-seven hospitalised chronic LBP sufferers assessed in ecological conditions a sample of seven LBP-related websites. The sites were assessed using a simplified version of a rating scale of patients' expectations. Analysis of the relative importance of the different kinds of information delivered was done using a point sharing method.

RESULTS

In a comfortable environment, patients gave high scores for medical and extra-medical information, but low scores for website design. Overall quality assessment was similar for patients and MDs. The relative importance of medical and extra-medical information, and design quality, was similar for Chronic LBP patients and MDs.

CONCLUSION

PMR MD seemed able to correctly evaluate the overall expectations of chronic LBP patients with regard to information, but their opinions on the different qualities of websites were different. Doctors and patients should collaborate in order to create or validate high quality websites concerned with LBP.

Functional restoration programs for low back pain: a systematic review

BACKGROUND

In developed countries, chronic low back pain (LBP) is one the most common reasons for disability and work-time loss. Conventional treatments have not slowed the increasing prevalence of chronic LBP. Therefore, in a search for new solutions to the problem, functional restoration programs were developed.

OBJECTIVE

To synthesize the literature on the efficacy of functional restoration programs for LBP.

METHODS

We performed a systematic literature search of the MedLINE database using the keywords LBP, functional restoration, work-hardening program, exercise therapy, rehabilitation, aerobic, and cognitive behavioral therapy.

SYNTHESIS

The term "functional restoration" has been associated with a full-day multidisciplinary program lasting from 3 to 6 weeks. Results of most published controlled studies on the efficacy of functional restoration programs are positive regarding the return-to-work rate. Maintaining job status with the pre-injury employer is often best accomplished by the provision of suitable modified duties. Finally, results of functional restoration programs in terms of return-to-work rate probably depend strongly on the social security system of the country where the program was developed.

Development and validation of a scale for mouth handicap in systemic sclerosis: the Mouth Handicap in Systemic Sclerosis scale

OBJECTIVE

To develop and assess the reliability and construct validity of a scale assessing disability involving the mouth in systemic sclerosis (SSc).

METHODS

We generated a 34-item provisional scale from mailed responses of patients (n = 74), expert consensus (n = 10) and literature analysis. A total of 71 other SSc patients were recruited. The test-retest reliability was assessed using the intraclass coefficient correlation and divergent validity using the Spearman correlation coefficient. Factor analysis followed by varimax rotation was performed to assess the factorial structure of the scale.

RESULTS

The item reduction process retained 12 items with 5 levels of answers (total score range 0-48). The mean total score of the scale was 20.3 (SD 9.7). The test-retest reliability was 0.96. Divergent validity was confirmed for global disability (Health Assessment Questionnaire (HAQ), r = 0.33), hand function (Cochin Hand Function Scale, r = 0.37), inter-incisor distance (r = -0.34), handicap (McMaster-Toronto Arthritis questionnaire (MACTAR), r = 0.24), depression (Hospital Anxiety and Depression (HAD); HADd, r = 0.26) and anxiety (HADa, r = 0.17). Factor analysis extracted 3 factors with eigenvalues of 4.26, 1.76 and 1.47, explaining 63% of the variance. These 3 factors could be clinically characterised. The first factor (5 items) represents handicap induced by the reduction in mouth opening, the second (5 items) handicap induced by sicca syndrome and the third (2 items) aesthetic concerns.

CONCLUSION

We propose a new scale, the Mouth Handicap in Systemic Sclerosis (MHISS) scale, which has excellent reliability and good construct validity, and assesses specifically disability involving the mouth in patients with SSc.

Establishing recommendations for physical medicine and rehabilitation: the SOFMER methodology

OBJECTIVE

The development of a rigorous methodology based on published results of clinical trials, evaluation of daily practice in France and multidisciplinary expert opinion to elaborate recommendations for rehabilitation interventions.

METHODS AND RESULTS

The following describes the methodology of SOFMER (Société Française de Médecine Physique et de Réadaptation [French Society of Physical Medicine and Rehabilitation]) for developing recommendations for rehabilitation interventions. The test case was developing recommendations for rehabilitation in hip or knee osteoarthritis (OA) and hip or knee arthroplasty. Physicians in rehabilitation, orthopedic surgery and rheumatology identified, synthesized, and analyzed data from the literature by use of the usual French system of grading trials (the French Agency for Accreditation and Evaluation in Healthcare [ANAES] scale). The data were published results of comparative controlled studies such as randomized controlled trials, controlled clinical trials, cohort studies, case control studies, reviews of clinical trials, and case series, as well as uncontrolled cohort studies. The resulting recommendations were presented to the three annual French national congresses of rehabilitation, rheumatology, and orthopedic surgery for comment and for adapting to French professional practice. Finally, a panel of multidisciplinary experts (physicians in physical medicine and rehabilitation, rheumatologists, orthopedic surgeons, general practitioners, physical therapists, social workers, podologists, occupational therapists, nurses, and patients) validated the recommendations.

CONCLUSION

The SOFMER methodology could be an interesting tool for use in developing recommendations elaborated by all the concerned medical and surgical specialists in the wide domain of rehabilitation.

3-D scapular kinematics during arm elevation: effect of motion velocity

BACKGROUND

No three-dimensional (3-D) data exist on the influence of motion velocity on scapular kinematics. The effect of arm elevation velocity has been studied only in a two-dimensional setting.

METHODS

Thirty healthy subjects performed dominant (right) arm elevation in two planes, sagittal and frontal, and at slow and fast self-selected arm speed. Scapular orientation and humeral elevation were measured at 30 Hz recording frequency with use of a 6-degree-of-freedom electromagnetic system (Polhemus Fastraka). Motion was computed according to the International Society of Biomechanics standards. Scapular orientation was also determined with the arm held in different static positions.

FINDINGS

We obtained a full 3-D kinematic description of scapula achieving a reliable, complex 3-D motion during humeral elevation and lowering. The maximal sagittal arm elevation showed a characteristic "M"-shape pattern of protraction/retraction curve. Scapular rotations did not differ significantly between slow and fast movements. Moreover, protraction/retraction and tilt angular values did not differ significantly between static and dynamic tasks. However, scapular lateral rotation values differed between static and dynamic measurements during sagittal and frontal arm elevation. Lateral scapular rotation appears to be less in static than in dynamic measurement, particularly in the sagittal plane.

INTERPRETATION

Interpolation of statically recorded positions of the bones cannot reflect the kinematics of the scapula.

Fear-avoidance beliefs about back pain in patients with subacute low back pain

The fear-avoidance beliefs of patients with subacute low back pain (LBP) considered at risk for chronic disabling LBP are not well known. The objectives of this cross-sectional descriptive survey, conducted in secondary care practice, were to assess fear-avoidance beliefs about back pain in patients with subacute LBP and to seek an association between physician or patient characteristics and level of fear-avoidance beliefs. A total of 286 rheumatologists completed a self-administered questionnaire assessing physicians' demographic, professional data, personal history of back pain, and back pain fear-avoidance beliefs (on the Fear-Avoidance Belief Questionnaire [FABQ]) and 443 patients with sLBP completed one on pain, perceived handicap and disability (Quebec Back Pain Disability Scale), anxiety and depression (Hospital Anxiety Depression questionnaire), and back pain beliefs (FABQ). Mean FABQ scores for rheumatologists for physical activities (FABQ Phys) and occupational activities (FABQ Work) were 9.2+/-4.4 (range 0-21) and 16.7+/-6.9 (range 2-37), respectively, and patient scores were 16.7+/-5.2 and 19.3+/-12.4, respectively. A total of 68% of patients and 10% of physicians had a high rating on the FABQ Phys (>14). Patients' fear-avoidance beliefs about physical activity were associated with low level of education (odds ratio [OR] 4.19; 95% confidence interval [CI] 1.83-9.57), patients' perceived disability (OR 1.05; CI 1.03-1.07), and physicians' high FABQ Phys score (OR 5.92; CI 1.31-26.32). Here we show that fear-avoidance beliefs about back pain were high in patients with subacute LBP and their rheumatologists.

[The role of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain. A randomized controlled trial in a rehabilitation unit]

OBJECTIVES

To compare the efficacy of an information booklet or oral information about back pain in reducing disability and fear-avoidance beliefs among patients with subacute and chronic low back pain referred to a rehabilitation department.

METHODS

An alternate-month design was used for 142 patients with subacute or chronic low back pain who were hospitalized for treatment. Seventy-two patients received written standardized information about back pain (the "back book") and usual physical therapy (intervention group), and 70 received usual physical therapy only along with nonstandardized oral information (control group). The main outcome measure was disability (measured on the Quebec back-pain disability scale), and secondary outcome measures were pain intensity (measured on a visual analog scale), fear-avoidance beliefs (measured on the Fear-Avoidance Beliefs Questionnaire [FABQ] Physical component), and knowledge of the relation of back pain to physical activity assessed at baseline, just before discharge from the hospital and 3 months after discharge. Satisfaction related to the information received was assessed on the day of discharge.

RESULTS

Receiving the "back book" had a significant impact on disability at 3 months, from 48.40+/-14.55 to 34.57+/-18.42 in the intervention group and from 52.17+/-16.88 to 42.40+/-14.95 in the control group (p=0.03). Receipt of the book also had a significant impact on patients' knowledge and satisfaction about information but a nonsignificant effect on fear-avoidance beliefs.

CONCLUSIONS

Providing an information booklet about back pain to patients with subacute and chronic low back pain referred to a rehabilitation unit contributes to reduced disability in these patients.

[Psychobehavioural assessment for chronic low back pain]

INTRODUCTION

Psychobehavioural assessment may be a complementary approach to assess response to treatment for pain and disability in patients with low back pain.

OBJECTIVES

To assess the correlation between psychobehavioural factors and pain and disability in patients with chronic low back pain in France.

METHODS

We asked 83 patients with chronic low back pain to complete questionnaires during a primary care consultation by a general practitioner. Pain was measured by a visual analog scale (VAS), disability by the Quebec Back Pain Disability Scale and psychobehavioural factors by the Fear-Avoidance Beliefs Questionnaire (FABQ) and the Coping Strategy Questionnaire (CSQ).

RESULTS

Pain was poorly correlated with anxiety (R = 0.36) and scores on the FABQ 1 (R = 0.46) and FABQ 2 (R = 0.30) and not correlated with depression (R = 0.22), duration of pain evolution (R = 0,10) and body mass index (R = 0.12). The duration of stopping work was poorly correlated with disability (R = 0.35) and FABQ 1 score (R = 0.43) and not correlated with pain (R = 0.11), anxiety (R = 0.11), depression (R = 0.26) and FABQ 2 score (R = 0.23). Disability was poorly correlated with scores on the FABQ 1 (R = 0.45) and FABQ 2 (R = 0.3), anxiety (R = 0.39) and depression (R = 0.47) and not correlated with pain (R = 0.25). Dramatization is the only way to cope with pain and was correlated with pain (R = 0.34), scores on the FABQ 1 (R = 0.47) and FABQ 2 (R = 0.43), disability (R = 0.38), anxiety (R = 0.44) and depression (R = 0.46). The use of prayer was poorly correlated with FABQ 1 score (R = 0.37) and anxiety (R = 0.30). Distraction was poorly correlated with scores on the FABQ 1 (R = 0.40) and FABQ 2 (R = 0.30). No strategy was correlated with duration of pain and stopping work.

DISCUSSION-CONCLUSION

All the correlation assessments with psychobehaviour factors are weak. So evaluating each of these parameters will be interesting. Duration of pain was not correlated with increasing pain or change in behavioural strategy. Psychobehavioural factors are more invalidating than pain. More study is needed to assess psychobehavioural therapies in patients with low back pain.

Outcome of subacute low back pain: influence of patients' and rheumatologists' characteristics

OBJECTIVES

To assess the outcome of subacute low back pain, to identify the characteristics of patients and physicians which were related to outcome and to evaluate the influence of rheumatologists' beliefs about back pain on their following the guidelines for physical and occupational activity.

METHODS

DESIGN

a longitudinal descriptive survey.

SETTING

a secondary care practice in France.

PARTICIPANTS

266 rheumatologists; 440 patients with subacute low back pain.

OUTCOME MEASURES

the main outcome measure was persistence of back pain 3 months after baseline evaluation. A self-administered questionnaire for physicians assessed attitudes and beliefs about back pain [Fear-Avoidance Beliefs Questionnaire (FABQ)], and one for patients assessed pain, perceived handicap and disability (Quebec Scale), anxiety and depression (Hospital Anxiety Depression Questionnaire), and beliefs about back pain (FABQ).

RESULTS

Forty per cent of patients had persistent low back pain at 3 months; 5.5% of these had sciatica. A total of 10% of rheumatologists and 68% of patients at baseline had a high FABQ physical score (phys; >14). Determinants of outcomes were work-related back pain [odds ratio (OR) = 3.37; 95% confidence interval (CI) 1.08-5.17], anxiety (OR = 2.41; 95% CI 1.44-4.09), sex (female OR = 2.03; 95% CI 1.30-3.18) and patients' beliefs about back pain at work (OR = 1.02; 95% CI 1.00-1.05). Physicians with high FABQ physical scores were less likely to follow guidelines on prescribing rest and occupational activity for back pain.

CONCLUSION

Back pain commonly persists 3 months later in patients with subacute low back pain. Patients and rheumatologists still have negative beliefs about back pain. Rheumatologists' beliefs influence their following guidelines on physical and occupational activities. National education programmes about low back pain are needed in France.

Tête tombante fixée : efficacité d'une rééducation intensive

OBJECTIVES

To point out the diagnostic and etiologic context of neck extensor weakness and to consider orthopedic and rehabilitation treatment of dropped head syndrome.

METHODS

We report a case of a 68-year-old hospitalized woman with atypical and serious idiopathic neck extensor weakness who was treated by orthopedic measurements and intensive rehabilitation.

RESULTS

Our patient had progressive neck extensor weakness and total inflection of the cervico-cephalic axis over two years. Fixed and permanent contact of the chin and the sternum severely affected her ability to eat, and mandibular and sternal pressure ulcers developed. Cervical spine radiography revealed degenerative lesions. Other clinical and biological parameters were normal. Atypical idiopathic head drop was diagnosed because of painful and fixed head position. Rehabilitation consisted of cervical traction with a halo apparatus during eight weeks and an exercise programme based on cervical proprioception and muscular work. Orthopedic management consisted of cervical collar immobilization after cutaneous cicatrization. After ten weeks of treatment, the patient was able to raise her head and maintain it horizontally. Two years later, clinical results were stable.

DISCUSSION

Neck extensor weakness may be the presenting feature of several neuromuscular disorders. Generally, idiopathic dropped head syndrome appears to be the most likely diagnosis in patients with isolated neck extensor involvement. For our patient, clinical findings and cervical computed tomography showed important muscular weakness. However, painful passive extension and progressive stiffness of the neck do not represent the typical clinical course of idiopathic head drop. Neither degenerative lesions of the cervical spine nor other joint diseases can cause head drop. This case may result from the combined effects of idiopathic dropped head syndrome and cervical arthrosis. Orthopedic treatment and intensive rehabilitation had spectacular effects. Clinical management of head drop syndrome should always consist of orthopedic and rehabilitation treatment.

[The Oswestry index for low back pain translated into Arabic and validated in a Arab population]

OBJECTIVE

To translate into Arabic and validate the Oswestry index for low back pain in an Arab population.

BACKGROUND

No functional disability index to assess low back pain written in the Arabic language and validated in an Arab population is available.

DESIGN

Arabic translation of the Oswestry index was obtained by the "forward translation/backward translation" method. Adaptations were made after a pilot study involving ten patients aged 18 to 65 years old. Impairment outcome measures (pain as measured on a visual analog scale [VAS], Schober-McRae, index, duration of morning stiffness and number of night awakenings), disability (Quebec index, Waddell index), handicap (as measured on a VAS) and Beck depression scale scores were recorded. Inter-rater reliability was assessed by use of the intra-class correlation coefficient (ICC) and the Bland and Altman method. Construct validity was investigated with use of the Spearman rank correlation coefficient (convergent and divergent validity), and factor analysis was performed. Internal consistency was assessed by use of the Cronbach alpha coefficient.

RESULTS

Eighty Tunisian patients with low back pain were included in the validation study. Two items were excluded. Inter-rater reliability was excellent (ICC = 0.98). Expected divergent and convergent validity results suggested good construct validity. Two main factors were extracted by factor analysis and explained 58.19% of the cumulative variance: the first factor represented discomfort in dynamic activities, the second discomfort in static activities. The Cronbach alpha coefficient was 0.76 for factor 1 and 0.70 for factor 2.

CONCLUSION

We translated into and adapted the Oswestry index for the Arabic language in a population of Tunisian women? with low back pain. The 8-item version is reliable and valid. Although the scale was validated in a Tunisian population, we expect that it is suitable for other Arab populations, especially North Africans. Further study is needed to confirm such a hypothesis.