An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle

Myofascial pain associated with myofascial trigger points (MTrPs) is a common cause of nonarticular musculoskeletal pain. Although the presence of MTrPs can be determined by soft tissue palpation, little is known about the mechanisms and biochemical milieu associated with persistent muscle pain. A microanalytical system was developed to measure the in vivo biochemical milieu of muscle in near real time at the subnanogram level of concentration. The system includes a microdialysis needle capable of continuously collecting extremely small samples (approximately 0.5 microl) of physiological saline after exposure to the internal tissue milieu across a 105-microm-thick semi-permeable membrane. This membrane is positioned 200 microm from the tip of the needle and permits solutes of <75 kDa to diffuse across it. Three subjects were selected from each of three groups (total 9 subjects): normal (no neck pain, no MTrP); latent (no neck pain, MTrP present); active (neck pain, MTrP present). The microdialysis needle was inserted in a standardized location in the upper trapezius muscle. Due to the extremely small sample size collected by the microdialysis system, an established microanalytical laboratory, employing immunoaffinity capillary electrophoresis and capillary electrochromatography, performed analysis of selected analytes. Concentrations of protons, bradykinin, calcitonin gene-related peptide, substance P, tumor necrosis factor-alpha, interleukin-1beta, serotonin, and norepinephrine were found to be significantly higher in the active group than either of the other two groups (P < 0.01). pH was significantly lower in the active group than the other two groups (P < 0.03). In conclusion, the described microanalytical technique enables continuous sampling of extremely small quantities of substances directly from soft tissue, with minimal system perturbation and without harmful effects on subjects. The measured levels of analytes can be used to distinguish clinically distinct groups.

Controlled trial of pamidronate in children with types III and IV osteogenesis imperfecta confirms vertebral gains but not short-term functional improvement

Bisphosphonates have been widely administered to children with OI based on observational trials. A randomized controlled trial of q3m intravenous pamidronate in children with types III and IV OI yielded positive vertebral changes in DXA and geometry after 1 year of treatment, but no further significant improvement during extended treatment. The treated group did not experience significantly decreased pain or long bone fractures or have increased motor function or muscle strength.

INTRODUCTION

Bisphosphonates, antiresorptive drugs for osteoporosis, are widely administered to children with osteogenesis imperfecta (OI). Uncontrolled pamidronate trials in OI reported increased BMD, vertebral coronal area, and mobility, and decreased pain. We conducted a randomized controlled trial of pamidronate in children with types III and IV OI.

MATERIALS AND METHODS

This randomized trial included 18 children (4-13 years of age) with types III and IV OI. The first study year was controlled; 9 children received pamidronate (10 mg/m2/day IV for 3 days every 3 months). Four children in each group also received recombinant growth hormone (rGH) injections (0.06 mg/kg/day for 6 days/week). Seven children in the treatment group received pamidronate for an additional 6-21 months. All patients had L1-L4 DXA, spine QCT, spine radiographs, and musculoskeletal and functional testing.

RESULTS

In the controlled phase, treated patients experienced a significant increase in L1-L4 DXA z score (p < 0.001) and increased L1-L4 mid-vertebral height (p = 0.014) and total vertebral area (p = 0.003) compared with controls. During extended treatment, DXA z scores and vertebral heights and areas did not increase significantly beyond the 12-month values. Fracture rate decreased significantly in the upper extremities (p = 0.04) but not the lower extremities (p = 0.09) during the first year of treatment. Gross motor function, muscle strength, and pain did not change significantly during the controlled or extended treatment phases.

CONCLUSIONS

A controlled trial confirmed the spine benefits of short-term pamidronate treatment in children with types III and IV OI. Pamidronate increased L1-L4 vertebral DXA and decreased vertebral compressions and upper extremity fractures. Vertebral measures did not improve during the extended treatment phase. The treatment group did not experience decreased lower extremity long bone fractures, significant improvement in growth, ambulation, muscle strength, or pain. There was substantial variability in individual response to treatment.

Use of nitisinone in patients with alkaptonuria

Alkaptonuria, a rare autosomal recessive disorder caused by mutations in the HGD gene and deficiency of homogentisate 1,2 dioxygenase, is characterized by ochronosis, arthritis, and daily excretion of gram quantities of homogentisic acid (HGA). Nitisinone, an inhibitor of the enzyme 4-hydroxyphenylpyruvate dioxygenase, can drastically reduce urinary excretion of HGA in individuals with alkaptonuria. We investigated the safety and the HGA-depleting efficacy of nitisinone in an open-label, single-center study of 9 alkaptonuria patients (5 women, 4 men; 35-69 years of age) over the course of 3 to 4 months. Each patient received nitisinone in incremental doses, 0.35 mg bid followed by 1.05 mg bid, and remained on this dosage and a regular diet for 3 months. Nitisinone reduced urinary HGA levels from an average of 4.0 +/- 1.8 (SD) g/day to 0.2 +/- 0.2 g/day ( P < .001). The average plasma tyrosine concentration, initially 68 +/- 18 mmicro mol/L, rose to 760 +/- 181 micro mol/L ( P < .001). During the final week of the study, 5 patients adhered to a protein-restricted diet (40 g/day), and their mean plasma tyrosine level fell from 755 +/- 167 to 603 +/- 114 mu mol/L. Six of the 7 patients who received nitisinone for more than 1 week reported decreased pain in their affected joints. Weekly ophthalmologic examinations showed no signs of corneal toxicity. Adverse events included the passing of kidney stones, the recognition of symptoms related to aortic stenosis, and elevation of liver transaminase levels. We conclude that low-dose nitisinone effectively reduced urinary HGA levels in patients with alkaptonuria. Future long-term clinical trials are planned to determine the benefits of nitisinone in preventing joint deterioration and providing pain relief, and its long-term side effects.

Multisegment foot motion during gait: proof of concept in rheumatoid arthritis

OBJECTIVE

To test a multisegment foot model for kinematic analysis during barefoot walking in patients with well established rheumatoid arthritis (RA) and foot impairments.

METHODS

Five healthy adult subjects and 11 RA patients with advanced disease were studied. Foot impairments were assessed using standardized outcomes and clinical examination techniques. A 6-camera 60 Hz video-based motion analysis system was used to measure motion of the shank, rearfoot, forefoot, and hallux segments and the vertical displacement of the navicular. Face validity and estimates of repeatability were determined. Motion patterns were calculated and comparisons were made between healthy subjects and patients with RA. Relationships between clinical impairment and abnormal motion were determined through inspection of individual RA cases.

RESULTS

Across the motion variables, the within-day and between-day coefficient of multiple correlation values ranged from 0.677 to 0.982 for the healthy subjects and 0.830 to 0.981 for RA patients. Based on previous studies, motion parameters for the healthy subjects showed excellent face validity. In RA patients, there was reduced range of motion across all segments and all planes of motion, which was consistent with joint stiffness. In the RA patients, rearfoot motion was shifted towards eversion and external rotation and peak values for these variables were increased, on average, by 7 degrees and 11 degrees, respectively. Forefoot range of motion was reduced in all 3 planes (between 31% and 53%), but the maximum and minimum angles were comparable to normal. The navicular height, during full foot contact, was on average 3 mm lower in the RA patients in comparison to normal. The hallux was less extended in the RA subjects in comparison to normal (21 degrees vs 33 degrees) during the terminal stance phase. Individual cases showed abnormal patterns of motion consistent with their clinical impairments, especially those with predominant forefoot pain or pes planovalgus.

CONCLUSION

In RA, multisegment foot models may provide a more complete description of foot motion abnormalities where pathology presents at multiple joints, leading to complex and varied patterns of impairment. This technique may be useful to evaluate functional changes in the foot and to help plan and assess logical, structurally based corrective interventions.

Ultrasound imaging distinguishes between normal and weak muscle

OBJECTIVE

To determine whether real-time ultrasound imaging can provide quantitative data that distinguish pathologic from healthy muscle and that correlate with strength measures.

DESIGN

Nonrandomized matched-pair, repeated-measures design.

SETTING

Ultrasound imaging laboratory, rehabilitation medicine department, government research hospital.

PARTICIPANTS

Nine patients with stable active or inactive myositis, stratified into 3 groups based on their 10-point manual muscle test (MMT) scores, and 9 age- and gender-matched controls.

INTERVENTIONS

Maximal isometric contraction of the rectus femoris muscle in 2 knee-flexion positions (60 degrees, 90 degrees ) during simultaneous ultrasound imaging and muscle force dynamometry.

MAIN OUTCOME MEASURES

Changes of the rectus femoris muscle in horizontal (X) and vertical (Y) diameters between relaxed and contracted states, and muscle force measurements.

RESULTS

The X diameters decreased and the Y diameters increased during isometric contraction in all participants. For each group, average changes in cross-sectional diameters were consistently higher in controls than in patients. Patients with MMT less than 8 differed significantly from controls in both X and Y dimensions. A moderately strong correlation was found between muscle force and the Y diameter during contraction at 60 degrees (r =.78) and 90 degrees (r =.67) knee-flexion angles.

CONCLUSIONS

Ultrasonography provided a quantitative measure of change between relaxed and contracted state of muscle, which correlated with muscle force. Ultrasound identified significant differences in cross-sectional diameters between the myopathic and normal muscles sampled and may be useful for measuring muscle response to drug and exercise therapy.

Walking ability and its relationship to lower-extremity muscle strength in children with idiopathic inflammatory myopathies

OBJECTIVE

To describe gait deficits and their association with lower-extremity muscle strength in children with juvenile idiopathic inflammatory myopathies (IIM).

DESIGN

Cross-sectional, descriptive study.

SETTING

Clinical research center.

PARTICIPANTS

Consecutive sample of 25 ambulatory children diagnosed with juvenile IIM.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Manual muscle test (MMT) of bilateral hip flexor, extensor, and abductor; knee extensor; and ankle plantarflexor strength, all measured on a 0- to 10-point scale and summary strength measures. Video-based movement analysis to determine walking speed; gait cycle time; right and left step time; stride length; right and left step length; and stance, swing, and double-limb support phase durations.

RESULTS

Walking speed (1.03+/-0.27 m/s) was reduced because of shortened stride lengths (1.03+/-0.21 m) more than prolonged gait cycle times (1.05+/-0.22s). Walking speed highly correlated with the number of muscle groups weaker than grade 7 out of 10 (r=-.89) and the strength of the hip flexors (r=.85).

CONCLUSIONS

Lower-extremity strength measures, including MMT scores of individual muscle groups and the number of weak muscle groups, were predictive of gait limitations in children with juvenile IIM.

Pentoxifylline in the Treatment of Radiation-Induced Fibrosis

Purpose

Fibrotic sequelae remain the most important dose-limiting toxicity of radiation therapy to soft tissue. Functionally, this is reflected in loss of range of motion and muscle strength and the development of limb edema and pain. Tumor necrosis factor alpha and fibroblast growth factor 2 (FGF2), which are abnormally elevated in irradiated tissues, may mediate radiation fibrovascular injury.

Patients and Methods

In an open label drug trial, we studied the effects of pentoxifylline (400 mg orally tid for 8 weeks) on 30 patients who displayed late, radiation-induced fibrosis at 1 to 29 years posttreatment (40 to 84 Gy). The primary outcome measurement was change in physical impairments thought to be secondary to radiation, including active and passive range of motion (AROM and PROM), muscle strength, limb edema, and pain. Plasma levels of cytokines (tumor necrosis factor alpha and FGF2) also were measured. Twenty-seven patients completed baseline and 8-week assessments, and 24 patients completed baseline, 8-week, and 16-week assessments.

Results

After 8 weeks of pentoxifylline intervention, 20 of 23 patients with impaired AROM and 19 of 22 with impaired PROM improved; 11 of 19 patients with muscle weakness showed improved motor strength; five of seven patients with edema had decreased limb girth; and nine of 20 patients had decreased pain. Pretreatment FGF2 levels dropped from an average of 44.9 pg/mL to 24.0 pg/mL after 8 weeks of treatment.

Conclusion

Patients receiving pentoxifylline demonstrated improved AROM, PROM, and muscle strength and decreased limb edema and pain. Reversal of these delayed radiation effects was associated with a decrease in circulating FGF2.

Number of active joints, not diagnosis, is the primary determinant of function and performance in early synovitis

OBJECTIVE

A substudy within a larger study of patients with inflammatory arthritis of less than one year, to analyze baseline measures or joint counts, laboratory values, patient questionnaires and ARA diagnostic criteria for rheumatoid arthritis, as predictors of one year performance and functional status.

METHODS

229 patients with synovitis of less than one year were enrolled and evaluated at baseline and one year. Measures included the number of swollen or tender joints [active joint counts]; biological indices of inflammation [erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)]; and patient questionnaire measures of pain [Wisconsin Brief Pain Inventory], fatigue [multi-dimensional assessment of fatigue], depression [Center for Epidemiologic Studies--Depression Scale], sleep [Sleep Quality Index], performance [Human Activity Profile], and function [Sickness Impact Profile ambulation subscale and Health Assessment Questionnaire]. Correlations between these measures were evaluated using the Spearman rank order correlation. Patients were classified according to whether they met ARA criteria for RA, had high (> 7) or low (< or = 7) numbers of affected joints; and high, intermediate, or low levels of performance; and were compared using the Kruskal-Wallis test.

RESULTS

At baseline, an active joint count of > 7 versus < or = 7 was associated significantly with higher age, rheumatoid factor positivity, a diagnosis of rheumatoid arthritis versus spondyloarthropathy or undifferentiated arthritis, and receiving a disease modifying antirheumatic drug (DMARD), but not with sex, race, erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), or receiving prednisone. Furthermore, high baseline active joint counts were associated significantly with patient questionnaire scores for maximum activity, fatigue and depression, but differences were not significant for sleep, ambulation and pain scores. A comparison of patients who met or did not meet criteria for RA indicated significant differences only according to the fatigue scores, but none of the other questionnaire measures. Correlations of baseline measures with one-year performance were highest for the baseline active joint count compared to laboratory and questionnaire variables. The maximum activity score at one year was predicted significantly by the baseline maximum activity score, active joint count, and age, but not by laboratory tests or whether the patient met criteria for RA.

CONCLUSION

The active joint count predicts subsequent performance and function for patients with recent onset, inflammatory synovitis more effectively than whether patients met ARA criteria for RA.

Long-term treatment of hypoparathyroidism: a randomized controlled study comparing parathyroid hormone-(1-34) versus calcitriol and calcium

Hypoparathyroidism is one of the few remaining hormonal insufficiency states for which replacement therapy is unavailable. Previous short-term controlled trials have shown PTH to be a safe and effective treatment of hypoparathyroidism. In this randomized, parallel group, open-label trial, we compared synthetic human PTH-(1-34) (PTH) with conventional therapy, calcitriol and calcium, over a 3-yr period. Twenty-seven patients with confirmed hypoparathyroidism, aged 18-70 yr, were randomized to either twice daily sc PTH or oral calcitriol and calcium. The primary end points were calcium levels in serum and urine. Secondary end points were creatinine clearance, markers of bone turnover, and bone mineral density. Throughout the 3-yr study period, serum calcium levels were similar in both treatment groups within or just below the normal range. Mean urinary calcium excretion was within the normal range from 1-3 yr in PTH-treated patients, but remained above normal in the calcitriol group. Bone mineral content and bone mineral density showed no significant between-group differences over the 3-yr study period. We conclude that treatment with twice daily sc PTH provides a safe and effective alternative to calcitriol therapy and is able to maintain normal serum calcium levels without hypercalciuria for at least 3 yr in patients with hypoparathyroidism.

Constraint-induced therapy in stroke: magnetic-stimulation motor maps and cerebral activation

Constraint-induced movement therapy (CI), a standardized intensive rehabilitation intervention, was given to patients a year or more following stroke. The goal was to determine if CI was more effective than a less-intensive control intervention in changing motor function and/or brain physiology and to gain insight into the mechanisms underlying this recovery process. Subjects were recruited and randomized more than 1 year after a single subcortical infarction. Clinical assessments performed before and after the intervention and at 6 months postintervention included the Wolf Motor Function Test (WMFT), the Motor Activity Log (MAL), and the Assessment of Motor and Process Skills (AMPS). Transcranial magnetic stimulation was used to map the motor cortex. Positron emission tomography was used to measure changes in motor task-related activation due to the intervention. MAL increased by 1.08 after CI therapy and decreased by 0.01 after control therapy. The difference between groups was significant (P < 0.001). Changes in WMFT and AMPS were not significantly different between groups. Cerebral activation during a motor task decreased significantly, and motor map size increased in the affected hemisphere motor cortex in CI patients but not in control patients. Both changes may reflect improved ability of upper motor neurons to produce movement.

Ultrasound, magnetic resonance imaging, and posterior tibialis dysfunction

The authors studied posterior tibialis tendons in 31 subjects with posterior tibialis tendon pain to compare clinical findings with those of magnetic resonance imaging and ultrasound images. All subjects received clinical, ultrasound, and magnetic resonance imaging examinations using T1-weighted, T2-weighted, and enhanced magnetic resonance imaging, and high resolution ultrasound using power Doppler. Forty-four tendons in 25 women and six men with a mean age 43.3 years (range, 20-73 years) were studied. Magnetic resonance imaging tendon and peritendon enhancement are associated statistically with increasing pain intensity on resistance to testing. Ultrasound tendon and peritendon flow were associated with increasing pain intensity on resistance to testing. There is no statistically significant association between magnetic resonance imaging inhomogeneity and pain intensity on resistance to testing. Clinical and ultrasound examinations positively identify peritendinitis and tendonitis but not inhomogeneity (partial tear) of the posterior tibialis tendon. The magnetic resonance imaging is a more sensitive test for posterior tibialis tendon tear than either clinical or ultrasound evaluation.

Temperament and physical performance in children with osteogenesis imperfecta

OBJECTIVE

Children with osteogenesis imperfecta (OI) must participate in therapy to achieve motor performance objectives. Their behavioral style may influence motor performance. For this reason, the temperament of children with types III or IV OI was assessed prospectively to 1) compare their temperament with that of nondisabled children, 2) investigate the relationship between temperament and gross motor performance, and 3) examine relationships among temperament, parental overprotection and coping, physical activity, muscle strength, and motor performance.

METHODS

Age-appropriate Carey Temperament Scales, Brief Assessment of Motor Function (BAMF), and the Vulnerable Child/Overprotecting Parents Scale were completed for 35 children 1 to 12 years old. Additional measures included the Childhood Health Assessment Questionnaire, Parent Daily Hassles Scale, manual muscle testing, Pediatric Activity Record, and a Summed Severity Score. Spearman correlations and multiple regression were used to identify and predict significant relationships.

RESULTS

Temperament of children with OI differed from age-based norms in only 1 domain: activity. Motor performance (BAMF) correlated significantly with 3 domains of temperament: persistence (r = -.48), approach (r = -.34), and activity (r =.40). Activity was also related to the ratio of head circumference to body length (r = -.45) and the number of fractures in the preceding year (r = -.35). Parents' reports of their daily hassles significantly correlated with several domains of the child's temperament. No significant relationships were identified between parental overprotection and temperament or motor performance.

CONCLUSIONS

The temperament of children with types III and IV OI does not differ from that of their nondisabled peers, with the exception of lower activity scores. Although it is considered a biological attribute, the expression of temperament, specifically activity, may be influenced by learned behaviors. Because gross motor performance is related to activity, persistence, and approach/avoidance, knowledge of an individual's temperament may enhance the child's ability to benefit from interventions to improve motor skill and activity levels.

Brief assessment of motor function: reliability and concurrent validity of the Gross Motor Scale

OBJECTIVE

The Brief Assessment of Motor Function (BAMF) is a series of 10-point ordinal scales developed for rapid description of gross motor, fine motor, and oral motor performance. We examined interrater and intrarater reliability and concurrent validity of the BAMF Gross Motor Scale.

DESIGN

This validation study included 48 children (age, 5 mo to 17 yr) with a wide range of gross motor capability. Ten children with varied diagnoses participated in the reliability study. For concurrent validity, the BAMF performance of 38 children with osteogenesis imperfecta was compared with scores on the Peabody Developmental Motor Scales, laboratory gait analysis, and manual muscle testing.

RESULTS

Reliability values for intraclass correlations were 0.996 (interrater) and 1.00 (intrarater). Significant relationships were identified between the BAMF and gait speed ( r = 0.68, P < 0.0001), stride length (r = 0.71, P < 0.0001), duration of double-limb support ( r = -0.40, P < 0.03), number of weak muscles (r = -0.74, P< 0.0001), and the Peabody Developmental Motor Scales (r = 0.95, P < 0.0001). Number of weak muscles was the strongest predictor of BAMF score R2 = 0.5080, F = 24.77, P < 0.0001).

CONCLUSIONS

The BAMF demonstrates good reliability for children with a range of diagnoses and acceptable concurrent validity with gross motor development, muscle strength, and formal gait assessment in children with osteogenesis imperfecta.

Natural history of alkaptonuria

BACKGROUND

Alkaptonuria, caused by mutations in the HGO gene and a deficiency of homogentisate 1,2-dioxygenase, results in an accumulation of homogentisic acid (HGA), ochronosis, and destruction of connective tissue. There is no effective therapy for this disorder, although nitisinone inhibits the enzyme that produces HGA. We performed a study to delineate the natural history of alkaptonuria.

METHODS

We evaluated 58 patients with alkaptonuria (age range, 4 to 80 years), using clinical, radiographic, biochemical, and molecular methods. A radiographic scoring system was devised to assess the severity of spinal and joint damage. Two patients were treated with nitisinone for 10 and 9 days, respectively.

RESULTS

Life-table analyses showed that joint replacement was performed at a mean age of 55 years and that renal stones developed at 64 years, cardiac-valve involvement at 54 years, and coronary-artery calcification at 59 years. Linear regression analysis indicated that the radiographic score for the severity of disease began increasing after the age of 30 years, with a more rapid increase in men than in women. Twenty-three new HGO mutations were identified. In a 51-year-old woman, urinary HGA excretion fell from 2.9 to 0.13 g per day after a 10-day course of nitisinone (7 days at a dose of 0.7 mg per day and 3 days at 2.8 mg per day). In a 59-year-old woman, urinary HGA fell from 6.4 g to 1.7 g per day after nine days of treatment with nitisinone (0.7 mg per day). Plasma tyrosine levels in these patients rose from approximately 1.1 mg per deciliter (60 micromol per liter) in both to approximately 12.8 mg per deciliter (700 micromol per liter) and 23.6 mg per deciliter (1300 micromol per liter), respectively, with no clinical signs or symptoms.

CONCLUSIONS

The reported data on the natural history of alkaptonuria provide a basis for the evaluation of long-term therapies. Although nitisinone can reduce HGA production in humans with homogentisate 1,2-dioxygenase deficiency, the long-term safety and efficacy of this treatment require further evaluation.

High prevalence of osteonecrosis of the femoral head in HIV-infected adults

BACKGROUND

Osteonecrosis has been reported to occur occasionally among HIV-infected patients. The diagnosis of symptomatic osteonecrosis of the hip in two of the authors' patients, together with reports from community physicians, raised a concern that the prevalence of osteonecrosis is increasing.

OBJECTIVE

To determine the prevalence of osteonecrosis of the hip in asymptomatic HIV-infected patients and to identify potential risk factors associated with osteonecrosis.

DESIGN

Survey and comparison study.

SETTING

The Clinical Center of the U.S. National Institutes of Health.

PARTICIPANTS

339 asymptomatic HIV-infected adults (of 364 asked to participate) and 118 age- and sex-matched HIV-negative volunteers enrolled between 1 June and 15 December 1999.

MEASUREMENTS

Osteonecrosis of the hip, as documented by magnetic resonance imaging. Data from clinic records and a patient questionnaire administered before magnetic resonance imaging were used in an analysis of risk factors. A subset of patients was evaluated for hypercoagulable state.

RESULTS

Fifteen (4.4% [95% CI, 2.5% to 7.2%]) of 339 HIV-infected participants had osteonecrosis lesions on magnetic resonance imaging, and no HIV-negative participants had similar lesions. Among HIV-infected participants, osteonecrosis occurred more frequently in those who used systemic corticosteroids, lipid-lowering agents, or testosterone; those who exercised routinely by bodybuilding; and those who had detectable levels of anticardiolipin antibodies.

CONCLUSIONS

Patients infected with HIV have an unexpectedly high occurrence of osteonecrosis of the hip. Although screening asymptomatic patients is not warranted, HIV-infected patients with persistent groin or hip pain should be evaluated for this debilitating complication.

Sonography and MR imaging of posterior tibial tendinopathy

OBJECTIVE

The purpose of the study is to describe the appearance of the posterior tibialis tendon on MR imaging and high-resolution sonography with color and power Doppler imaging and to determine whether sonography is as accurate for diagnosing tendinosis as MR imaging.

SUBJECTS AND METHODS

Fifteen healthy volunteers and 31 patients (44 tendons) who were clinically suspected of having posterior tibial tendinopathy were prospectively evaluated with MR imaging and sonography.

RESULTS

On MR imaging, the normal tendon was elliptic on cross section and showed low signal intensity on all sequences. Minimal peritendinous enhancement and fluid were seen. On sonography, the tendon showed homogeneous longitudinal echogenic fibers. No flow was seen in or around the tendon. Tendinopathy was characterized by enhancement of the tendon on MR imaging (19/44 tendons); intratendinous flow on color Doppler sonography (16/44 tendons); increase in the anteroposterior diameter causing a rounding of the tendon (18/44 tendons); and inhomogeneity of the tendon (16/44 tendons on MR imaging and 21/44 tendons on sonography). Peritendinosis was characterized by peritendinous enhancement on MR imaging (29/44 tendons); flow on color Doppler sonography (20/44 tendons); and increased soft tissue (20/44 tendons on MR imaging and 27/44 tendons on sonography). When compared with MR imaging, the sensitivity and specificity of sonography for diagnosing tendinopathy were 80% and 90%, respectively, and for diagnosing peritendinosis were 90% and 80%. Addition of abnormal size to the structural abnormality criteria did not improve diagnostic ability.

CONCLUSION

Sonography can be useful as the initial imaging study in evaluating abnormalities caused by posterior tibial tendinopathy.

Cancer rehabilitation into the future

The 5-year survival for many cancer sites exceeds 50%, suggesting that these patients are living longer and may be considered to have a chronic illness. The incidence of cancer increases from 500 in 100,000 to 2000-4000 in 100,000 as women or men age from 50 to 80 years. Our population is aging and the prevalence of cancer is increasing. Treatments for cancer are quite complex, and they are often delivered to elders who have a variety of medical problems and are receiving additional medications that may complicate overall patient management. Hence, these patients may have extremely complex functional problems. Cancer patients need comprehensive care designed to relieve symptoms of pain, fatigue, and weakness. They need education to help support their ability to reach functional independence and maintain quality of life. Rehabilitation professionals are essential for the comprehensive care of cancer patients throughout the phases of their disease: treatment planning, treatment, remission, recurrence, and end of life. The needs of this population can better be served if several processes are put into effect. Rehabilitation professionals must be trained to manage problems associated with cancer and its treatments. Research about what are effective and efficient rehabilitation treatments must be done to determine how best to treat cancer patients throughout the various phases of their illness. Physicians and patients must be alerted to the importance of rehabilitation interventions to the overall function of these patients.

A review of measures of lymphedema

BACKGROUND

Lymphedema usually is identified by patients, and rarely is it screened for routinely. Many assessments have been reported and have been used in evaluating a variety of treatments for lymphedema.

METHODS

A review of the literature was undertaken.

RESULTS

Five frequently used measures of lymphedema include circumferential measures of limbs at various points (usually at bony landmarks); volumetric measures using limb submersion in water; skin tonometry, in which soft tissue compression is quantified; imaging techniques to describe tissue characteristics as well as to quantify soft tissue swelling (magnetic resonance imaging and computerized tomography; and ultrasound with and without Doppler flow studies for volumetric measures. Circumferential measures with calculations designed to compute limb volumes and volumetric measures are used most frequently, but these have some difficulty with reliability. No significant effort has been made to develop a patient based questionnaire that describes the size as well as the impact of lymphedema on an individual's functional level.

CONCLUSIONS

Existing physical measures of lymphedema are available that are easy to use, inexpensive, have limited reliability, and do not address the issue of functional impact. Imaging techniques may provide valuable qualitative and quantitative information in selected populations.

Forefoot deformity, pain, and mobility in rheumatoid and nonarthritic subjects

OBJECTIVE

To evaluate how painful metatarsal arthritis affects foot and ankle mechanics and mobility.

METHODS

We studied 16 symptomatic forefeet in 10 patients with rheumatoid arthritis (RA) and compared them with 14 asymptomatic forefeet in 7 nonarthritic subjects. RA limbs with significant disease at other locations were excluded. We measured pain and deformity of the foot using a visual analog scale and a modified articular index. A video based 3 dimensional gait analysis system and force platform were used to collect data on subjects walking barefoot at a self-selected pace according to an established protocol. Mobility level was quantified using the Sickness Impact Profile (SIP) ambulation subscale.

RESULTS

We observed considerable pain and deformity of the forefeet of RA subjects. During gait, motion and force measures revealed that RA subjects significantly (p < 0.005) delayed and reduced forefoot loading, which minimized use of the foot as a rigid level for push off. As a result, stride lengths were shorter and gait was slower compared to nonarthritic subjects. SIP scores revealed that these changes in gait resulted in moderate disability in RA subjects (p=0.05).

CONCLUSION

Impairments of the forefoot due to RA include pain and deformity, which produce characteristic stance phase abnormalities in foot function, a slow walking speed, and moderate disability.

Effects of withdrawal of bracing in matched pairs of children with osteogenesis imperfecta

OBJECTIVES

To evaluate the effects of withdrawal of long-leg braces (hip-knee-ankle-foot orthoses [HKAFO]) on activity and ambulation in children with osteogenesis imperfecta.

DESIGN

A prospective, randomized cross-over trial, that describes the effects of withdrawing HKAFO.

PATIENTS

Ten children who were ambulatory with the assistance of braces. All had type III or IV osteogenesis imperfecta. Children were paired for age and clinical severity. Strength testing, fractures, and independence in daily activity were monitored at 4-month intervals for 32 months (16 months each of braced and unbraced periods). Gait was analyzed during braced and unbraced conditions.

RESULTS

Muscle strength declined .35 grade during unbraced and .1 grade during braced intervals. Children spent more time in upright activity during braced intervals than during unbraced intervals (p = .17). Children were more independent in daily activities during braced than during unbraced periods (p = .14). Seventeen fractures of lower extremities occurred during all the unbraced periods, and 8 occurred during the braced intervals (p = .08); the fracture rate was higher during unbraced intervals. (p = .06) Bracing was associated with increased hip flexion and stride length and decreased transverse plane pelvic rotation.

CONCLUSION

Withdrawal of HKAFO in children with osteogenesis imperfecta who had achieved upright activity was not associated with significant decrease in muscle strength or independence, but there was an associated increase in fracture rate that nearly reached significance.