Measuring quality of movement in cerebral palsy: a review of instruments

There is a lack of appropriate evaluation instruments in the area of quality of movement in cerebral palsy. Ten measures of quality of movement, or gross motor performance, published between 1965 and 1990, were reviewed according to established criteria. These criteria include the purpose of the measure, validity, reliability, responsiveness, range of items, and description of qualitative components. These measures provide a foundation for further instrument development in the area of quality of movement. [Boyce WF, Gowland C, Rosenbaum PL, et al. Measuring quality of movement in cerebral palsy: a review of instruments.

A re-evaluation of the osteoarticular manifestations of psoriasis

A distinctive peripheral arthropathy associated with psoriasis is well recognized, the classical pattern describing an asymmetrical oligoarthritis with predominant distal interphalangeal joint (DIP) involvement. There is some dispute about the frequency of this classical pattern and of the pattern of symmetrical polyarthritis resembling rheumatoid arthritis. Some of the dispute may be a result of loose definitions. In this clinical and scintigraphic study of 50 patients with psoriatic arthritis we have used tighter definitions of disease pattern and have found that 68% of this group had a symmetrical polyarthritis similar to that found in rheumatoid arthritis. Yet, arthritis associated with psoriasis differs from rheumatoid arthritis in a number of ways including the pattern of joint involvement, extra-articular osseous features, and radiological changes. Scintigraphic changes in psoriatic arthritis suggest that subclinical involvement of the manubriosternal and sternoclavicular joints is common, suggesting an association between psoriasis vulgaris and arthro-osteitis. A modified classification of the osteoarticular manifestations of psoriasis is proposed.

Polymyalgia rheumatica and rheumatoid arthritis of the elderly: a clinical, laboratory, and scintigraphic comparison

Clinical, laboratory, and scintigraphic features of 16 patients with polymyalgia rheumatica and 23 patients matched for age presenting with classical or definite rheumatoid arthritis (American Rheumatism Association 1958 criteria) of the elderly were compared in order to define features that might distinguish between these two syndromes. The sensitivity of proposed diagnostic criteria for polymyalgia rheumatica was always higher in the group with polymyalgia rheumatica, though only significantly so for morning stiffness. A comparison of 27 different laboratory features showed few significant differences between the diseases, though correlation between laboratory variables within each of the disease groups differed, perhaps suggesting a fundamental pathogenetic difference between them. Scintigraphy of the shoulder joint proved of no value in differential diagnosis. It was concluded that polymyalgia rheumatica and rheumatoid arthritis of the elderly are probably discrete clinical entities. Bilateral upper arm tenderness, lack of positive rheumatoid factor, and a normal caeruloplasmin are the most valuable features for distinguishing polymyalgia rheumatica from rheumatoid arthritis of the elderly.

The role of aggression in peer relations: an analysis of aggression episodes in boys' play groups

Although aggression is frequently cited as a major cause of peer social rejection, no more than half of all aggressive children are rejected. Aggressive episode data from experimental play groups of 7- and 9-year-old black males were coded to examine whether qualitative aspects of aggressive behavior, as well as frequency of aggression, determine the relation between aggressiveness and peer rejection. Reactive aggression and bullying were related to peer status among 9-year-olds, but not 7-year-olds, whereas instrumental aggression was characteristic of highly aggressive, rejected boys at both ages. Qualitative features of aggressive interaction suggested a greater level of hostility toward peers and a tendency to violate norms for aggressive exchange among rejected, aggressive boys at both ages in contrast to other groups of boys. The descriptive data provide a distinctive picture of reactive, instrumental, and bullying aggression as well as differing social norms for target and aggressor behavior in each of these 3 types of aggression.

Cytidine deaminase activity, C reactive protein, histidine, and erythrocyte sedimentation rate as measures of disease activity in psoriatic arthritis

Cytidine deaminase activity, C reactive protein, histidine, and erythrocyte sedimentation rate were measured in 36 subjects with psoriatic arthritis of varying disease duration and severity. Although cytidine deaminase activity may provide an integrated measure of synovial inflammation in rheumatoid arthritis, neutrophil accumulation in psoriatic plaques compromises this measure in psoriatic arthritis. Low histidine concentrations confirm that this amino acid provides a non-specific index of synovial inflammation. In psoriatic arthritis high C reactive protein concentrations seem to be associated with extensive joint destruction. In this study the erythrocyte sedimentation rate was found to be the best laboratory guide to clinical disease activity in psoriatic arthritis.

Bioengineering aspects of rehabilitation

This paper discusses the development of bioengineering in the field of human joints and its particular relevance to rehabilitation.

Valuing and rewarding employees in the changed health service

Last November, at the IHSM conference on human resources, Vicky Wright spoke on valuing and rewarding people. Here, with David Patterson and Helen Murlis, she amplifies her argument. In a changing service pay policy must change, but change is not without risk and will not in itself revolutionise human resource management.

The development and use of Patient Knowledge Questionnaire in rheumatoid arthritis

A multi-choice Patient Knowledge Questionnaire (PKQ) was developed for use with patients with rheumatoid arthritis (RA). Test/re-test was used to test its stability (r = 0.81), and Kuder Richardson formula 20 (r = 0.72) for internal consistency. Seventy randomly selected RA patients then completed the PKQ in a rheumatology out-patient clinic of a large teaching hospital. There was a wide variation in total scores ranging from 3 to 28 out of 30. Total scores correlated with years of general education (P less than 0.05) but not with disease duration or age. Sixty-two per cent of patients knew that the cause of RA is, as yet, unknown but 27% thought it could be caused by injury and 11% by cold damp weather. Fifty-two per cent had no idea why they had blood tests. All but four patients were taking some form of medication but there was widespread confusion about disease-modifying drugs and non-steroidal anti-inflammatory drugs (NSAIDs). Exercise was reasonably well understood but many patients were unable to differentiate between methods of energy conservation and joint protection. This study highlights the need for careful individual knowledge assessment by use of tools such as the PKQ and effective patient education programmes.

Endocrine disorders

Recent studies emphasize the adverse effects of endocrine disorders on bone mass. Successful surgery for hyperparathyroidism results in an increase in bone mass, although impact on future fracture rates in these patients is unknown. The etiology of reduced bone mass in diabetes is still unclear, and the adverse effects of thyroxine replacement treatment on bone mass need to be carefully balanced against beneficial effects on hypercholesterolemia. Musculoskeletal problems in chronic renal failure are common, but investigations into their pathogenesis are complicated by the coexistence of renal endocrine failure and beta 2-microglobulin-related amyloid deposition in long-term dialysis patients. An improved definition of dialysis arthropathy is needed. The type of dialysis membrane does not appear to be important in the pathogenesis of this condition.

A study of adjunctive copper sulphate treatment in patients with rheumatoid arthritis who have relapsed while taking D-penicillamine

Formation of a D-penicillamine-copper complex may be necessary for the anti-rheumatic effect of D-penicillamine. Thus, depletion of copper stores by D-penicillamine may eventually lead to relapse in D-penicillamine treated patients. Twenty-one patients who relapsed on D-penicillamine were randomised to copper sulphate 20 mg daily (n = 13) or matched placebo (n = 8) in addition to penicillamine daily for 16 weeks. Urinary copper was increased in the copper treated patients but no statistically significant or clinically important improvement occurred in either group.

New engineering concepts and alternative materials for prostheses

This overview paper summarizes work in new materials and designs for prostheses and reports on the papers presented at the Fifteenth Annual Day Conference, held at Leeds, 5 January 1990, by the Bioengineering Group for the Study of Human Joints in association with the Biological Engineering Society.

Post-traumatic osteoarthritis--a medico-legal minefield

A consensus view has been obtained from 108 colleagues about four major questions relating to post-traumatic osteoarthritis (OA) posed by a retired judge. In determining the likelihood of OA developing after a fracture, several factors must be taken into account. These include whether the fracture goes through the joint, the resulting angular deformity, the degree of soft tissue damage, the ensuing laxity of the joint, the presence of generalized OA, the involvement of nearby blood vessels supplying the bones of the joint and possibly the degree of immobilization. Lower limb joints are more likely to develop arthritis after injury than arm joints as they carry more load (although it would be wrong to think that arm joints were not load bearing). Occupation is a further factor. Age is thought to be important, with the elderly more at risk immediately, but the younger having longer in which to develop the disease. Younger people are less likely to develop post-traumatic OA, unless there is involvement of the epiphysis or residual angular deformity. Whilst in animals and in some fractures, degenerative changes begin immediately after damage to the joint, in most adults they take at least 2 years. The span is 2-5 years in more severe cases, including fractures of the joint line with a step in the surface, and associated dislocation. Otherwise it may take 10 years. Most of these data are anecdotal or obtained from retrospective surveys. There is great need for prospective work in this field.

Introduction to rheumatic disease

Rheumatic diseases are very common. They comprise one of the commonest causes of consultation by patients with general practitioners and hospital specialists. There are considerable financial implications for the community, as well as morbidity for the patient. Inflammatory and non-inflammatory categories are the major subdivisions of this group of over 200 diseases. They involve the joints, the bones, the muscles and connective tissue throughout the body.

Patients' perceptions of staff in a department of rheumatology

Three groups of 44 rheumatic patients were studied in a Regional Rheumatology Centre, and two out-patient clinics (one conducted by a consultant, the other by a nurse practitioner). A questionnaire determined their perceptions of staff members, their spouses, and the patients with whom they had most contact. In the usual in- and out-patient setting, patients preferred to be told about their condition by the consultant. In the clinic where they saw a nurse practitioner regularly, over half preferred to be told by her. The patients found it easier to discuss their condition with a nurse (particularly of a lower rank than a sister). Much came from spouses and other patients. The consultant and sister had important roles in reassuring the patients, but doctors were not successful in making patients feel useful and needed. Nurses were somewhat better--but not that good (30%). This was a vital role for the spouse, who nevertheless in hospital produced much anxiety, closely followed by visitors, other patients and doctors. Nurses and occupational therapists were very calming and relaxing people.