Circulating levels of inflammatory cytokines and cytokine receptors in patients with ankylosing spondylitis: a cross-sectional comparative study

OBJECTIVES

Insight into the most important inflammatory pathways in ankylosing spondylitis (AS) could be of importance in risk stratification and the development of treatment strategies. Therefore, we aimed to compare circulating levels of inflammatory biomarkers between AS patients and controls, and explore associations between these biomarkers and clinical measures of disease activity.

METHOD

In a cross-sectional study, 143 AS patients were compared with 124 population controls. Blood samples were analysed by immunoassays for interleukin (IL)-6, IL-17a, IL-23, soluble tumour necrosis factor receptor 1 (sTNF-R1) and 2 (sTNF-R2), and osteoprotegerin (OPG). Disease activity was measured by the AS Disease Activity Score (ASDAS) and the Bath AS Disease Activity Index (BASDAI).

RESULTS

Analysis of covariance (ANCOVA) demonstrated elevated plasma levels of sTNF-R1 [geometrical mean 0.94 (95% CI 0.88-1.00) vs. 0.83 (95% CI 0.78-0.89) ng/mL, p < 0.01] and OPG (2.3, 95% CI 2.1-2.4 vs. 2.0, 95% CI 1.9-2.2 ng/mL, p = 0.02) and, although not significant, of IL-23 (122, 95% CI 108-139 vs. 106, 95% CI 93-120 pg/mL, p = 0.07) in AS patients vs.

CONTROLS

More AS patients had a high level of sTNF-R2 than controls (22 vs. 1, p < 0.01). No differences between the groups were seen for IL-6 and IL-17a. In patients, no significant associations were seen between inflammatory markers and disease activity measures after adjusting for personal characteristics.

CONCLUSION

Significantly higher plasma levels of sTNF-R1, sTNF-R2, and OPG and numerically but non-significantly higher levels of IL-23 were found in AS patients compared to controls, indicating that these cytokines and cytokine receptors are important inflammatory pathways. Clinical measures of disease activity were not significantly correlated with circulating inflammatory markers.

Efficacy of high intensity exercise on disease activity and cardiovascular risk in active axial spondyloarthritis: a randomized controlled pilot study

BACKGROUND

Physical therapy is recommended for the management of axial spondyloarthritis (axSpA) and flexibility exercises have traditionally been the main focus. Cardiovascular (CV) diseases are considered as a major health concern in axSpA and there is strong evidence that endurance and strength exercise protects against CV diseases. Therefore, the aim of this study was to investigate the efficacy of high intensity endurance and strength exercise on disease activity and CV health in patients with active axSpA.

METHODS

In a single blinded randomized controlled pilot study the exercise group (EG) performed 12 weeks of endurance and strength exercise while the control group (CG) received treatment as usual. The primary outcome was the Ankylosing Spondylitis (AS) Disease Activity Score (ASDAS). Secondary outcomes included patient reported disease activity (Bath AS Disease Activity Index [BASDAI]), physical function (Bath AS Functional Index [BASFI]), and CV risk factors measured by arterial stiffness (Augmentation Index [Alx]) and Pulse Wave Velocity [PWV]), cardiorespiratory fitness (VO2 peak) and body composition. ANCOVA on the post intervention values with baseline values as covariates was used to assess group differences, and Mann Whitney U-test was used for outcomes with skewed residuals.

RESULTS

Twenty-eight patients were included and 24 (EG, n = 10, CG, n = 14) completed the study. A mean treatment effect of -0.7 (95%CI: -1.4, 0.1) was seen in ASDAS score. Treatment effects were also observed in secondary outcomes (mean group difference [95%CI]): BASDAI: -2.0 (-3.6, -0.4), BASFI: -1.4 (-2.6, -0.3), arterial stiffness (estimated median group differences [95% CI]): AIx (%): -5.3 (-11.0, -0.5), and for PVW (m/s): -0.3 (-0.7, 0.0), VO2 peak (ml/kg/min) (mean group difference [95%CI]: 3.7 (2.1, 5.2) and trunk fat (%): -1.8 (-3.0, -0.6). No adverse events occurred.

CONCLUSION

High intensity exercise improved disease activity and reduced CV risk factors in patients with active axSpA. These effects will be further explored in a larger trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01436942.

Muscle activity and head kinematics in unconstrained movements in subjects with chronic neck pain; cervical motor dysfunction or low exertion motor output?

Background

Chronic neck pain after whiplash associated disorders (WAD) may lead to reduced displacement and peak velocity of neck movements. Dynamic neck movements in people with chronic WAD are also reported to display altered movement patterns such as increased irregularity, which is suggested to signify impaired motor control. As movement irregularity is strongly related to the velocity and displacement of movement, we wanted to examine whether the increased irregularity in chronic WAD could be accounted for by these factors.

Methods

Head movements were completed in four directions in the sagittal plane at three speeds; slow (S), preferred (P) and maximum (M) in 15 men and women with chronic WAD and 15 healthy, sex and age-matched control participants. Head kinematics and measures of movement smoothness and symmetry were calculated from position data. Surface electromyography (EMG) was recorded bilaterally from the sternocleidomastoid and splenius muscles and the root mean square (rms) EMG amplitude for the accelerative and decelerative phases of movement were analyzed.

Results

The groups differed significantly with regard to movement velocity, acceleration, displacement, smoothness and rmsEMG amplitude in agonist and antagonist muscles for a series of comparisons across the test conditions (range 17 – 121%, all p-values < 0.05). The group differences in peak movement velocity and acceleration persisted after controlling for movement displacement. Controlling for differences between the groups in displacement and velocity abolished the difference in measures of movement smoothness and rmsEMG amplitude.

Conclusions

Simple, unconstrained head movements in participants with chronic WAD are accomplished with reduced velocity and displacement, but with normal muscle activation levels and movement patterns for a given velocity and displacement. We suggest that while reductions in movement velocity and displacement are robust changes and may be of clinical importance in chronic WAD, movement smoothness of unconstrained head movements is not.

Protocol for a qualitative study of knowledge translation in a participatory research project

INTRODUCTION

In this article, we present a methodological design for qualitative investigation of knowledge translation (KT) between participants in a participatory research project. In spite of a vast expansion of conceptual models and frameworks for conducting KT between research and practice, few models emphasise how KTs come about. Better understanding of the actions and activities involved in a KT process is important for promoting diffusion of knowledge and improving patient care. The purpose of this article is to describe a methodological design for investigating how KTs come about in participatory research.

METHODS AND ANALYSIS

The article presents an ethnographic study which investigates meetings between participants in a participatory research project. The participants are researchers and primary healthcare clinicians. Data are collected through observation, interviews and document studies. The material is analysed using the analytical concepts of knowledge objects, knowledge forms and knowledge positions. These concepts represent an analytical framework enabling us to observe knowledge and how it is translated between participants. The main expected outcome of our study is to develop a typology of KT practices relevant to participatory research.

ETHICS AND DISSEMINATION

The project has been evaluated and approved by the Norwegian Social Science Data Services. Informed consent was obtained for all participants. The findings from this study will be disseminated through peer-reviewed publications and national and international conference presentations.

Traditional Chinese medicine patterns and recommended acupuncture points in infertile and fertile women

BACKGROUND

Acupuncture is rooted in traditional Chinese medicine (TCM) and emphasises individualised treatment according to TCM patterns. Eight TCM patterns are regarded as typical for female infertility. There are no empirical data comparing these patterns in fertile and infertile women.

OBJECTIVE

To identify and compare the TCM patterns and recommended acupuncture points in infertile and fertile women. The hypothesis that infertile and fertile women should differ in occurrence of TCM patterns described as typical for infertility was examined.

METHODS

A cross-sectional study examined the distribution of TCM patterns and acupuncture points among 24 infertile and 24 fertile women. TCM patterns and points proposed by two acupuncturists were analysed. The odds ratio was used as the effect measure.

RESULTS

Three patterns were found in more than 92% of the women. Five patterns occurred more frequently among infertile (p≤0.03), and four among fertile (p≤0.02) women. Only three of the eight patterns assumed typical for infertile women were more common among infertile women. Two of the eight patterns were more common among fertile women. Acupuncture points KI3, LI3 and SP6 were chosen for almost all women, whereas CV4, CV3 and ST29 were chosen more often for infertile women (p<0.03), and SP3 more often for fertile women (p<0.001).

CONCLUSION

The data indicate that the presence of some, and the absence of other, TCM patterns are associated with infertility. These results are not consistent with the assumed associations between eight specific patterns and infertility, as maintained by TCM textbooks.

Intermuscular relationship of human muscle fiber type proportions: slow leg muscles predict slow neck muscles

INTRODUCTION

Our aim in this study was to examine whether the muscle fiber type proportions in different muscles from the same individual are interrelated.

METHODS

Samples were excised from five skeletal muscles in each of 12 human autopsy cases, and the fiber type proportions were determined by immunohistochemistry. We further examined the intermuscular relationship in fiber type proportion by reanalyzing three previously published data sets involving other muscles.

RESULTS

Subjects demonstrated a predominantly high or low proportion of type 1 fibers in all examined muscles, and the overall difference between individuals was statistically significant (P < 0.001). Accordingly, the type 1 fiber proportions in most muscles were positively correlated (median r = 0.42, range -0.03-0.80). Similar results were also obtained from the three reanalyzed data sets.

CONCLUSIONS

We suggest the existence of an across-muscle phenotype with respect to fiber type proportions; some individuals display generally faster muscles and some individuals slower muscles when compared with others.

Low inter-rater reliability in traditional Chinese medicine for female infertility

BACKGROUND

Treatment of patients according to individual pattern diagnoses is an important feature of acupuncture rooted in traditional Chinese medicine (TCM). Little is known about the reliability of TCM pattern diagnoses.

OBJECTIVE

To examine in a cross-sectional study the inter-rater reliability of TCM diagnoses and acupuncture point selection.

METHODS

30 infertile and 24 previously pregnant women were examined for TCM patterns by two acupuncturists. An operational interview guide related to gynaecology was used. The acupuncturists independently decided on the TCM patterns (categorised as excess, deficiency and merged patterns) and the prescription of acupuncture points. Kappa Statistics were used in the analyses.

RESULTS

39 different TCM patterns and 36 different acupuncture points were used. For the choice of acupuncture points, poor to no agreement was found. Moderate to fair agreement was seen in excess/deficiency and merged patterns. Perfect match to moderate agreement on treatment was obtained when choosing meridians given certain TCM patterns.

CONCLUSIONS

The low agreement on diagnoses indicates that acupuncturists follow individual pattern differentiation processes. The selection of acupuncture points seem to be closely related to the choice of TCM pattern diagnoses. The results indicate that the poor reliability in the diagnoses and thus treatment received by a patient will vary individually, which in turn is a challenge for clinical trials of acupuncture.

Significant effect of gender on hamstring-to-quadriceps strength ratio and static balance in prepubescent children from 7 to 12 years of age

BACKGROUND

A number of studies have reported lower muscular strength of the hamstring and the quadriceps and better postural control in female compared with male athletes. Whether those differences are innate and also exist in children and adolescents or are caused by training and participation in different sports is unknown.

HYPOTHESIS

Gender differences in hamstring and quadriceps muscular strength and static balance exist even before maturity.

STUDY DESIGN

Cross-sectional study; Level of evidence, 4.

METHODS

A total of 368 children between 7 and 12 years of age participated in the study. They performed isokinetic concentric hamstring and quadriceps muscle strength measurements at 60 and 240 deg/s and a static balance test using the KAT 2000. Data analysis consisted of independent-samples t tests and multiple regression analysis.

RESULTS

Gender had a significant effect on both the hamstring/quadriceps (HQ) ratios and static balance in children between 7 and 12 years of age. Except for the 7-year-old participants, boys showed significantly higher HQ ratios than the girls in every age group, indicating that the hamstring muscles in girls were relatively weak when compared with the quadriceps muscles. There was also a gender effect on the balance index with better balance in girls than boys.

CONCLUSION

There is a significant gender difference in HQ ratios and static balance in children between 8 and 12 years of age. Because many children start their handball careers before the age of 10 years, the present findings indicate that prevention programs including hamstring strength training should be prescribed at an earlier age than recommended in previously published studies.

A normative sample of isotonic and isokinetic muscle strength measurements in children 7 to 12 years of age

AIM

To provide normative age- and gender-associated values on muscular strength, power and endurance and to establish a reference database on healthy school children aged 7 to 12 years. In addition, associations between some simple functional tests and the more sophisticated isokinetic strength measures were investigated.

METHODS

Three hundred seventy-six children, 191 girls and 185 boys, performed different muscle-strength tests like knee flexion/extension, handgrip, back extension and vertical jump.

RESULTS

There was a significant and linear increase in strength with no gender differences from 7 up to 11 years of age. There was a large variability within each age group, indicating that a normative sample of muscle-strength measurements includes a wide range of values for each age group. The relationship between hand- grip strength and observed quadriceps strength was high (r = 0.84) and the correlation between vertical jump and relative quadriceps strength was moderate (r = 0.50).

CONCLUSION

All the different strength measures showed almost the same pattern, indicating increased absolute strength values with increasing age and no significant gender differences except for flexion at the age of 11 and 12 years . The association between grip strength, vertical jump and quadriceps strength measured isokinetically was moderate to strong. The back muscle endurance test (The Biering-Sørensen test) showed a great roof effect and should not be included in a test battery for school children.

Impaired Motor Competence in School-aged Children With Complex Congenital Heart Disease

OBJECTIVE

To explore the extent and type of motor problems in children with complex congenital heart disease (CHD) compared with schoolchildren without any documented heart failure.

DESIGN

Cohort study.

SETTING

Biomechanical Laboratory, Rikshospitalet-Radiumhospitalet Medical Centre.

PARTICIPANTS

One hundred twenty children aged 7 to 12 years with complex CHD and 387 healthy schoolchildren in the same age range (control group).

INTERVENTIONS

All children with CHD were surgically treated with multiple corrections within the first year of life.

MAIN OUTCOME MEASURES

Movement Assessment Battery for Children, grip strength, quadriceps muscle strength, and balance.

RESULTS

Compared with the control group, children with CHD had a risk of having any degree of impaired motor competence of 5.8 (95% confidence interval, 3.8-8.8). The risk for having severe motor problems was 11.0 (95% confidence interval, 5.4-22.5). There were highly significant differences between the groups for manual dexterity, ball skills, grip strength, quadriceps muscle strength, and static and dynamic balance (P<.001).

CONCLUSIONS

Children with CHD have a risk of severe motor problems 11-fold that of schoolchildren without any known heart failure. This suggests that primary health care providers should screen the motor competence in children with CHD at an early age to initiate therapeutic actions for children who show incipient motor problems. Optimal rehabilitative, social, and environmental support may improve the children's motor competence and prevent future health problems.

Abdominal and pelvic floor muscle function in women with and without long lasting pelvic girdle pain

Approximately 5-20% of postpartum women suffer from long-lasting pelvic girdle pain (PGP). The etiology and pathogenesis of PGP are still unclear. The aim of this study was to examine whether subjects with and without persisting PGP and disability differed with respect to their ability to voluntarily contract the deep abdominals (TrA and IO) and to the strength of the pelvic floor muscles (PFM). Twenty subjects (12 with persisting PGP, 8 recovered from PGP) were examined. Contractions of the deep abdominal muscles (TrA and IO) were imaged by real-time ultrasound. Vaginal palpation and observation were used to assess the women's ability to perform correct a PFM contraction. PFM strength was measured by a vaginal balloon catheter connected to a pressure transducer. The active straight leg raise test was used to assess the ability of load transfer. The results showed no statistical significant difference between the groups in increase of muscle thickness of the deep abdominal muscles (TrA; P = 0.87 and IO; P = 0.51) or regarding PFM strength (P = 0.94). The ability to voluntarily contract the deep abdominal muscles and the strength of the PFMs are apparently not associated to PGP. However, the results are based on a small sample and additional studies are needed.

To treat or not to treat postpartum pelvic girdle pain with stabilizing exercises?

Women with pelvic girdle pain (PGP) often consult physical therapists for help and are treated with different therapies without firm evidence for the effectiveness. Two randomized controlled trials have investigated the effect of stabilizing exercises for PGP. The most recent study demonstrated significant positive results in favour of exercises (Stuge et al. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy. A randomized controlled trial. Spine 2004a;29(10):351-9), the other did not (Mens et al. Diagonal trunk muscle exercises in peripartum pelvic pain: a randomized clinical trial. Phys. Ther. 2000;80(12):1164-73). Consequently, the two studies provide contradictory advice for treatment of PGP. The question is thus, whether stabilizing exercises should be recommended as treatment for PGP. Both the studies are of high methodological quality and are comparable with regard to subjects studied. However, there are several differences in the interventions and these are explored and discussed for better understanding of the conflicting results. Exercises that focused on only global muscles showed no effect. However, these exercises were not individualized and they were instructed by videotape. In the more recent study, exercises that initially focused on local muscles, and then gradually added global muscles showed a significant, positive effect. Exercises in that study were supervised, corrected, individualized concerning choice of exercises, order and dosage, and pain was avoided. This comparison indicates that effective treatment of postpartum PGP may be achieved when exercises for the entire spinal musculature are included, individually guided and adapted to each individual.

The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a two-year follow-up of a randomized clinical trial

STUDY DESIGN

A randomized clinical trial.

OBJECTIVES

To examine the effects of a treatment program focusing on specific stabilizing exercises after a 2-year follow-up period.

SUMMARY OF BACKGROUND DATA

An individualized treatment approach with specific stabilizing exercises is shown to be effective for women with pelvic girdle pain 1 year after delivery. No previous study has examined the long-term effects of treatment for women with postpartum pelvic girdle pain.

METHODS

Eighty-one women with pelvic girdle pain postpartum were assigned randomly to 2 treatment groups for 20 weeks. Patient self-reported questionnaires measuring pain, disability, and health-related quality of life were collected after 20 weeks of treatment and 1 and 2 years postpartum.

RESULTS

All 81 women returned the questionnaires for the 2-year follow-up. Sixteen were excluded from the analysis, mainly due to new pregnancies. The significant differences between the groups in functional status, pain, and physical health (SF-36) were maintained 2 years after delivery. Minimal disability was found in 85% of the specific stabilizing exercise group as compared to 47% in the control group. The control group showed significant improvement in functional status with median change score of 6.0 (Q1-Q3 of -12-0). Minimal evening pain was reported by 68% in the specific stabilizing exercise group versus 23% in the control group. However, the group differences disappeared for all measures when controlling for score level 1 year after delivery by regression analysis.

CONCLUSION

The significant differences between the groups persisted with continued low levels of pain and disability in the specific stabilizing exercise group 2 years after delivery. Significant reduction in disability was found within the control group. Those with the highest level of disability and greatest potential for improvements recovered most, regardless of intervention group.

The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a randomized controlled trial

STUDY DESIGN

A randomized controlled trial with stratified block design.

OBJECTIVES

To evaluate a treatment program focusing on whether specific stabilizing exercises for patients with pelvic girdle pain after pregnancy reduce pain, improve functional status, and improve quality of life. SUMMARY OF BACKGROUND DATA. : The evidence of effectiveness of treatment for pelvic girdle pain is weak. Recent research has focused on the importance of activation of muscles for motor control and stability of the lumbopelvic region. To the authors' knowledge, the efficacy of applying these principles for pelvic girdle pain has not previously been evaluated in a randomized controlled trial.

METHODS

Eighty-one women with pelvic girdle pain were assigned randomly to two treatment groups for 20 weeks. One group received physical therapy with a focus on specific stabilizing exercises. The other group received individualized physical therapy without specific stabilizing exercises. Assessments were administered by a blinded assessor, at baseline, after intervention and 1 year post partum. Main outcome measures were pain, functional status and quality of life.

RESULTS

There were no dropouts. After intervention and at 1 year post partum, the specific stabilizing exercise group showed statistically and clinically significant lower pain intensity, lower disability, and higher quality of life compared with the control group. Group difference in median values for evening pain after treatment was 30 mm on the Visual Analog Scale. Disability was reduced by more than 50% for the exercise group; changes were negligible in the control group. Significant differences were also observed for physical tests, in favor of the specific exercise group.

CONCLUSION

An individualized treatment approach with specific stabilizing exercises appears to be more effective than physical therapy without specific stabilizing exercises for women with pelvic girdle pain after pregnancy.

Physical therapy for pregnancy-related low back and pelvic pain: a systematic review

BACKGROUND

A systematic review of prospective controlled clinical trials was performed to assess the effectiveness of physical therapy interventions for the prevention and treatment of pregnancy-related back and pelvic pain. Pregnancy-related low back and pelvic pain has an impact on daily life for many women. Prevention and treatment of back and pelvic pain is therefore an important issue for all those concerned with women's health.

METHODS

All prospective controlled clinical trials retrieved by systematic searching of electronic databases, checking of reference lists and contacting of authors were examined. Two reviewers independently selected trials for inclusion and independently assessed the internal validity of the included trials. Authors were contacted to obtain missing information.

RESULTS

Nine trials with a total of 1350 patients were reviewed. Except for three high-quality studies, the validity of the trials was moderate to low. Two high-quality studies showed no difference in pain intensity and functional status between the exercise groups and the control groups. In the third high-quality study significant reduction in sick leave was found in favor of water gymnastics compared with no intervention. Because the included trials were considered heterogeneous with regard to study design, population intervention and outcome, no meta-analysis was performed.

CONCLUSIONS

Because of heterogeneity and the varying quality of the studies no strong evidence exists concerning the effect of physical therapy interventions on the prevention and treatment of back and pelvic pain related to pregnancy. Future studies should meet current methodological standards, and interventions to be evaluated should be based on established theoretical framework.