Patient education in physiotherapy of low back pain: acute outcomes of group instruction

BACKGROUND

Adults with recalcitrant mechanical low back pain of more than six weeks duration can encounter unacceptable waiting periods for specialised care.

AIM

To evaluate the effectiveness of rapid treatment by means of group sessions.

METHODS

We instituted a rapidly accessed patient education programme in physiotherapy for low back pain. Pain and disability were assessed before and after the programme. The programme included four sessions of group instruction for self-actuated physiotherapy There were six to 10 patients per group.

RESULTS

In eight months, 160 patients were admitted to the programme. The average waiting time was 16 business days for the first appointment. Seventy-three per cent of the patients who attended some portion of the programme completed all sessions. At least 30% of the incompletions were ascribable to rapid improvement. Of patients completing the programme, 80% reported significant resolution of the pain and improvement in function. Twenty per cent reported no significant response, but no patients worsened during participation. Of the 20% with no subjective improvement, 50% were pursuing medico-legal claims. In comparison, 9% of those reporting a successful response were pursuing litigation.

CONCLUSIONS

Group instruction in physiotherapy for low back pain is safe, generally successful, and highly acceptable to patients.

Synthesis and biological activity of analogues of the antidiabetic/antiobesity agent 3-guanidinopropionic acid: discovery of a novel aminoguanidinoacetic acid antidiabetic agent

3-Guanidinopropionic acid (1, PNU-10483) has been demonstrated to both improve insulin sensitivity and to promote weight loss selectively from adipose tissue in animal models of non-insulin-dependent diabetes mellitus (NIDDM). However, 1 has also been shown to be a substrate for both the creatine transporter and creatine kinase, leading to marked accumulation in muscle tissue as the corresponding N-phosphate 4. In an effort to identify novel entities that maintain antidiabetic potency without susceptibility to creatine-like metabolism, an analogue program was undertaken to explore the effects of various structural modifications, including homologation, simple substitution, single atom mutations, and bioisosteric replacements for the guanidine and carboxylic acid. Overall, the scope of activity encompassed by the set of new analogues proved to be exceedingly narrow. Notable exceptions demonstrating equivalent or improved antidiabetic activity included the alpha-amino derivative 29, aminopyridine 47, isothiourea 67, and aminoguanidine 69. On the basis of its superior therapeutic ratio, aminoguanidine 69 was selected for preclinical development and became the foundation for a second phase of analogue work. Furthermore, in vitro studies demonstrated that 69 is markedly less susceptible to phosphorylation by creatine kinase than the lead 1, suggesting that it should have less potential for accumulation in muscle tissue than 1.

Synthesis of a series of stromelysin-selective thiadiazole urea matrix metalloproteinase inhibitors

The synthesis and enzyme inhibition data for a series of thiadiazole urea matrix metalloproteinase (MMP) inhibitors are described. A broad screening effort was utilized to identify several thiadiazoles which were weak inhibitors of stromelysin. Optimization of the thiadiazole leads to include an alpha-amino acid side chain with variable terminal amide substituents provided a series of ureas which were moderately effective stromelysin inhibitors, with Ki's between 0.3 and 1.0 microM. The most effective analogues utilized an L-phenylalanine as the amino acid component. In particular, unsubstituted 46 had a Ki of 710 nM, while the p-fluoro analogue 52 displayed increased potency (100 nM). Stromelysin inhibition was further improved using a pentafluorophenylalanine substituent which resulted in 70, a 14 nM inhibitor. While gelatinase inhibition was generally poor, the use of 1-(2-pyridyl)piperazine as the amide component usually provided for enhanced activity, with 71 inhibiting gelatinase with a Ki of 770 nM. The combination of this heterocycle with a p-fluorophenylalanine substituent provided the only analogue, 69, with collagenase activity (13 microM). The SAR for analogues described within this series can be rationalized through consideration of the X-ray structure recently attained for70 complexed to stromelysin. Uniquely, this structure showed the inhibitor to be completely orientated on the left side of the enzyme cleft. These results suggest that thiadiazole urea heterocycles which incorporate a substituted phenylalanine can provide selective inhibitors of stromelysin. Careful selection of the amide substituent can also provide for analogues with modest gelatinase inhibition.

Structural characterizations of nonpeptidic thiadiazole inhibitors of matrix metalloproteinases reveal the basis for stromelysin selectivity

The binding of two 5-substituted-1,3,4-thiadiazole-2-thione inhibitors to the matrix metalloproteinase stromelysin (MMP-3) have been characterized by protein crystallography. Both inhibitors coordinate to the catalytic zinc cation via an exocyclic sulfur and lay in an unusual position across the unprimed (P1-P3) side of the proteinase active site. Nitrogen atoms in the thiadiazole moiety make specific hydrogen bond interactions with enzyme structural elements that are conserved across all enzymes in the matrix metalloproteinase class. Strong hydrophobic interactions between the inhibitors and the side chain of tyrosine-155 appear to be responsible for the very high selectivity of these inhibitors for stromelysin. In these enzyme/inhibitor complexes, the S1' enzyme subsite is unoccupied. A conformational rearrangement of the catalytic domain occurs that reveals an inherent flexibility of the substrate binding region leading to speculation about a possible mechanism for modulation of stromelysin activity and selectivity.

The otological manifestations of Wegener's granulomatosis

Three cases of Wegener's granulomatosis are described in which the common presenting symptoms were those of aural discomfort and discharge. The otological manifestations of this disease process are discussed and a review of the literature is presented.

Complications of Venturi jet ventilation during microlaryngeal surgery

Microlaryngoscopy for the diagnosis and treatment of laryngeal pathology is a commonly performed procedure in otolaryngology. The use of this technique continues to increase in frequency due to the availability of laser surgery for the management of laryngeal disease. Ventilation during microlaryngoscopy, however, poses a problem as the airway must be shared by the anesthesiologist and the otolaryngologist. Although many techniques of ventilation during microlaryngoscopy are used, the use of high-pressure Venturi jet ventilation, especially during laser surgery, is most frequent. Complications during high-pressure Venturi jet ventilation are uncommon but may occur suddenly and present the surgeon with a life-threatening emergency. Hypoventilation, pneumomediastinum, pneumothorax, severe abdominal distention, and death (directly attributable to various methods of jet ventilation) have been described.

Pigmented villonodular synovitis of the temporomandibular joint

Pigmented villonodular synovitis ( PVNS ) is a benign disease of unknown etiology arising from the synovial membranes of joints, bursae, and tendon sheaths. Though histologically benign, it is a very aggressive lesion, capable of bone destruction and widespread infiltration of surrounding tissues. It is a rare disease, usually confined to large joints, particularly the knee. Its propensity for recurrence is emphasized in this report. Involvement of the temporomandibular joint (TMJ) is unusual. It most commonly presents in the TMJ region as a left pre-auricular mass. Symptoms of TMJ dysfunction are usually present, but may be subtle. These may consist of painful mastication, clicking, trismus, malocclusion, and deep pain in the TMJ. Radiological evidence of bone destruction is frequently present, and together with the pre-auricular mass, should suggest the diagnosis. Surgical excision is the preferred mode of treatment. While cosmesis is a consideration, radical excision, including involved bone, is mandatory to prevent recurrence. The effect of radiotherapy on this disease in the head and neck region is documented.

The pathogenesis, differential diagnosis, and treatment of malignant otitis externa

Three cases of malignant external otitis with varied clinical causes are presented. It is most important to suspect the condition in any diabetic who has external otitis refractory to the usual treatment. Once the diagnosis is made, aggressive medical management is imperative to prevent progression of the disease.