Diagnosis and Management of Hypermobility Spectrum Disorders in Primary Care

Hypermobility spectrum disorders (HSDs) encompass an array of connective tissue disorders characterized by joint instability and chronic pain. Fatigue and other systemic symptoms that affect daily functioning may occur, as well. Accurate data on incidence and prevalence of HSDs is hampered by lack of awareness of these conditions and the wide heterogeneity of their clinical presentation. Identifying which type of HSD is present is important in guiding appropriate care. In particular, making the diagnosis of hypermobile Ehlers-Danlos syndrome (hEDS) is important, as individuals with hEDS may be at risk for more significant multisystem involvement. Diagnostic criteria for hEDS include measures of joint hypermobility, skin and other connective tissue findings, and lack of evidence of a different type of Ehlers-Danlos syndrome. Beyond accurate diagnosis, HSDs pose many challenges for primary care providers, as ongoing patient education, patient empowerment, and coordination of a multidisciplinary treatment team are integral to proper care. This article describes the incidence and prevalence, pathophysiology, diagnosis, and management of HSDs, including clinical cases exemplifying how joint hypermobility might present within a primary care setting.

Image-based biomechanical models of the musculoskeletal system

Finite element modeling is a precious tool for the investigation of the biomechanics of the musculoskeletal system. A key element for the development of anatomically accurate, state-of-the art finite element models is medical imaging. Indeed, the workflow for the generation of a finite element model includes steps which require the availability of medical images of the subject of interest: segmentation, which is the assignment of each voxel of the images to a specific material such as bone and cartilage, allowing for a three-dimensional reconstruction of the anatomy; meshing, which is the creation of the computational mesh necessary for the approximation of the equations describing the physics of the problem; assignment of the material properties to the various parts of the model, which can be estimated for example from quantitative computed tomography for the bone tissue and with other techniques (elastography, T1rho, and T2 mapping from magnetic resonance imaging) for soft tissues. This paper presents a brief overview of the techniques used for image segmentation, meshing, and assessing the mechanical properties of biological tissues, with focus on finite element models of the musculoskeletal system. Both consolidated methods and recent advances such as those based on artificial intelligence are described.

Physiological Effect of Exercise Training with Whole Body Electric Muscle Stimulation Suit on Strength and Balance in Young Women: A Randomized Controlled Trial

Many studies about Electrical muscle stimulation (EMS) have been performed to determine the effectiveness of EMS. However, most studies enrolled only elderly patients. Moreover, only a few studies have verified the effect of a whole body (WB)-EMS suit on young healthy women. Thus, the main purpose of this study was to verify the physiological effects of exercise training with a WB-EMS suit in young women. During the study periods, 24 young women were randomly assigned into two groups: 1) the WB-EMS training group, and 2) the control. All participants in the two groups performed the same low-intensity resistance exercise three times a week for 6 weeks at a training center. Group 1 used an electric current for WB-EMS suit which was switched on during the exercise period. Outcome measures were body composition, body circumference of hips and abdomen, isokinetic muscle function of knees, balance functions, Magnetic resonance imaging (MRI)s, cardiopulmonary functions, and lipid profiles. All outcomes were measured before and after the exercise protocol over 6 weeks. A total of 23 young women (group 1, n=11; group 2, n=12) completed a 6-week exercise regimen. After exercise, we compared the differences before and after the exercise program in each group. There were significant differences (p≤0.05) in body circumference, cardiopulmonary function in group 1 and 2. In particular, group 1 that activated WB-EMS showed significant differences in the isokinetic muscle function on knee flexors and balance functions. The results of this study show that exercise with a WB-EMS suit can be considered as an effective exercise addition for young women.

TUMOR CONTAMINATION IN THE BIOPSY PATH OF PRIMARY MALIGNANT BONE TUMORS

Objective: To study factors possibly associated with tumor contamination in the biopsy path of primary malignant bone tumors. Method: Thirty-five patients who underwent surgical treatment with diagnoses of osteosarcoma, Ewing's tumor and chondrosarcoma were studied retrospectively. The sample was analyzed to characterize the biopsy technique used, histological type of the tumor, neoadjuvant chemotherapy used, local recurrences and tumor contamination in the biopsy path. Results: Among the 35 patients studied, four cases of contamination occurred (11.43%): one from osteosarcoma, two from Ewing's tumor and one from chondrosarcoma. There was no association between the type of tumor and presence of tumor contamination in the biopsy path (p = 0.65). There was also no association between the presence of tumor contamination and the biopsy technique (p = 0.06). On the other hand, there were associations between the presence of tumor contamination and local recurrence (p = 0.01) and between tumor contamination and absence of neoadjuvant chemotherapy (p = 0.02). Conclusion: Tumor contamination in the biopsy path of primary malignant bone tumors was associated with local recurrence. On the other hand, the histological type of the tumor and the type of biopsy did not have an influence on tumor contamination. Neoadjuvant chemotherapy had a protective effect against this complication. Despite these findings, tumor contamination is a complication that should always be taken into consideration, and removal of the biopsy path is recommended in tumor resection surgery.

Effectiveness of adding motivational interviewing or a stratified vocational advice intervention to usual case management on return to work for people with musculoskeletal disorders: the MI-NAV randomised controlled trial

OBJECTIVES

To evaluate if adding motivational interviewing (MI) or a stratified vocational advice intervention (SVAI) to usual case management (UC), reduced sickness absence over 6 months for workers on sick leave due to musculoskeletal disorders.

METHODS

We conducted a three-arm parallel pragmatic randomised controlled trial including 514 employed workers (57% women, median age 49 (range 24-66)), on sick leave for at least 50% of their contracted work hours for ≥7 weeks. All participants received UC. In addition, those randomised to UC+MI were offered two MI sessions from social insurance caseworkers and those randomised to UC+SVAI were offered vocational advice from physiotherapists (participants with low/medium-risk for long-term sickness absence were offered one to two sessions, and those with high-risk were offered three to four sessions).

RESULTS

Median sickness absence was 62 days, (95% CI 52 to 71) in the UC arm (n=171), 56 days (95% CI 43 to 70) in the UC+MI arm (n=169) and 49 days (95% CI 38 to 60) in the UC+SVAI arm (n=169). After adjusting for predefined potential confounding factors, the results showed seven fewer days in the UC+MI arm (95% CI -15 to 2) and the UC+SVAI arm (95% CI -16 to 1), compared with the UC arm. The adjusted differences were not statistically significant.

CONCLUSIONS

The MI-NAV trial did not show effect on return to work of adding MI or SVAI to UC. The reduction in sickness absence over 6 months was smaller than anticipated, and uncertain due to wide CIs.

TRIAL REGISTRATION NUMBER

NCT03871712.

Treatment of a Patient With Central Pain Sensitization Using Graded Motor Imagery Principles: A Case Report

Objective

This case report describes the application of graded motor imagery principles to a patient experiencing central sensitization and chronic pain.

Clinical Features

A 46-year-old woman presented with pain in all 4 limbs along with global spinal pain and loss of range of motion. These symptoms initiated after a motor vehicle accident 5 years before and were exacerbated by 2 subsequent motor vehicle accidents. Examination indicated global loss of spinal range of motion, severe apprehension toward any movement, decreased grip strength bilaterally, and loss of 2-point discrimination. A variety of outcome assessments indicated severe disability.

Intervention and Outcome

The patient was seen at the chiropractic clinic 5× over 6 weeks and showed marked improvement with each visit. Treatment included pain neuroscience education, laterality training using the Recognize app, and explicit motor imagery. The patient demonstrated improvement in all baseline measures just described, including outcome assessment scores.

Conclusions

Over time, the patient reported decreased chronic pain and disability, along with improvement in grip strength and range of motion, after application of graded motor imagery strategies.

Do functional hamstring to quadriceps ratio differ between men and women with and without stroke?

BACKGROUND

The functional hamstrings/quadriceps ratio (FH/Q) is useful to detect muscle imbalances after stroke. However, is necessary to investigate possible differences between men and women affected by stroke and controls.

OBJECTIVES

To compare the FH/Q between men and women with stroke and matched controls.

METHOD

Cross-sectional study. Fifty-six participants (10 men - MSTK and 18 women - WSTK with stroke; and 10 men - MCONT and 18 women - WCONT, matched controls) were recruited. The concentric knee extension (conc) and eccentric flexion exercises (ecc) were performed, and peak torque (PT) was used to calculate the FH/Q. Comparisons of PT between sexes (MSTK vs WSTK; MCONT vs WCONT) and comparisons of FH/Q between sexes and groups (MSTK vs MCONT; WSTK vs WCONT), considering dominant vs non-paretic side and non-dominant vs paretic side were performed by ANOVA and Kruskal-Wallis test, when applicable.

RESULTS

No significant FH/Q differences were found between STK vs CONT and sexes (non-paretic vs dominant). The paretic FH/Q was significantly higher than the non-dominant (CONT), for both sexes. PTconc and PTecc were significant higher for men, considering limbs comparisons. No significant PTecc an PTconc differences were found between STK vs CONT, for men's non-paretic and paretic limb's. However, men's non-dominant limb presented a higher PTconc compared to men's paretic limbs.

CONCLUSIONS

Our study demonstrated that individuals affected by stroke had a higher FH/Q in the paretic limb compared to the non-dominant limb of the control group, for both men and women. One interesting finding was the absence of significant FH/Q differences between men and women with stroke.

Development and characterization of an intra-articular fracture mediated model of post-traumatic osteoarthritis

PURPOSE

This study aimed to develop and characterize a closed intra-articular fracture (IAF) mediated post-traumatic osteoarthritis (PTOA) model in rats to serve as a testbed for putative disease modifying interventions.

METHODS

Male rats were subject to a 0 Joule (J), 1 J, 3 J, or 5 J blunt-force impact to the lateral aspect of the knee and allowed to heal for 14 and 56 days. Micro-CT was performed at time of injury and at the specified endpoints to assess bone morphometry and bone mineral density measurements. Cytokines and osteochondral degradation markers were assayed from serum and synovial fluid via immunoassays. Histopathological analyses were performed on decalcified tissues and assessed for evidence of osteochondral degradation.

RESULTS

High-energy (5 J) blunt impacts consistently induced IAF to the proximal tibia, distal femur, or both while lower energy (1 J and 3 J) impacts did not. CCL2 was found to be elevated in the synovial fluid of rats with IAF at both 14- and 56-days post-injury while COMP and NTX-1 were upregulated chronically relative to sham controls. Histological analysis showed increased immune cell infiltration, increased osteoclasts and osteochondral degradation with IAF relative to sham.

CONCLUSION

Based on results from the current study, our data indicates that a 5 J blunt-forced impact adequately and consistently induces hallmark osteoarthritic changes to the articular surface and subchondral bone at 56 days after IAF. Marked development of PTOA pathobiology suggest this model will provide a robust testbed for screening putative disease modifying interventions that might be translated to the clinic for militarily relevant, high-energy joint injuries.

Surveillance is the first step to preventing injury among fast jet aircrew: results of a 2-year prospective cohort study

OBJECTIVES

Injury surveillance is imperative for injury prevention but difficult in military populations. Our objective was to accurately describe the pattern of musculoskeletal complaints among Royal Australian Air Force (RAAF) fast jet aircrew (FJA) using the validated University of Canberra Fast Jet Aircrew Musculoskeletal Questionnaire (UC-FJAMQ) over a 2-year period, and determine injury burden on the workforce and operational capability.

METHODS

306 RAAF FJA were monitored over a 2-year period (4×5 month reporting periods). Musculoskeletal complaint episodes (MCEs) were captured weekly using the UC-FJAMQ. Time loss episodes (TLEs) were captured from the UC-FJAMQ and injury registers completed by embedded physiotherapists. Cumulative severity and operational impact scores from the UC-FJAMQ, and time loss duration, were used to describe severity and calculate burden.

RESULTS

Mean weekly UC-FJAMQ response rate was 62%. 1012 MCEs were captured, with a mean weekly prevalence of 14.9% (95% CI 14.2-15.6), and incidence of 4.1 episodes per person-year (95% CI 3.9-4.4). A total of 145 TLEs were captured, with a mean 5-month prevalence of 12.4% (range 8.9-15.3%), and incidence of 0.37 episodes per person-year (95% CI 0.31-0.43). Spinal regions accounted for 81% of MCEs and contributed 76% and 85% of burden in relation to cumulative severity and operational impact, respectively. 57% of TLE burden came from spinal regions.

CONCLUSIONS

Despite modest weekly UC-FJAMQ response rates, musculoskeletal complaints were shown to be widespread and negatively impact operational capability. Future injury prevention efforts among FJA should focus on spinal regions, particularly the neck.

INJURY EPIDEMIOLOGY IN BEACH TENNIS: INCIDENCE AND RISK FACTORS

Introduction

Due to the growing increase in beach tennis practice in Brazil and the lack of studies on the injuries that occur in this sport, it has become necessary to develop more research on the subject.

Objective

to identify risk and protection factors for injuries in beach tennis, in order to generate prevention strategies for musculoskeletal injuries.

Method

A cross-sectional epidemiological study, level 3 of evidence, was carried out through an electronic form with 698 Beach Tennis players, who answered questions about their relationship with the practice of the sport and occurrences of injuries. We researched the prevalence of injuries, their types, and their relation with personal physical characteristics and the practice of other sports.

Results

We found a positive relationship between injuries when associated with longer exposure time and the presence of a previous injury. We did not find differences regarding BMI, gender, and stretching and muscle strengthening performance.

Conclusion

the most frequent non-traumatic injuries were to the elbow and shoulder (tendonitis) and traumatic (sprain) injuries to the knee and ankle. Level of Evidence II; Cohort Study.

Impact of work pace on cardiorespiratory outcomes, perceived effort and carried load in industrial workers: a randomised cross-over trial

OBJECTIVES

This study investigates the impact of different work paces on cardiorespiratory outcomes, perceived effort and carried load (CL) in industrial workers.

METHODS

A randomised cross-over trial was conducted at a mid-sized steel company. We included 12 healthy industrial workers (8 females, age: mean 44±SD 9 years, height: 1.70±0.08 m, body mass: 79.5±13.4 kg) with at least 6 months of working experience. All participants performed 5 min of piece work at 100% (P100), 115% (P115) and 130% (P130) of the company's internal target yielded in a randomised order, separated by 5 min familiarisation breaks. The primary outcome was energy expenditure (EE), calculated from a respiratory gas exchange using a metabolic analyser. Secondary outcomes were total ventilation, oxygen uptake, carbon dioxide release, respiratory exchange ratio, heart rate and rating of perceived effort (0-10). Furthermore, the metabolic equivalent and the CL were calculated. Data were analysed with repeated measure analyses of variance.

RESULTS

For EE, a large 'pace' effect with a small difference between P100 and P130 (165.9±33.4 vs 178.8±40.1 kcal/hour-1, p=0.008, standard mean difference, SMD=0.35) was revealed. Additionally, a large difference in CL between all paces (p<0.001, SMD≥1.10) was revealed. No adverse events occurred.

CONCLUSIONS

Cardiorespiratory outcomes rise with increased work pace, but the practical relevance of these differences still needs to be specified. However, the CL will add up over time and may impact musculoskeletal health in the long term.

Explorative study using ultrasound time-harmonic elastography for stiffness-based quantification of skeletal muscle function

Time-harmonic elastography (THE) is an emerging ultrasound imaging technique that allows full-field mapping of the stiffness of deep biological tissues. THE's unique ability to rapidly capture stiffness in multiple tissues has never been applied for imaging skeletal muscle. Therefore, we addressed the lack of data on temporal changes in skeletal muscle stiffness while simultaneously covering stiffness of different muscles. Acquiring repeated THE scans every five seconds we quantified shear-wave speed (SWS) as a marker of stiffness of the long head (LHB) and short head (SHB) of biceps brachii and of the brachialis muscle (B) in ten healthy volunteers. SWS was continuously acquired during a 3-min isometric preloading phase, a 3-min loading phase with different weights (4, 8, and 12 kg), and a 9-min postloading phase. In addition, we analyzed temporal SWS standard deviation (SD) as a marker of muscle contraction regulation. Our results (median [min, max]) showed both SWS at preloading (LHB: 1.04 [0.94, 1.12] m/s, SHB: 0.86 [0.78, 0.94] m/s, B: 0.96 [0.87, 1.09] m/s, p < 0.001) and the increase in SWS with loading weight to be muscle-specific (LHB: 0.010 [0.002, 0.019] m/s/kg, SHB: 0.022 [0.017, 0.042] m/s/kg, B: 0.039 [0.019, 0.062] m/s/kg, p < 0.001). Additionally, SWS during loading increased continuously over time by 0.022 [0.004, 0.051] m/s/min (p < 0.01). Using an exponential decay model, we found an average relaxation time of 27 seconds during postloading. Analogously, SWS SD at preloading was also muscle-specific (LHB: 0.018 [0.011, 0.029] m/s, SHB: 0.021 [0.015, 0.027] m/s, B: 0.024 [0.018, 0.037] m/s, p < 0.05) and increased by 0.005 [0.003, 0.008] m/s/kg (p < 0.01) with loading. SWS SD did not change over loading time and decreased immediately in the postloading phase. Taken together, THE of skeletal muscle is a promising imaging technique for in vivo quantification of stiffness and stiffness changes in multiple muscle groups within seconds. Both the magnitude of stiffness changes and their temporal variation during isometric exercise may reflect the functional status of skeletal muscle and provide additional information to the morphological measures obtained by conventional imaging modalities.

Dystrophic muscle distribution in late-stage muscular dystrophy

There is scant information about the comprehensive distribution of dystrophic muscles in muscular dystrophy. Despite different clinical presentations of muscular dystrophy, a recent multi-center study concluded that phenotypic distribution of dystrophic muscles is independent of clinical phenotype and suggested that there is a common pattern of involved muscles. To evaluate this possibility, the present case report used cadaveric dissection to determine the whole-body distribution of fat-infiltrated, dystrophic muscles from a 72-year-old white male cadaver with adult-onset, late-stage muscular dystrophy. Severely dystrophic muscles occupied the pectoral, gluteal and pelvic regions, as well as the arm, thigh and posterior leg. In contrast, muscles of the head, neck, hands and feet largely appeared unaffected. Histopathology and a CT-scan supported these observations. This pattern of dystrophic muscles generally conformed with that described in the multi-center study, and provides prognostic insight for patients and the physicians treating them.

Improving trends estimates for specific work-related ill-health conditions when excess zeros are present in a voluntary health reporting scheme

BACKGROUND

Trends in occupational disease incidence are estimated in voluntary reporting schemes such as The Health and Occupational Reporting (THOR) Network in the UK. Voluntary reporting schemes request responses even if no cases are observed to reduce uncertainty in non-response. This may result in false zeros that bias trends estimates. Analysis using zero-inflated models is unsuitable for specific health outcomes due to overestimates of the excess zeros. Here, we attempt to account for excess zeros while investigating condition-specific trends.

METHODS

Zero-inflated negative binomial (ZINB) models were fitted to three THOR work-related ill health surveillance schemes Occupational Skin Disease Surveillance (437 reporters between 1996 and 2019), Occupational Physicians Reporting Activity (1094 between 1996 and 2019) and Surveillance of Work-Related and Occupational Respiratory Disease (878 between 1999 and 2019). The probability associated with a response being a false zero was estimated and applied in weighted negative binomial (wgt-NB) models fitted to specific ill-heath conditions. Three ill-health conditions from the three THOR schemes were considered; contact dermatitis, musculoskeletal and asthma, respectively.

RESULTS

Wgt-NB models approximately estimated the incidence rate ratios reported by the ZINB models (eg, EPIDERM; ZINB=0.969, NB=0.963, wgt-NB=0.968) for all health outcome annual trends. This was consistent for specific health outcomes which also tended towards the null (eg, contact dermatitis; NB=0.964, wgt-NB=0.969), indicating potentially overestimated downward trends. Though as the ratio of excess zeros to true zeros decreased in rarer health outcomes, the influence on trends also decreased.

CONCLUSIONS

Through weighting, we were able to adjust for excess zeros in health outcome-specific trends estimates. Though uncertainty is still present in underlying reporter behaviour meaning caution should be applied with interpretation of any results.

Precarious employment, strenuous working conditions and the long-term risk of diagnosed chronic musculoskeletal disorders

OBJECTIVES

To investigate the effect of precarious employment (PE) on the risk of diagnosed chronic musculoskeletal disorders (MSDs) among Swedish workers in occupations with strenuous working conditions.

METHODS

This nationwide register-based cohort study included workers registered as living in Sweden in 2005, aged 21-60 at the 2010 baseline. Three samples were included: workers with high biomechanical workload (n=680 841), repetitive work (n=659 422) or low job control (n=703 645). PE was evaluated using the SWE-ROPE (2.0) construct, which includes: contractual insecurity, temporariness, multiple jobs, income and collective bargaining agreement from 2010. Three exposure groups were created: PE, substandard and standard employment (SE). MSD data were obtained from outpatient registers (2011-2020). Cox proportional-hazards models estimated crude and adjusted sex-specific HRs with 95% CIs. Various outcomes were investigated for the different samples.

RESULTS

Among workers with heavy biomechanical workload, results suggest increased risks of back MSDs in PE compared with those in SE. No association was found between PE and tendonitis in repetitive work, but PE was associated with an increased Carpal Tunnel Syndrome risk among men. Among workers with low job control, PE was associated with increased risks of soft tissue disorders among men and fibromyalgia among women.

CONCLUSIONS

PE was associated with an increased risk of MSDs among workers with strenuous working conditions, with variations depending on disorder and sex. The findings suggest a differential exposure to biomechanical workload within occupations. Targeted interventions and strengthened workplace safety regulations are needed to protect the musculoskeletal health of workers in PE.

Evaluation of an exercise and ergonomics intervention for the prevention of neck pain in office workers: exploratory analysis of a cluster randomised trial

OBJECTIVES

To determine the impact of a 12-week ergonomic/exercise programme compared with an ergonomic/health education programme on the development of neck pain in office workers over 12 months.

METHODS

This cluster-randomised trial prospectively recruited office workers from public and private organisations. Only non-neck pain cases at baseline were included (n=484). All participants received an ergonomic workstation review then randomly allocated to receive a neck/shoulder progressive exercise programme (20 min, 3 ×/week; intervention group) or health education sessions (60 min, 1 ×/week; active control) for 12 weeks. Generalised estimating equations evaluated group differences in the point prevalence of neck pain cases (defined as those with a neck pain score of ≥3 on a 0 (no pain) to 9 (worst pain) scale) over time (3, 6, 9 and 12 months) with cumulative incidence of neck pain cases evaluated descriptively.

RESULTS

While no significant group × time interaction was evident, the 12-month point prevalence of neck pain cases in the intervention group (10%) was half that of the active control group (20%) (adjusted OR 0.46, 95% CI 0.21 to 1.01, p=0.05). Lower cumulative incidence of neck pain cases was observed in the intervention (17%) compared with active control group (30%) over the 12 months.

CONCLUSIONS

A combined ergonomics and exercise intervention may have more benefits in preventing neck pain cases in office workers than an ergonomic and health education intervention. Group differences were modest and should be interpreted with caution when considering strategies for primary prevention of neck pain in the office worker population.

TRIAL REGISTRATION

ACTRN12612001154897.