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« on: December 24, 2005, 12:29:11 pm »

Fast Facts About Arthritis

Learn the basics.
A Single Disease?
Arthritis literally means joint inflammation. Arth refers to the joints and itis refers to inflammation. Arthritis is not a single disease. There are more than 100 different types of arthritis affecting people of all ages, including about 300,000 children.


Arthritis Screening Quiz
I Think I Have Arthritis. Now What?
Misconceptions About Arthritis
Arthritis Quiz: Myth or Fact?

Warning Signs And Symptoms Of Arthritis
The warning signs for arthritis include:

Pain
Swelling
Stiffness
Difficulty moving one or more joints

If the signs or symptoms persist for more than 2 weeks, you should consult a doctor.


How To Recognize The Signs And Symptoms Of Arthritis
The Pain Relief Quiz

Most Common Form Of Arthritis
The most common more of arthritis is osteoarthritis, sometimes referred to as wear-and-tear arthritis or degenerative joint disease. Osteoarthritis affects more than 20 million people in the United States. The primary form of osteoarthritis is usually related to aging, but osteoarthritis can also result from injury (athletes) or obesity.


Osteoarthritis Screening Quiz
Quiz: Is It Rheumatoid Arthritis Or Osteoarthritis?

Rheumatoid Arthritis Is An Autoimmune Disease
Rheumatoid arthritis is another common form of arthritis. It is an autoimmune disease and affects 2.1 million adults in the United States. In rheumatoid arthritis, a person's own immune system attacks cells within its own joint capsule. Chronic inflammation associated with rheumatoid arthritis destroys cartilage, bone, and ligaments leading to possible deformity and disability. There can also be systemic effects associated with severe cases of rheumatoid arthritis.


Rheumatoid Arthritis Screening Quiz
Rheumatoid Arthritis Guide 8-Day E-Course
Is It Rheumatoid Arthritis Or Lupus?

There Is No Cure For Arthritis
Unfortunately there is no cure for arthritis. There are various treatment options which help with managing pain and reducing deformity and disability. Early diagnosis and an aggressive treatment plan are recognized as two very important factors in getting arthritis under control.


Arthritis Drugs: What Are My Options?
Alternative and Natural Treatments - Test Your Knowledge

An Aggressive Treatment Plan - What's That?
Depending on your individual symptoms and examination, your doctor may decide to treat you aggressively and not conservatively. Treating conservatively involves prescribing only aspirin, tylenol, or one of the older traditional NSAIDS (non-steroidal anti-inflammatory drugs.

If they wish to treat more aggressively they may add methotrexate or Arava to your regimen. Methotrexate and Arava are among a class of drugs known as DMARDS (disease-modifying anti-rheumatic drugs).

Beyond that, there is a newer class of drugs known as TNF blockers or biologics:


Enbrel
Remicade
Humira

Prednisone is also a consideration when trying to stop an arthritic flare aggressively. More drugs are still in development. There are myriad arthritis treatments to try. Exercise programs, physical therapy, surgery, and other complementary treatments may become part of your treatment regimen.


TNF Blockers (Enbrel, Remicade, Humira) - Test Your Knowledge
The Prednisone Quiz - True or False?
Arthritis and Exercise Quiz
Types Of Joint Surgery - Test Your Knowledge

How Arthritis Is Diagnosed
If you suspect you have arthritis or if arthritic symptoms persist for more than 2 weeks, you should see a doctor. An examination will be performed in the doctor's office and your medical history will be taken. After your consultation, the doctor will order appropriate laboratory tests and x-rays to confirm the diagnosis of arthritis. Basic tests will be ordered at first and there may be more complicated tests ordered later. The tests determine if you have abnormal signs of inflammation (from labs) or joint damage or erosions (from x-ray).


Diagnosing Arthritis
Inflammation: The Battle Within

Get A Referral To A Rheumatologist
Rheumatologists are medical doctors who specialize in arthritis and arthritis-related diseases. Rheumatologists are highly qualified diagnosticians and experts regarding treatment options for arthritis. Have your internist or primary doctor refer you to a rheumatologist.


First Visit To The Rheumatologist
The Right Doctor For You

Fast Statistics About Arthritis

In 2005, 66 million (nearly 1 in 3) adults in the United States have arthritis or chronic joint symptoms.
42.7 million are doctor-diagnosed arthritis
23.2 million live with chronic joint symptoms but are not doctor-diagnosed
Arthritis is the nation's leading cause of disability among Americans over 15 years of age.
Generally, arthritis strikes women more often than men.
From Carol & Richard Eustice,Your Guide to Arthritis. 
« Last Edit: May 17, 2006, 06:26:16 pm by Kathy » Logged


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« Reply #1 on: December 27, 2005, 10:46:50 am »

Arthritis Trivia

Did You Know?
More than 200 years ago, a gout attack kept the English statesman William Pitt from stopping the passage of a tax on tea by Parliament. The tax led to the Boston Tea Party and the independence of the American colonies.
Lyme Disease is named after Old Lyme, Connecticut where it was first reported in 1962.

As of 1995, Lyme Disease has been reported in every state except Montana.

Lupus was named 130 years ago by a French doctor who thought the tell-tale rash on the face resembled bites of a wolf. Today the rash is referred to as butterfly-like but the wolf name persists. "Lupus" is Latin for wolf, and "erythematosus" means reddening of the skin.

Dr. Christiaan Barnard, who performed the first-ever human heart transplant in 1967, was forced into retirement in 1983 by the rheumatoid arthritis that had plagued him since his youth.

Famous actress-comedienne Lucille Ball suffered with rheumatoid arthritis beginning in her teenage years.

Pierre-Auguste Renoir, nineteenth century impressionist artist, was crippled by rheumatoid arthritis. His hands were so severely affected that his paintbrush needed to be strapped to his hand so he could continue to paint.

Roman Emperor Diocletian exempted citizens with severe arthritis from paying taxes, no doubt realizing that the disease itself can be taxing enough.

Arthritis is the most widespread crippling disability in the United States today, second only to heart disease as a cause of work disability.

Arthritis is the predominant cause of activity limitation in the United States and is a major determinant of nursing home institutionalization for the elderly.

More than 42.7 million Americans have doctor-diagnosed arthritis.

One million new patients develop arthritis each year.

Approximately 300,000 children have arthritis (juvenile arthritis).

One of every seven people and one in every three families is affected by arthritis.

Forty percent of the population over age 65 have arthritis.

More money is spent by patients with arthritis for quack and unproven remedies in this country than is spent on basic research to find the causes of arthritis.

Arthritis costs the U.S. economy more than $86.2 billion annually.

Arthritis accounts for 427 million days of restricted activities, 156 million days in bed and 45 million days lost in work annually.

At least 25 percent of a general practitioner's time is spent treating arthritis related diseases.

There are over 100 different types of arthritis.

1 in 8 people have osteoporosis.

1 in 10 people have osteoarthritis.

1 in 33 people have fibromyalgia.

1 in 100 people have rheumatoid arthritis.

1 in 1,000 children have juvenile chronic arthritis.

1 in 1,000 people have ankylosing spondylitis.

1 in 2,000 people have systemic lupus erythematosus.

1 in 10,000 people have scleroderma.

REFERENCES:
Facts About Arthritis, Thurston Arthritis Research Center
General Information on Rheumatologic Diseases, Division of Rheumatology, University of Florida
Arthritis Research, Dept. of Orthopedics, University of Washington
Arthritis Foundation
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« Last Edit: May 17, 2006, 06:25:27 pm by Kathy » Logged


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« Reply #2 on: May 09, 2006, 11:30:57 am »

The differential diagnosis of joint pain
Narrowing the differential diagnosis

When evaluating the patient with joint pain, I find it useful to consider six key concepts during the history and physical examination that help me narrow my differential diagnosis. By narrowing the differential, one can focus the work-up in a more expedient and cost efficient manner.

The six key concepts are:

Is the joint pain really an arthritis?
Is the condition acute or chronic?
Is the problem inflammatory or noninflammatory?
What is the pattern of joint involvement?
Are there associated systemic features?
What are the demographics of the patient that might make one diagnosis more tenable?
Articular, periarticular, or nonarticular?

There are a variety of structures that can become painful and might be interpreted as an arthritis by patients. Causes of joint pain from outside the joint (structures inside the joint capsule) can be from periarticular structures. The following is a list of structures around a joint that might present to you as joint pain.

Periarticular causes of joint pain

Bursitis
Faciitis
Tendonitis
Ligament Injury
Epicondylitis
Myofacial Pain/Fibromyalgia
There are also a variety of nonarticular abnormalities affecting bone, nerve, or blood vessels that may present as joint pain. Below is a list of such causes.

Nonarticular causes of joint pain

Tumors of Bone
Radiculopathy
Osteomyelitis
Neuroma
Nerve Entrapment
Vasculopathy
Differentiation of these problems from an arthritis requires careful physical examination which should include:

Inspection of the joint area for evidence of swelling or redness
Passive range of motion of the joint(s) in the area noting pain, reduction of motion, or instability
Active range of motion of the joint(s) in the area noting pain that was not there when the joint(s) were passively moved
Resisted range of motion of the joint(s) in the area again noting pain
Palpation of the joint line(s) and surrounding structures noting tenderness, joint effusion(s), and boney changes.
Most soft tissue problems do not hurt with passive motion while most forms of arthritis do.
Tendonitis is typically painful with active or resisted motion.
A bursitis is usually painful only with palpation.
Myofacial pain is also painful to palpation and may be widespread as in fibromyalgia.
Acute vs. chronic

Acute refers to conditions lasting less than 8 weeks while chronic signifies conditions that persist for a longer period of time. Acute also suggests a rapid onset. Many acute disorders are also self-limited. This division of acute and chronic can help focus the evaluation especially for conditions that have been present for more than 8 weeks.
Inflammatory vs. noninflammatory

This is a very helpful point in limiting your differential diagnosis. Inflammatory disorders usually present with morning stiffness that lasts longer than 30-40 minutes, stiffness that increases with rest, relief of symptoms with exercise, some degree of swelling, and a synovial fluid WBC that is above 2000/mm3. Most of the 2000 cells should also be PMNs.

Noninflammatory disorders usually present with only limited morning stiffness (< 15 minutes), pain with use, relief of pain with rest, swelling may or may not be present, and synovial fluid WBC is typically less than 2000/mm3.

An initial determination of the character of the synovial fluid at the bed side can be made by looking at the fluid in a glass tube against newsprint. The print can still be read through noninflammatory fluid while inflammatory fluid will obscure the print. The intensity of the synovial inflammation is only relatively helpful in the differential diagnosis. Below is a chart of synovial fluid differentiated by cell count. An important point to remember is that an infected joint may not have septic range WBC. If you at all suspect infection send the fluid for gram stain and culture.

Table 1. Synovial fluid analysis

Classification Clarity Wbc %Polys
Normal Transparent <200 <25
Noninflammatory Transparent <2000 <25
Inflammatory Translucent <75000 >50
Septic Opaque >75000 >75

One other type of presentation in this regard is worthy of note. Fibromyalgia typically presents with marked AM stiffness, pain with use and pain and stiffness at night so that it is not clearly inflammatory or noninflammatory.

3 different classes

Rheumatologists spend a good deal of their training learning to recognize various forms of arthritis by their pattern of joint involvement.

I divide the conditions into monoarticular (one joint only), pauciarticular (2-5 joints), and polyarticular (more than 6 joints). These are not set in stone as there is some overlap but is a useful construct and has withstood the test of time and medical students. The following lists are not all inclusive. They include the most common entities someone in the primary care setting would encounter. The purpose of this differentiation is to focus the initial evaluation and help the "splitters" among us. The "don't forget" (because of potential serious consequences) conditions are in italics and the most common causes in each category are bold.

Monoarticular arthritis

Table 3. Causes of monoarthritis

Inflammatory Noninflammatory
Infection
Disseminated gonorrhea
Other bacteria
Tuberculosis
Fungi
Lyme athritis
Endocarditis
Crystals
Monosodium urate
Calcium pyrophosphate
Hydroxyappatite
Spondyloarthropathy
Ankylosing spondylitis
Reiter's syndrome
Psoriatic arthritis
Miscellaneous
Palindromic rheumatism
 Trauma/fracture
Osteoarthritis
Neoplasm
Osteonecrosis
 

Nongonococcal septic arthritis is the most serious cause of monoarthritis. The presentation is that of an acute or subacute onset of mono- or rarely pauciarthritis. Large joints are usually affected especially knees. Patients most often look systemically ill and will have fever, chills, and will have an elevated WBC and ESR. Patients with underlying arthritis especially rheumatoid arthritis are at increased risk of septic arthritis and may not have the usual symptoms due to antiinflammatory medications. The most common organisms are Staphylococcus aureus, Streptococcus sp. and much less common are gram negatives but think of the latter in the immunosuppressed or in IV drug users. The initial evaluation should include arthrocentesis for gram stain and culture and WBC, blood cultures, as well as an ESR. The patient should be admitted and IV antibiotics started while waiting for culture results. If there is any concern for a septic joint do an arthrocentesis!

Gonococcal arthritis is seen in sexually active young adults and only 25% have local genitourinary symptoms. Patients are usually systemically ill and have dermatitis, tenosynovitis, and migratory arthritis. Blood cultures are positive in only 5%, GU cultures in 80%, and synovial fluid cultures in 30%. One often resorts to treatment of presumptive gonococcal arthritis. Luckily, most strains that cause gonococcal arthritis are penicillin sensitive although , resistant strains are emerging. Initial evaluation should include the above cultures plus consideration of pharyngeal and rectal cultures. Patients often need a few days of hospitalization then can be treated as an outpatient.

Endocarditis causes musculoskeletal symptoms in up to 40% of affected patients. Inflammatory low back pain is common as is mono- or pauciarthritis. It is interesting to note that the fluid while inflammatory is usually sterile. This is thought to be due to immune complex deposition in the synovium. Look for peripheral signs of immune complex deposition such as cutaneous vasculitis, painful nodules, listen for a murmur, check an ESR, blood cultures, CBC, cultures of synovial fluid, and if endocarditis is likely, admit the patient and begin antibiotics. Of note, rheumatoid factor is frequently positive in these patients.

Crystals causing arthritis include urate, calcium pyrophosphate, and appatite. Urate gout is probably the most common cause of acute inflammatory monoarthritis. Inflammation is usually intense and the patient will relate a history of previous self-limited attacks. First MTP is a common site for urate gout and knee for calcium pyrophosphate. Young women can have so called hydroxyappatite pseudopodagra affecting the 1st MTP. Patients can have a pauciarticular presentation with urate and pyrophosphate. For urate gout, a history of ETOH use, history of kidney stones, or a family history of urate gout is helpful. Females rarely get urate gout before menopause. There are some distinctive X-ray findings for calcium pyrophosphate and appatite arthritis (chondrocalcinosis and fluffy calcification respectively) On examination, look for tophi and synovial fluid analysis is very helpful in the definitive diagnosis of all but hydroxyappatite. A useful hint to remember is that bugs, blood, and crystals (BBC) cause the most intense joint pain.

Palindromic rheumatism is an episodic condition usually affecting one joint at a time. The attacks can be fairly intense and the fluid can be quite inflammatory. Attacks usually last several days and resolve. With time, many individuals progress on to frank rheumatoid arthritis.

TB and fungi are relatively rare but any chronic monoarthritis without a diagnosis should be considered for synovial biopsy and granulomatous synovitis considered.

Osteoarthritis is probably the overall most common cause of monoarthritis and trauma/internal derangement of the knee is not far behind. Meniscal tears can cause chronic noninflammatory type pain and may give symptoms of knee locking or giveway.

Avascular necrosis is caused by trauma, alcohol abuse, steroid use, divers, and in patients with hemaglobinopathies. Pain is initially out of proportion to X-rays. Hips, knees and shoulders are usually involved. Early diagnosis is by MRI scan.

Synovial neoplasm to remember and is pigmented villonodular synovitis. It can cause dark bloody effusions and is diagnosed by MRI/arthroscopy.

Pauciarticular arthritis

Table 4. Causes of pauciarthritis

Inflammatory Noninflammatory
Infection
Endocarditis
Disseminated gonorrhea
Rheumatic fever
Lyme disease
Crystals
Monosodium urate
Calcium pyrophosphate
Spondyloarthropathy
Sarcoidosis
Miscellaneous
Polymyalgia rheumatica
 Osteoarthritis
 

Rheumatic fever - In many of these conditions systemic features play an important role in the differential diagnosis. Rheumatic fever is certainly one of these although most adults with rheumatic fever present with only arthritis. The pain is usually out of proportion to the swelling and the symptoms tend to be migratory. Other Jones criteria include carditis, erythema marginatum, chorea, and subcutaneous nodules. Be sure to listen for a murmur and check ASO/streptozyme. The ASO should be followed serially and remember that a positive test still does not prove rheumatic fever. Throat cultures are usually negative by the time rheumatic fever occurs. One often spends time ruling out other diseases even with a suspicion for rheumatic fever due to the lack of definitive diagnostic testing. The presence of carditis though, is very compelling and can be made by echocardiogram.

Lyme arthritis is a late manifestation of lyme disease and usually presents with recurrent attacks of mono- or pauciarthritis especially including the knee. In this condition, the swelling is often out of proportion to the pain!. A history of exposure and the characteristic rash of Lyme disease are important. By time the arthritis is present, the vast majority of patients have a positive Lyme antibody test. One may have to treat presumptively for at least one course of antibiotics in some marginal cases.

Spondyloarthropathies are characterized by their association with the HLA-B27 gene (except the peripheral arthritis of psoriatic arthritis). Features of these illness that are helpful in the diagnosis include inflammatory low back pain, history of inflammatory eye disease (uveitis, iritis, conjunctivitis), urethritis, cervicitis, diarrhea, a variety of hyperkeratotic rashes, and diffuse swelling of digits called sausage digits. Joints most often affected are the large joints of the lower extremities. In my experience, the most common cause of inflammatory pauciarthritis is a spondyloarthropathy, especially Reiter's disease or psoriatic arthritis. Up to 7% of patients with psoriasis will have arthritis.

Sarcoidosis frequently presents with pauciarthritis. One typical presentation is called Lofgren syndrome and consists of erythema nodosum, hilar adenopathy, and pauciarthritis usually affecting the large joints of the lower extremities. A chronic destructive form also exists and is often seen along with extensive bone cysts on X-ray. Other important features include uveitis and skin lesions.

Polymyalgia rheumatica will be discussed below.

Polyarticular arthritis

Table 5. Causes of polyarthritis

Inflammatory Noninflammatory
Viruses
Parvovirus
Hepatitis B
Rubella
Hepatitis C
Autoimmune diseases
Rheumatoid arthritis
Systemic lupus erythematosus
Sjogren's syndrome
Scleroderma
Polymyositis/Dermatomyositis
Serum sickness
Antibiotics
 Primary osteoarthritis
Secondary osteoarthritis
Hemachromatosis
CPPD
Ochronosis
Acromegaly
 

Viruses are a common cause of acute self limited arthritis. The ones to remember include hepatitis B, parvovirus B19, and rubella. HIV can cause a variety of rheumatologic syndromes but polyarthritis is unusual. Viral arthridities are usually symetrical and cause more pain than swelling. They usually are self limited and are associated with rash. The prodrome of hepatitis B can be polyarthritis even before liver function tests are abnormal. Be sure to check for hepatitis B surface antigen. The arthritis usually goes away by the time the patient has clinical hepatitis. Hepatitis C is being recognized as a common infection. It can cause a symmetric polyarthritis that is often accompanied by a positive rheumatoid factor thus being confused with rheumatoid arthritis. There are no nodules with hepatitis C nor does it cause erosive joint changes. Parvovirus will be discussed below.

Rheumatoid arthritis is a relatively common disease affecting 1-2% of the US population. Remember that rheumatoid factor is seen in only 70% of patients and may not appear for 1 year. RA is a symmetric arthritis and almost always affects the small joints of the hands and feet.

Diagnosis of systemic lupus erythematosus is aided greatly by the ANA testing. A negative ANA plus a negative antiSSA antibody rules out SLE! On the other hand, a positive ANA does not mean SLE! One has to look for other features to go along with the positive ANA not just fatigue and arthralgias. I usually am not impressed with an ANA of less than 1:160 and look for the presence of other autoantibodies as well as objective evidence of inflammation on laboratory testing and examination. Urgent cases of SLE include those with new onset or exacerbation of nephritis or cerebritis.

Secondary causes of osteoarthrits especially metabolic causes, are conditions I keep in the back of my mind when I see a patient with clinical osteoarthritis in a symmetric pattern but in places atypical for primary OA. These include the shoulders, elbows, wrists, and MCP joints. The most important cause is idiopathic calcium pyrophosphate disease and less common, but with more significant implications, is hemachromatosis. I usually check a calcium, FE, TIBC, and TSH in a patient with what may be a secondary cause of OA without other explanation (old RA) and or significant chondrocalcinosis on X-ray.

Serum sicknesses are actually in this day and age serum sickness-like reactions. Symptoms include rash often uriticarial, and inflammatory arthritis affecting large joints. Fever is common and laboratory abnormalities include mild hypocompletemia and normal eosinophil count. The process is self limited resolving in 1-3 weeks after exposure. Typical causes of serum sickness-like reactions are antibiotics especially penicillins and sulfa drugs.

Systems and related diseases/syndromes

There are a variety of systemic features that can help in the differential diagnosis of joint pain/arthritis. Finding these requires a complete review of systems and a good general examination with emphasis on the skin, eyes, heart, lungs, GI, GU, and nervous system. Below is a list of some of the diseases/syndromes for which systemic features are important in the differential diagnosis.

Skin
Gout
Spondyloarthropathy
Sarcoidosis
Lyme disease
Disseminated gonorrhea
Rheumatic fever
Viral syndromes
Rheumatoid arthritis
Systemic lupus
Serum sickness
Eyes
Spondyloarthropathy
Sarcoidosis
Rheumatoid arthritis
Heart
Spondyloarthropathy
Lyme disease
Endocarditis
Systemic lupus
Rheumatic fever
Rheumatoid arthritis
Lungs
Tuberculosis
Fungi
Sarcoidosis
Systemic lupus
Rheumatoid arthritis
GI/GU
Spondyloarthropathy
Systemic lupus
Gout
Endocarditis
CNS/PNS
Sarcoidosis
Lyme disease
Systemic lupus
Demographics and related conditions

There are features of the history that can help you focus the differential diagnosis. Knowing which diseases are more common in certain patient groups may move certain conditions to the top of your list. Below is listed some items worthy of note.

Age
Younger
Spondyloarthropathy
Disseminated gonorrhea
Older
Polymyalgia rheumatica
Gout
Osteoathritis
Gender
Men
Gout
Spondyloarthropathy
Women
Rheumatoid arthritis
Systemic lupus
Race
Africans
Sarcoidosis
Systemic lupus
Europeans
Polymyalgia rheumatica
Lifestyle
Bacteria
Gout (ETOH overuse)
Endocarditis (IDU)
Disseminated gonorrhea
Lyme disease (outdoors)
Avascular necrosis (ETOH overuse)
Other illness
Bacteria: immunosuppression, rheumatoid arthritis
Gout: renal disease, medications, obesity
Tuberculosis & fungi: immunosuppresion
Avascular necrosis: steroid use.

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« Last Edit: November 24, 2006, 02:00:25 pm by Kathy » Logged


I look normal, as I have an "Invisible Illness". You can not catch it, you can not see it. It's called Lupus.My body is attacking itself on the inside.
www.LupusMCTD.com Represents:
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« Reply #3 on: June 03, 2006, 05:01:52 pm »

Joint Function and Lupus
Joint pain or arthritis is experienced by 95% of people with lupus at some time during the course of their disease. In fact, joint pain is usually the first symptom of lupus. Unlike rheumatoid arthritis, the arthritis of lupus tends to be temporary. It is also less damaging to the joints. The joints most commonly involved are those of the fingers, wrists, and knees. Elbows, ankles, and shoulders are not affected as often. When a particular joint is affected on one side of the body, the same joint on the other side of the body is usually affected as well.

Arthralgia:
Arthralgia means “joint pain.” Morning stiffness, swelling, or heat in the joints can also occur.

Myalgia or myositis:
Myalgia means “pain in the muscles”; myositis means “inflammation of the muscle.” These may include overall muscle pain and tenderness, especially in the upper arms and upper legs. They are common in 40–80% of people with lupus, especially during a flare.

Other joint complications:
Several types of joint complications occur rarely in lupus. They include osteonecrosis (damage to the hip joint that leads to severe arthritis), development of nodules in the small joints of the hands, tendinitis, tendon rupture, and carpal tunnel syndrome. Your doctor or nurse can give you more information about these problems.

Taking Care of Your Joints

If you have joint or muscle problems, the first goal is to keep pain at a tolerable level. You can do this in several ways:

Apply heat or cold to the affected joints.
Support the affected joints with pillows, blankets, or splints (if ordered by your doctor).
Rest the affected joints as much as possible and keep them elevated to help reduce swelling.
Follow your doctor’s plan for managing pain and using anti-inflammation medication.
Your second goal is to maintain joint function and increase muscle strength. You can do this by using the following techniques:

Take warm showers or baths to lessen stiffness.
Don’t put any weight on an acutely inflamed joint. Sit or lie down. Avoid strenuous activity and avoid any activity that causes increased pain, swelling, tenderness, or heat to the affected joint.
Ask a physical therapist or trained family member or friend to gently move the inflamed joint in all the directions it can be moved (this is called passive range of motion [ROM]).This will help prevent stiffness. Your doctor can let you know when and how often this should be done.
Gently move the affected joint yourself when the acute inflammation is over.
Talk with your doctor or nurse about physical or occupational therapy if you are having trouble regaining joint strength and motion or if activities of daily living (cooking, cleaning, bathing, etc.) are still difficult.
Hire a housekeeper or someone to help care for yourself or your children until you feel better.
When you are feeling better and your physical condition has improved, your doctor will probably recommend an exercise program tailored to your needs. Although rest and protecting joint function are extremely important, exercise is also necessary to keep muscles, bones, joints, and tendons strong and healthy. A well-planned exercise program combined with other aspects of your care will help you maintain joint function and improve your overall fitness.

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I look normal, as I have an "Invisible Illness". You can not catch it, you can not see it. It's called Lupus.My body is attacking itself on the inside.
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« Reply #4 on: June 23, 2006, 10:17:52 am »

Note* Myself, Karyl & Donna have alot of back problems and found this helpful explanation. I'm sure others may benefit from reading this if they too are having back pain/problems~Kathy
About Your Spine / Spinal Anatomy

Your spinal column is made up of 24 vertebrae, plus the sacrum and tailbone (coccyx). Between each vertebrae is a “cushioning pad” called a disc. This flexible design supports your body while allowing it to move freely. The spinal column also protects the main nerve “highway” (the spinal cord) which runs through an opening in the back of each vertebrae.

Coming from your spinal cord is a network of nerves that carry messages to and from your brain and the rest of your body. Pressure on any one of these sensitive nerve roots, or on the spinal cord itself, produces pain.

COMMON PROBLEMS

Disc Herniation or Herniated Nucleus Pulposus - a disc is made of two parts, a hard outer layer and a soft central core. A tear in the outer layer can allow the soft center portion of the disc to leak. This ruptured (herniated) disc may press up against a spinal nerve causing pain, numbness, tingling or weakness in your arms or legs. Herniated discs may occur at any level of the spine, but are more common in the lumbar or cervical areas, followed by the thoracic. 
 

Spinal Stenosis -
 a form of arthritis in the spine. The hole or canal where the spinal cord runs becomes narrow. Bony growths on the vertebra narrow this opening and cause pressure on the spinal cord and/or nerves. Patients may have pain, with numbness, tingling or weakness to the arms or legs. Spinal stenosis may occur at any level of the spine, but is more common in the lumber and cervical spine.

Degenerative Disc Disease -
another form of arthritis to the spine. The discs between your vertebrae shrink. Degenerative disc disease is often described as a “wear and tear” condition. It is a normal part of aging, but can also be caused by injury to the disc. Symptoms include pain in the involved areas of the spine and, in some instances, pain or numbness to the arms or legs. Loss of flexibility is also typical.

Spondylolisthesis -
 an abnormal spinal condition in which one vertebrae slips or is improperly aligned over another vertebrae. If abnormal motion allows this vertebrae to slip back and forth spinal nerves may be affected causing pain, numbness, tingling or weakness in the legs. Many individuals do not have symptoms with this condition while others experience long standing back pain. Spondylolisthesis is most common in the lumbar area.

Scoliosis -
 a condition where the natural curves of the spine are affected. A normal spine has three natural curves that keep your body balanced, but in scoliosis there is an abnormal side-to-side curve. As a result you may have back pain, an uneven waist, uneven shoulders, prominent shoulder blades or elevated hips. You may even lean to one side. In some individuals scoliosis does not cause pain, but in others symptoms are chronic.

Kyphosis -
involves the backwards bending of the spine. Normally kyphosis is seen in the thoracic region. When this natural curve is increased and structural changes in the vertebrae occur, this kyphosis may be defined as Scheuermann’s disease. This describes the wedging and irregular edges of the vertebrae as seen on x-rays. This spinal disorder is more commonly known as a “roundback” deformity of the spine.

Spinal Instability -
 a condition where vertebrae of the spine become unstable. This can come from an injury or a degenerative disorder. The normal structure and function of the spine is interrupted and deformity results. In some cases the spinal cord and/or spinal nerves are at risk for injury. Symptoms include pain, numbness, weakening and, in some cases, nerve damage.


DIAGNOSIS AND TESTS

A thorough history can help determine the type and seriousness of a spinal condition. This is followed by a physical examination of your spine. Examination of muscle strength, as well as neurological function, can pinpoint if any nerves are involved and the extent of any weakness.

X-rays - allow the doctor to identify any abnormality of your spinal anatomy. This may include signs of arthritis, a fracture or slippage of a vertebrae. Flexion and extension x-rays give further information about abnormal spinal motion when a person bends.

Magnetic Resonance Imaging (MRI) - another test used to diagnose spinal problems. These pictures of the spinal anatomy give further information about the soft tissue such as your discs and nerves. An MRI is often taken to confirm a disc herniation.

Myelogram -
a special x-ray test used to detect problems of the spinal canal, spinal cord, nerve roots and discs. A radiologist performs this outpatient procedure (no overnight stay in the hospital.) A special dye is injected into the spinal canal allowing for x-rays to view these structures more clearly. A myelogram may be taken to diagnose nerve compression by a disc or spinal stenosis, evaluate a spinal tumor or a spinal abscess. Usually a CAT scan is also performed while the dye is still in place.

CAT Scan, CT or Computerized Tomography -
another type of special study used to obtain information more specific than plain x-rays. Pictures taken in several different positions help in identifying spine abnormalities, most particularly of bone. This study is also useful for evaluating spinal nerves and fractures.

EMG or Electromyelogram -
used to identify problems with the nerves which go to the extremities. A sterile needle electrode is inserted into the muscle being tested. An EMG can determine abnormalities with the nerves and where the problem is located, i.e. the spine or extremities. Nerve problems can originate from your spine, a medical condition (such as diabetes) or a combination of both. EMG’s are performed by a neurologist.

Discogram or Discography -
allows for specific evaluation of the discs of the spine. A special dye is injected into the discs, along with saline and an antibiotic. Information about the discs structure and its relationship to back and/or leg pain symptoms is obtained. The study is often recommended for patients who may require fusion surgery.

TREATMENT

In most cases, spinal problems are treated without surgery. Individuals with acute episodes of back pain are managed differently than those with long-standing spine problems. Initial treatment may include 2-3 days of rest followed by a gradual return to normal activities.


Heat -
may help decrease pain to soft tissues. Heat may be applied for 20-30 minutes several times a day.

Medication -
anti-inflammatory medications, Ibuprofen or aspirin (such as Advil or Bufferin) are best. By taking these medications on a regular basis you are decreasing inflammation as well as pain and swelling. Check with your medical doctor before taking these medications for more than a few days.

Exercise or Physical Therapy -
 often recommended to assist in decreasing pain and regaining normal function. This may be performed as a home exercise program provided by your doctor or under the direction of a physical therapist.

Injection Therapy -
reserved for patients for whom other conservative treatments have not worked. Injections may consist of epidural steroid injections or spinal nerve blocks, or facet joint injections. Steroid injections can decrease inflammation to spinal nerves and thereby reduce the pain. Nerve blocks interrupt the signal of pain from a spinal nerve from reaching your brain. This can provide temporary relief of pain. These injections may also assist in confirming or negating a specific diagnosis regarding your spinal problem. Facet joint injections can provide relief of pain caused by an arthritic spine joint.

SURGICAL OPTIONS

Most people with spine problems do not require surgery. Individuals who fail conservative methods, continue to have a neurological deficit (i.e. weakness in muscle, loss of a reflex) and have ongoing disability may be candidates for surgery. Careful evaluation of neurological status, functional ability in regard to pain, studies of the spinal anatomy and diagnosis are needed prior to any spine surgery.


Discectomy -
an operation performed on patients with a herniated (ruptured) disc. The herniated part of the disc is removed which relieves pain and restores function to the affected spinal nerve.

Laminectomy -
an operation performed on patients with spinal stenosis. Part or all of the lamina of a vertebrae is removed to enlarge the opening through which the spinal cord and spinal nerves run. This permits removal of any protruding disc material or bony spurs. A laminectomy allows the surgeon to decompress a spinal nerve.
 
Spinal Fusion -
an operation performed to prevent or limit abnormal motion in the spine by fusing two or more vertebrae. A spine fusion may include fusion across the joint space of two or more adjacent vertebrae. This is done by surgically applying bone graft and/or spinal instrumentation. A decompressive procedure, such as a laminectomy, may also be performed. Any protruding disc material, as well as arthritic areas of the spine, are removed prior to the spinal fusion.
The bone graft used for a spinal fusion may be autograft (bone taken from your own body) or an allograft (bone from a bone bank). There are many types of instrumentation, or hardware, used in spinal fusions. Cervical spine fusions may utilize plates along with screws, wires or bone plugs for bone graft. Thoracic and lumbar spine fusions may include rods, hooks, screws, wires and bone grafts.

 


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« Reply #5 on: July 06, 2006, 08:57:04 pm »

Diverse Biologic and DMARD Combinations May Improve RA

 
NEW YORK (Reuters Health) Jun 23 - Although methotrexate is recommended for use with the anti-tumor necrosis factor agents infliximab and etanercept in patients with rheumatoid arthritis (RA), other disease-modifying antirheumatic (DMARDs) may also be useful, UK researchers report in the June issue of Arthritis and Rheumatism.

Dr. Kimme L. Hyrich of the University of Manchester and colleagues evaluated more than 2700 subjects with RA who began therapy with their first biologic agent. Slightly more than half were treated with infliximab and the remainder received etanercept. They were followed for 6 months. About 60% had monotherapy, 20% had methotrexate co-therapy and the remainder used one of a variety of DMARDs, including leflunomide and azathioprine.

Compared with monotherapy, etanercept patients had a greater likelihood of achieving higher European League Against Rheumatism responses when they had methotrexate co-therapy (odds ratio, 2.0) or therapy with another DMARD (odds ratio, 1.2). For infliximab patients, the corresponding ratios were 1.4 and 1.3.

Remission rates for etanercept monotherapy were 5%. With methotrexate, the proportion was 12% and with another DMARD, it was 11%. Findings were similar for infliximab.

Dr. Hyrich told Reuters Health that "adding etanercept to existing methotrexate therapy in patients with DMARD-resistant, active RA, offered a distinct therapeutic advantage, with both a better overall response rate and a higher rate of remission."

"In addition, there appeared to be a therapeutic advantage of combining infliximab with DMARDs other than methotrexate, compared to infliximab on its own. These combinations may be as effective as combining infliximab with methotrexate in situations in which methotrexate is contraindicated or not tolerated."

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« Reply #6 on: July 15, 2006, 12:35:07 pm »

Critical Therapeutics Announces Issuance of U.S. Patent Relating to HMGB1 for Methods to Diagnose Arthritis and Lupus

Patent Focuses on Measuring Concentration of Inflammatory Protein HMGB1
A New Window into Inflammatory Disease

LEXINGTON, Mass.--(BUSINESS WIRE)--July 12, 2006--Critical Therapeutics, Inc. (Nasdaq: CRTX - News) today announced the issuance of a U.S. patent for methods of diagnosing and monitoring the severity of several inflammatory conditions, including arthritis and lupus, by measuring the concentration of a key protein present in a patient's bloodstream.



U.S. Patent No. 7,060,504, "Antagonists of HMG1 for Treating Inflammatory Conditions," involves methods of measuring the concentration of the protein High Mobility Group Box 1 (HMGB1) and comparing that concentration to a representative normal sample. HMGB1 is measured using an antibody that binds to the protein. Arthritis, rheumatoid arthritis and lupus are among the inflammatory conditions claimed under the patent.

HMGB1 belongs to a class of proteins called pro-inflammatory cytokines and is secreted by the immune system as part of the body's response to trauma and infection. Increased levels of HMGB1 have been linked to acute and chronic inflammatory conditions, such as sepsis and rheumatoid arthritis. HMGB1 persists at elevated levels for a longer period than other major pro-inflammatory cytokines. This longer period of elevation makes HMGB1 an attractive development opportunity due to the ability for it to be measured in patients and targeted for treatment.

"This patent should enhance our therapeutic antibody development activities in arthritis and broaden our collaboration on diagnostic opportunities in the HMGB1 field," said Walter Newman, Ph.D., Critical Therapeutics' Senior Vice President of Research and Development and Chief Scientific Officer.
Critical Therapeutics' HMGB1 patent estate is exclusively licensed to MedImmune, Inc. for the treatment and prevention of diseases, such as arthritis and lupus. In addition, Critical Therapeutics licensed its HMGB1 diagnostic rights to Beckman Coulter, Inc., which is developing immunoassays to detect and manage inflammatory diseases.

"Through these discoveries we are striving to open a new window into inflammatory disease, and this patent gives us and our partners valuable intellectual property toward that goal. It encompasses not only a unique method to diagnose certain conditions, but also the potential to monitor disease severity and gauge clinical prognosis, insight that we hope will produce more successful outcomes," added Dr. Newman.

About Arthritis(1)
Arthritis is a term that describes a group of more than 100 medical conditions that collectively affect nearly 70 million adults and 300,000 children in the United States alone. All of these conditions affect the musculoskeletal system and specifically the joints - where two or more bones meet. Arthritis-related joint problems include pain, stiffness, inflammation and damage to joint cartilage and surrounding structures. Rheumatoid arthritis is one of the most serious and disabling forms of the disease, affecting about 2.1 million Americans.

About Lupus(2)
Lupus is a widespread and chronic autoimmune disease that causes the immune system to attack the body's tissue and organs, including the joints, kidneys, heart, lungs, brain, blood, or skin. Approximately 1.5 million Americans have a form of the disease, which has no known cause.

About Critical Therapeutics
Critical Therapeutics, Inc. is a biopharmaceutical company focused on the discovery, development and commercialization of products for respiratory, inflammatory and critical care diseases. The Company owns worldwide rights to ZYFLO® (zileuton tablets), as well as other formulations of zileuton. ZYFLO is the only 5-lipoxygenase inhibitor approved for marketing by the U.S. Food and Drug Administration. The Company's commercialization efforts for ZYFLO are carried out by its specialty sales force. Critical Therapeutics also is developing treatments directed toward the severe inflammatory response in acute diseases and conditions that lead to admission to the emergency room or intensive care unit, and acute exacerbations of other chronic diseases that frequently lead to hospitalization. For more information, please visit www.crtx.com.

About MedImmune, Inc.
MedImmune strives to provide better medicines to patients, new medical options for physicians, rewarding careers to employees, and increased value to shareholders. Dedicated to advancing science and medicine to help people live better lives, the company is focused on the areas of infectious diseases, cancer and inflammatory diseases. With more than 2,300 employees worldwide, MedImmune is headquartered in Maryland. For more information, visit the company's website at www.medimmune.com.

About Beckman Coulter, Inc.
Beckman Coulter, Inc. is a leading manufacturer of biomedical testing instrument systems, tests and supplies that simplify and automate laboratory processes. Spanning the biomedical testing continuum--from pioneering medical research and clinical trials to laboratory diagnostics and point-of-care testing--Beckman Coulter's 200,000 installed systems provide essential biomedical information to enhance health care around the world. The company, based in Fullerton, Calif., reported 2004 annual sales of $2.4 billion with 64 percent of this amount generated by recurring revenue from supplies, test kits and services. For more information, please visit www.beckmancoulter.com.

Forward-Looking Statements
Any statements in this press release about future expectations, plans and prospects for Critical Therapeutics, Inc., including, without limitation, the progress and timing of our drug development programs and related trials; the timing and success of regulatory filings, regulatory approvals and product launches; the efficacy of our drug candidates; prospects, plans and objectives of management; and all other statements that are not purely historical in nature, constitute "forward-looking statements" within the meaning of the Private Securities Litigation Reform Act of 1995. Without limiting the foregoing, the words "anticipate," "believe," "could," "estimate," "expect," "intend," "may," "plan," "project," "should," "will," "would" and similar expressions are intended to identify forward-looking statements. Actual results may differ materially from those indicated by such forward-looking statements as a result of various important factors, including risks and uncertainties relating to: conducting clinical trials, including difficulties or delays in the completion of patient enrollment, data collection or data analysis; the results of preclinical studies and clinical trials with respect to our products under development and whether such results will be indicative of results obtained in later clinical trials; the timing and success of submission, acceptance and approval of our regulatory filings; our ability to obtain the substantial additional funding required to conduct our research, development and commercialization activities; our dependence on our strategic collaboration with MedImmune, Inc.; and our ability to obtain, maintain and enforce patent and other intellectual property protection for ZYFLO, our drug candidates and our discoveries.

These and other risks are described in greater detail in the "Risk Factors" section of our most recent Quarterly Report on Form 10-Q and other filings that we make with the Securities and Exchange Commission (SEC). If one or more of these factors materialize, or if any underlying assumptions prove incorrect, our actual results, performance or achievements may vary materially from any future results, performance or achievements expressed or implied by these forward-looking statements.

In addition, the statements in this release reflect our expectations and beliefs as of the date of this release. We anticipate that subsequent events and developments will cause our expectations and beliefs to change. However, while we may elect to update these forward-looking statements publicly at some point in the future, we specifically disclaim any obligation to do so, whether as a result of new information, future events or otherwise. These forward-looking statements should not be relied upon as representing our views as of any date subsequent to the date of this release.

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« Reply #7 on: August 01, 2006, 07:23:57 pm »

New Arthritis Drug Linked to Increased Risk of Heart Attacks 

The new arthritis drug Prexige is said to be linked to an increased risk of heart attacks and strokes and arthritis sufferers have been warned to exercise caution in its use.

The federal government's Pharmaceutical Benefits Scheme (PBS) will make the drug Prexige (generic name, lumiracoxib) available from Tuesday. The drug is the first COX-2 inhibitor to be marketed in Australia since it was found in 2004 that these group of drugs increased risk of heart attacks and strokes.

Popular arthritis drug Vioxx was taken off shelves while the drug Celebrex was forced to carry warnings about heart disease ever since this revelation was made public in 2004. The National Prescribing Service has released an independent review warning that the evidence of long-term cardiovascular safety of the new drug is limited.

Dr Peter Roush from the National Prescribing Service says that the safer option for patients should be to first try to manage their condition with over-the-counter painkillers.

He said, "People with osteoarthritis should first consider an effective dose of paracetamol and speak with their doctor if they need a medicine to manage the pain. For some people, lumiracoxib may be an appropriate alternative to other medicines in the same class. This medicine has benefits for people at risk of a stomach ulcer, but we don't know everything about its risk to the heart and brain."

COX-2 inhibitors have been non-steroidal anti-inflammatory drugs (NSAIDs) which were developed as an alternative to older NSAIDs like ibuprofen, Voltaren, or naproxen. And studies showed that lumiracoxib caused fewer serious ulcer complications such as bleeding, than ibuprofen or naproxen. He said, "But people who are likely to have stomach trouble should use lumiracoxib with caution, as it does not eliminate the risk of getting an ulcer. There's limited evidence available about the long-term risk to your heart when using this medicine, but we do know you should not use it if you have, or are likely to have, cardiovascular disease."

The medicine is recommended for use for the shortest possible time, ideally when symptoms flare up or before painful activities.

 
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« Reply #8 on: August 01, 2006, 07:35:19 pm »

Move to Aussie for treatment, says Arthritis NZ

WEDNESDAY, 02 AUGUST 2006


If you want treatment for debilitating joint and skin conditions move to Australia, Arthritis New Zealand chief executive Roger Sowry says.

Mr Sowry said an estimated 10,000 Australians suffering from such ailments had access to a new drug, Enbrel, from this week and called on the Government's drug-funding agency Pharmac to make the same provisions here.

The drug, which treats various types of arthritis and psoriasis, was available to less than 50 New Zealand patients with juvenile chronic arthritis, Mr Sowry said.

"Arthritis patients are yet again getting a bad deal. We're not talking about minor joint pain. These conditions are chronic, causing significant pain, impacting immensely on patients' ability to fully participate in life."

He said Arthritis New Zealand recently discovered a woman in her late 20s was living in a rest-home to get the 24-hour care because she was so disabled by her psoriatic arthritis.

"It is simply unacceptable that New Zealanders continue to suffer when a treatment that has been proven to be extremely successful is available across the Tasman and not here.

"It is yet another example of how New Zealand is falling behind in the provision of innovative medicines to patients in real need." Pharmac said there were three arthritis treatment drugs available in New Zealand and all had similar effectiveness.

Funding criteria varied, but both young people and adults had access to the treatment drugs.

A Pharmac spokesman said while the agency was comfortable with its position, it was open to further discussions about widening access to such drugs.
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« Reply #9 on: August 11, 2006, 11:39:59 am »

Arthritis Drug Helps Debilitating Inflammatory Disease
BETHESDA, MD -- August 10, 2006 -- For children and young adults who suffer from a rare and debilitating disorder called neonatal-onset multisystem inflammatory disease (NOMID), a drug called anakinra brings marked improvement both in symptoms and the inflammation underlying the disease, a new study shows.

The study, published in the August 10 issue of the New England Journal of Medicine, was conducted in the Intramural Research Program of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a component of the National Institutes of Health.

NOMID, also known as chronic infantile neurologic cutaneous articular (CINCA) syndrome, is an inflammatory disorder that affects numerous organs and body systems, including the skin, joints, eyes and central nervous system. For most children, the first sign of the disease is a rash that develops within the first six weeks of life. Other problems, including fever, meningitis, joint damage, vision and hearing loss, and mental retardation, can follow. NOMID is one of a group of illnesses that NIAMS Clinical Director Daniel Kastner MD, PhD, has designated autoinflammatory diseases, because of their seemingly unprovoked episodes of inflammation. Despite treatment to control the inflammation -- including high-dose corticosteroids, disease-modifying antirheumatic drugs such as methotrexate, and nonsteroidal anti-inflammatory drugs such as ibuprofen or naproxen -- the disease is progressive and often fatal. As many as 20% of children with NOMID don't survive to adulthood.

"This research shows the importance of studying rare but enormously instructive diseases, a unique strength of the NIH intramural science program," says NIH Director Elias A. Zerhouni, MD. "This study provides new insights on fundamental mechanisms of inflammation. More importantly this new therapy will reduce the pain and suffering of these young patients allowing them to live a fuller life than previously possible."

While the mechanism of NOMID is not completely understood, research in recent years has revealed mutations in a gene called "CIAS1" in approximately 60% of patients with the disease. "CIAS1" encodes cryopyrin, which belongs to a group of interacting proteins involved in regulating inflammation and programmed cell death, which plays a crucial role in ridding the body of cells that are no longer needed. The mutations, scientists have found, lead to an imbalance of a cytokine, or chemical messenger, called interleukin-1 (IL-1), which is believed to drive the inflammation that causes damage in patients with the disease.

Isolated case reports have suggested that anakinra might be effective in treating the rash and other symptoms of NOMID. Anakinra is a biologic agent, a medicine based on compounds that are made by living cells and used to stimulate or restore the ability of the immune system to fight disease and/or infection. It works by blocking the effects of IL-1beta (IL-1ß), and is approved for treating rheumatoid arthritis. Until the new NIAMS study, however, the agent had not been systematically assessed in a larger group of patients with NOMID, and its effect on the most devastating organ manifestations -- including the central nervous system, the eyes and the ears -- had not been investigated, says Raphaela Goldbach-Mansky, MD, a rheumatologist and the study's lead author.

To determine the possible role of anakinra in treating NOMID, the researchers treated 18 NOMID patients (12 with identifiable "CIAS1" mutations) ages 4 to 32 with daily doses of anakinra based on body weight. At one, three and six months they assessed the treatment's effectiveness.

All 18 of the patients, they found, had an immediate clinical response to anakinra. Rash and conjunctivitis (inflammation of the membrane lining the eyelids), both common in NOMID, disappeared within three days. By three months, laboratory measures of inflammation, including erythrocyte sedimentation rate, c-reactive protein and serum amyloid A protein (SAA), had improved, and by six months, 33% of the patients showed improved hearing and another half of the patients had no further hearing loss from baseline. Other confirmed benefits of treatment included disappearance or lessening of headaches, reduction of central nervous system lesions, ability to lower corticosteroid doses, and remission of inflammation in more than half of patients by month six. At month three, disease flared in 11 patients when they were withdrawn from anakinra as part of the study, but when anakinra was restarted, the disease quickly responded again. Daily injections would be required for any long-term treatment.

"This study demonstrates the efficacy of anakinra in improving major organ manifestations and helps confirm the role of IL-1beta (IL-1 beta) in many features of the disease; most importantly, the central nervous system," says Dr. Goldbach-Mansky.

Because NOMID is a rare disease (400 to 600 children in the United States), the study was necessarily small and lacked a control group, but the study was strengthened by the magnitude of the clinical response to the agent and the fact that the disease flared when anakinra was temporarily stopped, she says.

"NOMID is a devastating disease for which previously there was little understanding or effective treatment," says NIAMS Director Stephen I. Katz, MD, PhD. "This study not only provides hope -- in the way of an already-available agent -- but it also provides a better understanding of the mechanism of the disease's damaging effects."

Furthermore, notes Goldbach-Mansky, anakinra was safe in this clinical investigation. Unlike some other treatments used for NOMID, it caused no serious side effects in any of the patients during the study.
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« Reply #10 on: September 15, 2006, 08:32:15 am »

The Facts about Low Back Pain

If you have low back pain, you are not alone. Nearly everyone at some point has back pain that interferes with work, routine daily activities, or recreation. Americans spend at least $50 billion each year on low back pain, the most common cause of job-related disability and a leading contributor to missed work. Back pain is the second most common neurological ailment in the United States - only headache is more common. Fortunately, most occurrences of low back pain go away within a few days. Others take much longer to resolve or lead to more serious conditions.

Structures of the Back
The back is an intricate structure of bones, muscles, and other tissues that form the posterior part of the body's trunk, from the neck to the pelvis. The centerpiece is the spinal column, which not only supports the upper body's weight but houses and protects the spinal cord - the delicate nervous system structure that carries signals that control the body's movements and convey its sensations. Stacked on top of one another are more than 30 bones - the vertebrae - that form the spine. The spaces between the vertebrae are maintained by round, spongy pads of cartilage called intervertebral discs that allow for flexibility in the lower back and act much like shock absorbers throughout the spinal column to cushion the bones as the body moves. Ligaments and tendons hold the vertebrae in place and attach the muscles to the spinal column.

Starting at the top, the spine has four regions:

the seven cervical or neck vertebrae (labeled C1-C7)
the 12 thoracic or upper back vertebrae (labeled T1-T12)
the five lumbar vertebrae (labeled L1-L5), which we know as the lower back
the sacrum and coccyx, a group of bones fused together at the base of the spine
The lumbar region of the back, where most back pain is felt, supports the weight of the upper body.

Causes of Lower Back Pain
As people age, bone strength and muscle elasticity and tone tend to decrease. The spinal discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae.

Pain can occur when, for example, someone lifts something too heavy or overstretches, causing a sprain, strain, or spasm in one of the muscles or ligaments in the back. If the spine becomes overly strained or compressed, a disc may rupture or bulge outward. This rupture may put pressure on one of the more than 50 nerves rooted to the spinal cord that control body movements and transmit signals from the body to the brain. When these nerve roots become compressed or irritated, back pain results.

Low back pain may reflect nerve or muscle irritation or bone lesions. Most low back pain follows injury or trauma to the back, but pain may also be caused by degenerative conditions such as arthritis or disc disease, osteoporosis or other bone diseases, viral infections, irritation to joints and discs, or congenital abnormalities in the spine. Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, posture inappropriate for the activity being performed, and poor sleeping position also may contribute to low back pain. Additionally, scar tissue created when the injured back heals itself does not have the strength or flexibility of normal tissue. Buildup of scar tissue from repeated injuries eventually weakens the back and can lead to more serious injury.

Occasionally, low back pain may indicate a more serious medical problem. Pain accompanied by fever or loss of bowel or bladder control, pain when coughing, and progressive weakness in the legs may indicate a pinched nerve or other serious condition. People with diabetes may have severe back pain or pain radiating down the leg related to neuropathy. People with these symptoms should contact a doctor immediately to help prevent permanent damage.

Low back pain unrelated to injury or other known cause is unusual in pre-teen children, however, a backpack overloaded with schoolbooks and supplies can quickly strain the back and cause muscle fatigue. The US Consumer Product Safety Commission estimates that more than 13,260 injuries related to backpacks were treated at doctors' offices, clinics, and emergency rooms in the year 2000. To avoid back strain, children carrying backpacks should bend both knees when lifting heavy packs, visit their locker or desk between classes to lighten loads or replace books, or purchase a backpack or airline tote on wheels.

Conditions Associated with Low Back Pain
Conditions that might cause low back pain and require treatment by a physician or other health specialist include:

Bulging disc (also called protruding, herniated, or ruptured disc). The intervertebral discs are under constant pressure. As discs degenerate and weaken, cartilage can bulge or be pushed into the space containing the spinal cord or a nerve root, causing pain. Studies have shown that most herniated discs occur in the lower, lumbar portion of the spinal column.
Sciatica is a condition in which a herniated or ruptured disc presses on the sciatic nerve, the large nerve that extends down the spinal column to its exit point in the pelvis and carries nerve fibers to the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg to below the knee, occasionally reaching the foot.
Spinal degeneration from disc wear and tear can lead to a narrowing of the spinal canal. A person with spinal degeneration may experience stiffness in the back upon awakening or may feel pain after walking or standing for a long time.
Spinal stenosis related to congenital narrowing of the bony canal predisposes some people to pain related to disc disease.
Osteoporosis is a metabolic bone disease marked by progressive decrease in bone density and strength. Fracture of brittle, porous bones in the spine and hips results when the body fails to produce new bone and/or absorbs too much existing bone. Women are four times more likely than men to develop osteoporosis. Caucasian women of northern European heritage are at the highest risk of developing the condition.
Skeletal irregularities produce strain on the vertebrae and supporting muscles, tendons, ligaments, and tissues supported by spinal column. These irregularities include scoliosis, a curving of the spine to the side; kyphosis, in which the normal curve of the upper back is severely rounded; lordosis, an abnormally accentuated arch in the lower back; back extension, a bending backward of the spine; and back flexion, in which the spine bends forward.
Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and multiple "tender points," particularly in the neck, spine, shoulders, and hips. Additional symptoms may include sleep disturbances, morning stiffness, and anxiety.
Spondylitis refers to chronic back pain and stiffness caused by a severe infection to or inflammation of the spinal joints. Other painful inflammations in the lower back include osteomyelitis (infection in the bones of the spine) and sacroiliitis (inflammation in the sacroiliac joints).
Diagnosis
A thorough medical history and physical exam can usually identify any dangerous conditions or family history that may be associated with low back pain. The patient describes the onset, site, and severity of the pain; duration of symptoms and any limitations in movement; and history of previous episodes or any health conditions that might be related to the pain. The physician will examine the back and conduct neurologic tests to determine the cause of pain and appropriate treatment. Blood tests may also be ordered. Imaging tests may be necessary to diagnose tumors or other possible sources of the pain.

A variety of diagnostic methods are available to confirm the cause of low back pain:

X-ray imaging includes conventional and enhanced methods that can help diagnose the cause and site of back pain. A conventional X-ray, often the first imaging technique used, looks for broken bones or an injured vertebra. Tissue masses such as injured muscles and ligaments or painful conditions such as a bulging disc are not visible on conventional X-rays.
Discography involves the injection of a special contrast dye into a spinal disc thought to be causing low back pain. The dye outlines the damaged areas on X-rays taken following the injection. This procedure is often suggested for patients who are considering lumbar surgery or whose pain has not responded to conventional treatments. Myelograms also enhance the diagnostic imaging of an X-ray. In this procedure, the contrast dye is injected into the spinal canal, allowing spinal cord and nerve compression caused by herniated discs or fractures to be seen on an X-ray.
Computerized tomography (CT) scanning is a quick and painless process used when disc rupture, spinal stenosis, or damage to vertebrae is suspected as a cause of low back pain.
Magnetic resonance imaging (MRI) is used to evaluate the lumbar region for bone degeneration or injury or disease in tissues and nerves, muscles, ligaments, and blood vessels. This noninvasive procedure is often used to identify a condition requiring prompt surgical treatment.
Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. EMG assesses the electrical activity in a nerve and can detect if muscle weakness results from injury or a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body. With nerve conduction studies the doctor uses two sets of electrodes that are placed on the skin over the muscles. The first set gives the patient a mild shock to stimulate the nerve that runs to a particular muscle. The second set of electrodes is used to make a recording of the nerve's electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes - one set to stimulate a sensory nerve and the other set on the scalp to record the speed of nerve signal transmissions to the brain.
Bone scans are used to diagnose and monitor infection, fracture, or disorders in the bone. A small amount of radioactive material is injected into the bloodstream and will collect in the bones, particularly in areas with some abnormality. Scanner-generated images are sent to a computer to identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.
Thermography involves the use of infrared sensing devices to measure small temperature changes between the two sides of the body or the temperature of a specific organ. Thermography may be used to detect the presence or absence of nerve root compression.
Ultrasound imaging, also called ultrasound scanning or sonography, uses high-frequency sound waves to obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual image. Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the back.
Treatment
Most low back pain can be treated without surgery. Treatment involves using analgesics, reducing inflammation, restoring proper function and strength to the back, and preventing recurrence of the injury. Most patients with back pain recover without residual functional loss. Patients should contact a doctor if there is not a noticeable reduction in pain and inflammation after 72 hours of self-care.

Although ice and heat (the use of cold and hot compresses) have never been scientifically proven to quickly resolve low back injury, compresses may help reduce pain and inflammation and allow greater mobility for some individuals. As soon as possible following trauma, patients should apply a cold pack or a cold compress (such as a bag of ice or bag of frozen vegetables wrapped in a towel) to the tender spot several times a day for up to 20 minutes. After 2 to 3 days of cold treatment, they should then apply heat (such as a heating lamp or hot pad) for brief periods to relax muscles and increase blood flow. Warm baths may also help relax muscles. Patients should avoid sleeping on a heating pad, which can cause burns and lead to additional tissue damage.

Bed rest (one to two days at most). A 1996 Finnish study found that persons who continued their activities without bed rest following onset of low back pain appeared to have better back flexibility than those who rested in bed for a week. Other studies suggest that bed rest alone may make back pain worse and can lead to secondary complications such as depression, decreased muscle tone, and blood clots in the legs. Patients should resume activities as soon as possible. At night or during rest, patients should lie on one side, with a pillow between the knees (some doctors suggest resting on the back and putting a pillow beneath the knees).

Exercise may be the most effective way to speed recovery from low back pain and help strengthen back and abdominal muscles. Maintaining and building muscle strength is particularly important for persons with skeletal irregularities. Doctors and physical therapists can provide a list of gentle exercises that help keep muscles moving and speed the recovery process. A routine of back-healthy activities may include stretching exercises, swimming, walking, and movement therapy to improve coordination and develop proper posture and muscle balance. Yoga is another way to gently stretch muscles and ease pain. Any mild discomfort felt at the start of these exercises should disappear as muscles become stronger. But if pain is more than mild and lasts more than 15 minutes during exercise, patients should stop exercising and contact a doctor.

Medications are often used to treat acute and chronic low back pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Patients should always check with a doctor before taking drugs for pain relief. Certain medicines, even those sold over the counter, are unsafe during pregnancy, may conflict with other medications, may cause side effects including drowsiness, or may lead to liver damage.

Over-the-counter analgesics, including nonsteroidal anti-inflammatory drugs (aspirin, naproxen, and ibuprofen), are taken orally to reduce stiffness, swelling, and inflammation and to ease mild to moderate low back pain. Counter-irritants applied topically to the skin as a cream or spray stimulate the nerve endings in the skin to provide feelings of warmth or cold and dull the sense of pain. Topical analgesics can also reduce inflammation and stimulate blood flow. Many of these compounds contain salicylates, the same ingredient found in oral pain medications containing aspirin.
Anticonvulsants - drugs primarily used to treat seizures - may be useful in treating certain types of nerve pain and may also be prescribed with analgesics.
Some antidepressants, particularly tricyclic antidepressants such as amitriptyline and desipramine, have been shown to relieve pain (independent of their effect on depression) and assist with sleep. Antidepressants alter levels of brain chemicals to elevate mood and dull pain signals. Many of the new antidepressants, such as the selective serotonin reuptake inhibitors, are being studied for their effectiveness in pain relief.
Opioids such as codeine, oxycodone, hydrocodone, and morphine are often prescribed to manage severe acute and chronic back pain but should be used only for a short period of time and under a physician's supervision. Side effects can include drowsiness, decreased reaction time, impaired judgment, and potential for addiction. Many specialists are convinced that chronic use of these drugs is detrimental to the back pain patient, adding to depression and even increasing pain.
Spinal manipulation is literally a "hands-on" approach in which professionally licensed specialists (such as chiropractors and physical therapists) use leverage and a series of exercises to adjust spinal structures and restore back mobility. These specialists do not prescribe drugs or use surgery in their treatment of low back pain.
Patients may also consider the following options:

Acupuncture involves the insertion of needles the width of a human hair along precise points throughout the body. Practitioners believe this process triggers the release of naturally occurring painkilling molecules called peptides and keeps the body's normal flow of energy unblocked. Clinical studies are measuring the effectiveness of acupuncture in comparison to more conventional procedures in the treatment of acute low back pain.
Biofeedback is used to treat many acute pain problems, most notably back pain and headache. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature (by controlling local blood flow patterns). The patient can then learn to effect a change in his or her response to pain, for example, by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects.
Interventional therapy can ease chronic pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids, or narcotics into affected soft tissues, joints, or nerve roots to more complex nerve blocks and spinal cord stimulation. When extreme pain is involved, low doses of drugs may be administered by catheter directly into the spinal cord. Chronic use of steroid injections may lead to decreased function.
Traction involves the use of weights to apply constant or intermittent force to gradually "pull" the skeletal structure into better alignment. Traction is not recommended for treating acute low back symptoms.
Transcutaneous electrical nerve stimulation (TENS) is administered by a battery-powered device that sends mild electric pulses along nerve fibers to block pain signals to the brain. Small electrodes placed on the skin at or near the site of pain generate nerve impulses that block incoming pain signals from the peripheral nerves. TENS may also help stimulate the brain's production of endorphins (chemicals that have pain-relieving properties).
Ultrasound is a noninvasive therapy used to warm the body's internal tissues, which causes muscles to relax. Sound waves pass through the skin and into the injured muscles and other soft tissues.
Minimally invasive outpatient treatments to seal fractures of the vertebrae caused by osteoporosis include vertebroplasty and kyphoplasty. Vertebroplasty uses three-dimensional imaging to help a doctor guide a fine needle into the vertebral body. A glue-like epoxy is injected, which quickly hardens to stabilize and strengthen the bone and provide immediate pain relief. In kyphoplasty, prior to injecting the epoxy, a special balloon is inserted and gently inflated to restore height to the bone and reduce spinal deformity.

In the most serious cases, when the condition does not respond to other therapies, surgery may relieve pain caused by back problems or serious musculoskeletal injuries. Some surgical procedures may be performed in a doctor's office under local anesthesia, while others require hospitalization. It may be months following surgery before the patient is fully healed, and he or she may suffer permanent loss of flexibility. Since invasive back surgery is not always successful, it should be performed only in patients with progressive neurologic disease or damage to the peripheral nerves.

Prevention
Recurring back pain resulting from improper body mechanics or other nontraumatic causes is often preventable. A combination of exercises that don't jolt or strain the back, maintaining correct posture, and lifting objects properly can help prevent injuries.

Many work-related injuries are caused or aggravated by stressors such as heavy lifting, contact stress (repeated or constant contact between soft body tissue and a hard or sharp object, such as resting a wrist against the edge of a hard desk or repeated tasks using a hammering motion), vibration, repetitive motion, and awkward posture. Applying ergonomic principles - designing furniture and tools to protect the body from injury - at home and in the workplace can greatly reduce the risk of back injury and help maintain a healthy back. More companies and homebuilders are promoting ergonomically designed tools, products, workstations, and living space to reduce the risk of musculoskeletal injury and pain.

Quick tips to a healthier back


Always stretch before exercise or other strenuous physical activity.
Don't slouch when standing or sitting. When standing, keep your weight balanced on your feet. Your back supports weight most easily when curvature is reduced.
At home or work, make sure your work surface is at a comfortable height for you.
Sit in a chair with good lumbar support and proper position and height for the task. Keep your shoulders back. Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of your back can provide some lumbar support. If you must sit for a long period of time, rest your feet on a low stool or a stack of books.
Wear comfortable, low-heeled shoes.
Sleep on your side to reduce any curve in your spine. Always sleep on a firm surface.
Ask for help when transferring an ill or injured family member from a reclining to a sitting position or when moving the patient from a chair to a bed.
Don't try to lift objects too heavy for you. Lift with your knees, pull in your stomach muscles, and keep your head down and in line with your straight back. Keep the object close to your body. Do not twist when lifting.
Maintain proper nutrition and diet to reduce and prevent excessive weight, especially weight around the waistline that taxes lower back muscles. A diet with sufficient daily intake of calcium, phosphorus, and vitamin D helps to promote new bone growth.
If you smoke, quit. Smoking reduces blood flow to the lower spine and causes the spinal discs to degenerate.
Following any period of prolonged inactivity, begin a program of regular low-impact exercises. Speed walking, swimming, or stationary bike riding 30 minutes a day can increase muscle strength and flexibility. Yoga can also help stretch and strengthen muscles and improve posture. Ask your physician or orthopedist for a list of low-impact exercises appropriate for your age and designed to strengthen lower back and abdominal muscles.
« Last Edit: November 24, 2006, 02:28:40 pm by Kathy » Logged


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« Reply #11 on: September 29, 2006, 08:47:16 am »

Sacroplasty Safe and Effective to Reduce Low Back Pain

LA GRANGE, IL -- September 28, 2006 -- The injection is safe when performed by physicians experienced with the technique, and pain reduction is both swift and sustained, according to the one-year, multi-center cohort study.

Among the 25 patients enrolled in the uncontrolled study, the mean pain score on a 10-point visual analog scale was 7.3 at baseline, 2.7 immediately post-procedure, 1.4 at two weeks, 0.5 at 24 weeks, and 0.3 at 52 weeks, according to Michael Frey, MD, a NASS member and physiatrist at Advanced Pain Management and Spine Specialists in Fort Myers, FL.

There are currently no treatments for sacral insufficiency fractures. Recovery is typically slow, and pain may linger for up to a year. In some cases, symptoms and disability last longer.

To calm the pain, physicians often prescribe bed rest, painkillers, corsets, or other measures. However, these can put patients at increased risk of thromboembolism, skin breakdown, pressure ulcers, constipation, depression, progressive osteoporosis, and reduced muscle strength and cardiac function.

"These patients are miserable," said Frey, who has performed sacroplasty on nearly 50 patients.

To explore better alternatives, Frey and others have adapted techniques developed for vertebroplasty in the lumbar spine. In vertebroplasty, physicians use fluoroscopic guidance to inject polymethylmethacrylate (PMMA) into osteoporotic compression fractures. After injection the acrylic bone cement hardens. The technique was designed to stabilize the fracture, reduce pain, and improve function.

Frey and colleagues reported on consecutive patients with osteoporosis who had incapacitating low back or gluteal pain and a sacral insufficiency fracture documented on MR imaging or CT scan, and who failed or could not tolerate conservative care. The authors excluded patients with fractures caused by malignancies.

About one in seven patients experienced complete relief of pain within 30 minutes, said Frey. Approximately one-fourth were pain-free at two weeks and about one-third at four weeks. Frey said there were no complications associated with the procedure at any time, though one patient died of what was deemed unrelated pulmonary disease within four weeks of undergoing the procedure. Excluding this patient, all but two patients reported 75% to 100% satisfaction at one year.

"Sacroplasty is a dramatic leap forward," said Frey.

Most previous reports about sacroplasty have been small case series with short follow-up. They suggested that the procedure is technically feasible and leads to short-term pain relief. But there is scant prospective evidence on the safety and efficacy of sacroplasty in larger cohorts followed for longer periods of time.

Frey says the procedure can be technically demanding, and recommends physicians have extensive experience in vertebral augmentation. Potentially, cement can leak outside the sacrum and compromise the sacral nerve root, the sacral spinal canal, or sacroiliac joint.

Several years ago, the FDA issued a surprisingly sharp warning about the risks associated with vertebroplasty, including pulmonary embolism, respiratory and cardiac failure, and death. (FDA Public Health Web Notification: Complications related to the use of bone cement in vertebroplasty and kyphoplasty procedures, October 31, 2002.)

Frey noted that sacroplasty is an off-label use of PMAA, and there is no Medicare code for the procedure, so reimbursement is problematic. His cost for one kit is about $400. He said he performs the service at no charge and receives no industry funding for his research.

Frey would like to see controlled trials to compare sacroplasty to a sham procedure. It is conceivable, he said, that sacroplasty is no better than placebo. In his study, none of the patients who declined sacroplasty was pain free at 12 weeks, though at six months and one year their pain had subsided to a level comparable to that of patients who received sacroplasty.

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« Reply #12 on: September 29, 2006, 08:50:05 am »

Fresh Evidence on a New Option for Total Disc Replacement

LA GRANGE, IL -- September 28, 2006 -- "The ProDisc artificial disc is the first motion-sparing technology ever shown to be superior to fusion," said NASS member Rick B. Delamarter, MD, of the Spine Institute at Saint John's Health Center in Los Angeles.

"There will always be a role for fusion to treat problems such as deformity, severe facet arthritis, and instability," he added. "But the whole pendulum is shifting to nonfusion technology."

According to criteria developed by ProDisc's maker Synthes, the overall success rate among patients who received the ProDisc was 64%, compared to 45% among those who underwent circumferential (360-degree) fusion. Some 94% of ProDisc patients had normal motion (mean 7.7 degrees).

By stricter FDA standards, success rates were less impressive – 53% in the ProDisc group and 41% in the fusion group. The FDA analysis acknowledged that ProDisc led to greater patient satisfaction and overall success than fusion, but found no advantage for ProDisc in disability and pain reduction. The FDA concluded that the ProDisc "is reasonably safe and effective."

Whether a motion-sparing artificial disc becomes the dominant treatment for patients with symptomatic disc degeneration remains to be seen. Third-party payers have been resistant to paying for TDR based on perceived gaps in the evidence about its long-term safety and effectiveness and a lack of evidence comparing TDR to nonoperative care.

Like other artificial discs, the ProDisc was designed to overcome limitations inherent in fusion. The new study demonstrated that the ProDisc preserves the natural mobility of the spine, eliminates the need for bone grafts, and limits the collateral damage associated with posterior surgical approaches. Clinical trials have not yet shown another hoped-for benefit of artificial discs -- that they can prevent degeneration of adjacent vertebral segments.

The ProDisc is the second artificial disc to win FDA clearance. The Charité artificial disc, made by Johnson & Johnson, was approved in October 2004 on the basis of a noninferiority trial showing that outcomes of the Charité device were no worse than those of fusion with a BAK fusion cage.

The new ProDisc study went further. It was also designed as a noninferiority trial, but included a secondary superiority analysis showing that the overall success rate of ProDisc was not only no worse than fusion's, but better. The FDA approved the ProDisc on August 14, 2006.

The ProDisc is comprised of a polyethylene central core sandwiched between two metal endplates. Unlike the Charité disc, which is designed with a free-floating central core, the ProDisc is a semi-constrained prosthesis with a keel intended to lend stability and minimize device migration and subsidence.

Delamarter and colleagues randomized 242 men and women with back and/or leg pain to the ProDisc (162 patients) or fusion (80 patients), then followed them for two years. Patients had previously failed at least six months of nonoperative care, demonstrated radiographic evidence of single-level degenerative disc disease, and scored greater than 40% impairment (> 20/50) on the Oswestry Disability Index. Their average weight was 176 pounds and their average age was 39 years.

According to the analysis by Delamarter et al., patients in both groups had similar pain and disability through postoperative month 18, but ProDisc patients reported significantly less pain and disability at the 24-month point. The findings appear to be at odds with the FDA analysis.

Complication rates were similar between groups, and no patient in either group suffered a major complication. About 4% of ProDisc recipients had reoperations, compared to 5% of fusion patients.

Delamarter emphasized that 81% of ProDisc patients said they were satisfied with the treatment, compared to 69% of fusion patients.

He pointed out that the stringent FDA success criteria did not include patient satisfaction. "We're in the business of improving quality of life. The FDA's determination of success is a mathematical formula. It isn't a patient success formula," he said.

The FDA in the conclusion to its summary said the trial "demonstrated that the ProDisc-L Total Disc Replacement is reasonably safe and effective by demonstrating its noninferiority when comparing Overall Success and adverse event rates to the control for the studied indication." Other statistically significant advantages observed in the ProDisc group -- diminished blood loss, surgery time, and hospital stay -- may not have been clinically significant, according to the FDA analysis.

The future of ProDisc in many ways lies in the hands of third-party payers. Though payers have expressed strong reservations about the Charité disc, it is unclear how they will respond to the ProDisc.

Questions remain about the long-term durability of artificial discs. Laboratory studies suggest the ProDisc will last 40 to 50 years, said Delamarter. "But what happens clinically at 30 to 40 years we don't know," he acknowledged. The FDA license requires Synthes to follow patients in the trial for a total of five years.

Some observers wonder if broader use of the technology might result in worse outcomes. FDA-regulated device trials typically employ some of the best surgeons in the field. Whether future ProDisc outcomes will be comparable, better, or worse than those documented in the FDA trial is unknown.

Delamarter believes the ProDisc is ready for widespread use. The Synthes training program is "intense on a small scale, allowing surgeons to be thoroughly trained," he said. "But patient selection and proper surgical training are critical."

The North American Spine Society recently issued training recommendations for TDR. They include the following:

•The surgeon should have extensive experience in anterior lumbar interbody fusion. The risks inherent in an anterior transperitoneal or retroperitoneal approach -- and, particularly, in a repeat anterior approach -- "are significant."

•The clinical setting should be equipped to deal with potential intra-operative and postoperative complications.

•Surgeons should be accomplished in the possible salvage procedures.

•Surgeons should have performed one to two TDR procedures per month for the preceding 12 months; be proficient with fluoroscopy; be certified in a training course given by the offering technology company; and first undergo a series of mentored operations.

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« Reply #13 on: October 03, 2006, 05:44:32 pm »

October 3, 2006
Really?
The Claim: Raisins Soaked in Gin Can Ease Arthritis Pain

THE FACTS In 2004, Teresa Heinz Kerry, the Mozambique-born heiress and wife of John Kerry, who was then running for president, advocated an unusual remedy for arthritis while discussing health care at a campaign stop in Nevada.

“You get some gin and get some white raisins — and only white raisins — and soak them in the gin for two weeks,” she said. “Then eat nine of the raisins a day.”

Although some people poked fun at the statement, Mrs. Heinz Kerry was repeating a popular folk remedy that has been around for decades. Countless Web sites for arthritis sufferers mention it as a cure for pain, and several books on folk remedies promote it. But whether there is any real science behind it is an open question.

To date, no rigorous studies have examined whether gin or raisins — together or alone — can ease arthritis symptoms. Grapes contain compounds called proanthocyanidins, which are thought to help fight infection and reduce inflammation. They also contain resveratrol, the powerful antioxidant that scientists say gives red wine many of its disease-fighting properties.

Dr. Steven Abramson, the director of rheumatology at the New York University Hospital for Joint Diseases, said studies are looking at whether resveratrol and other substances in red wine can affect joint disease. But raisins are a poor source of resveratrol, which is usually destroyed when grapes are dried. And the Agriculture Department says levels of proanthocyanidins in raisins are “undetectable.”

As for the gin, Dr. Abramson said, some people find it can help dull pain, but only in moderation.

THE BOTTOM LINE There is no evidence that raisins soaked in gin have any particular effect on arthritis pain
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« Reply #14 on: October 05, 2006, 09:29:00 am »

Rheumatoid arthritis is an inflammatory disease that causes pain, swelling, stiffness, and loss of function in the joints. There is much to learn about rheumatoid arthritis including:


cause, occurrence, and impact of rheumatoid arthritis
diagnosis of rheumatoid arthritis
treatment of rheumatoid arthritis
medications used to treat rheumatoid arthritis and surgery options

Rheumatoid arthritis has several special features that make it different from other types of arthritis. For example, rheumatoid arthritis generally occurs in a symmetrical pattern, meaning that if one knee or hand is involved, the other one also is.



The disease often affects the wrist joints and the finger joints closest to the hand. It can also affect other parts of the body besides the joints. In addition, people with rheumatoid arthritis may have fatigue, occasional fevers, and a general sense of not feeling well.

Rheumatoid arthritis affects people differently. For some people, it lasts only a few months or a year or two and goes away without causing any noticeable damage. Other people have mild or moderate forms of the disease, with periods of worsening symptoms, called flares, and periods in which they feel better, called remissions. Still others have a severe form of the disease that is active most of the time, lasts for many years or a lifetime, and leads to serious joint damage and disability.

Although rheumatoid arthritis can have serious effects on a person's life and well-being, current treatment strategies (including pain-relieving drugs and medications that slow joint damage), a balance between rest and exercise, and patient education and support programs, allow most people with the disease to lead active and productive lives. In recent years, research has led to a new understanding of rheumatoid arthritis and has increased the likelihood that, in time, researchers will find even better ways to treat the disease.




Features of Rheumatoid Arthritis

Features of rheumatoid arthritis include:


tender, warm, swollen joints
symmetrical pattern of affected joints
joint inflammation often affecting the wrist and finger joints closest to the hand
joint inflammation sometimes affecting other joints, including the:


neck
shoulders
elbows
hips
knees
ankles
feet

fatigue, occasional fevers, a general sense of not feeling well
pain and stiffness lasting for more than 30 minutes in the morning or after a long rest
symptoms that last for many years
variability of symptoms among people with the disease


Rheumatoid Arthritis Screening Quiz


How Rheumatoid Arthritis Develops and Progresses

The Joints

A joint is a place where two bones meet. The ends of the bones are covered by cartilage, which allows for easy movement of the two bones. The joint is surrounded by a capsule that protects and supports it. The joint capsule is lined with a type of tissue called synovium, which produces synovial fluid, a clear substance that lubricates and nourishes the cartilage and bones inside the joint capsule. In rheumatoid arthritis, the synovium becomes inflamed.

Like many other rheumatic diseases, rheumatoid arthritis is an autoimmune disease, so-called because a person's immune system, which normally helps protect the body from infection and disease, attacks joint tissues for unknown reasons. White blood cells, the agents of the immune system, travel to the synovium and cause inflammation (synovitis), characterized by warmth, redness, swelling, and pain--typical symptoms of rheumatoid arthritis. During the inflammation process, the normally thin synovium becomes thick and makes the joint swollen and puffy to the touch.

As rheumatoid arthritis progresses, the inflamed synovium invades and destroys the cartilage and bone within the joint. (illustration) The surrounding muscles, ligaments, and tendons that support and stabilize the joint become weak and unable to work normally. These effects lead to the pain and joint damage often seen in rheumatoid arthritis.

Rheumatoid arthritis also can cause more generalized bone loss that may lead to osteoporosis (fragile bones that are prone to fracture).

Researchers studying rheumatoid arthritis now believe that it begins to damage bones during the first year or two that a person has the disease, one reason why early diagnosis and treatment are so important.

Other Parts of the Body

Some people with rheumatoid arthritis also have symptoms in places other than their joints. Many people with rheumatoid arthritis develop anemia, or a decrease in the production of red blood cells. Other effects that occur less often include neck pain, dry eyes, and dry mouth. Very rarely, people may have inflammation of:


the blood vessels (vasculitis)
the lining of the lungs (pleurisy)
the sac enclosing the heart (pericarditis)


Searching For The Causes Of Rheumatoid Arthritis

Scientists still do not know exactly what causes the immune system to turn against itself in rheumatoid arthritis, but research over the last few years has begun to piece together the factors involved.

Genetic (inherited) factors: Scientists have discovered that certain genes known to play a role in the immune system are associated with a tendency to develop rheumatoid arthritis. Some people with rheumatoid arthritis do not have these particular genes; still others have these genes but never develop the disease. These somewhat contradictory data suggest that a person's genetic makeup plays an important role in determining if he or she will develop rheumatoid arthritis, but it is not the only factor. What is clear, however, is that more than one gene is involved in determining whether a person develops rheumatoid arthritis and how severe the disease will become.

Environmental factors: Many scientists think that something must occur to trigger the disease process in people whose genetic makeup makes them susceptible to rheumatoid arthritis.

This does not mean that rheumatoid arthritis is contagious: a person cannot catch it from someone else.

Other factors: Some scientists also think that a variety of hormonal factors may be involved.


Women are more likely to develop rheumatoid arthritis than men, pregnancy may improve the disease, and the disease may flare after a pregnancy.
Breastfeeding may also aggravate the disease.
Contraceptive use may alter a person's likelihood of developing rheumatoid arthritis.

Scientists think that levels of the immune system molecules interleukin 12 (IL-12) and tumor necrosis factor-alpha (TNF-á) may change along with the changing hormone levels seen in pregnant women. This change may contribute to the swelling and tissue destruction seen in rheumatoid arthritis. These hormones, or possibly deficiencies or changes in certain hormones, may promote the development of rheumatoid arthritis in a genetically susceptible person who has been exposed to a triggering agent from the environment.

Even though all the answers are not known, one thing is certain: rheumatoid arthritis develops as a result of an interaction of many factors. Researchers are trying to understand these factors and how they work together.


Hope for the Future

Scientists are making rapid progress in understanding the complexities of rheumatoid arthritis: how and why it develops, why some people get it and others do not, why some people get it more severely than others. Results from research are having an impact today, enabling people with rheumatoid arthritis to remain active in life, family, and work far longer than was possible 20 years ago. There is also hope for tomorrow, as researchers begin to apply new technologies such as stem cell transplantation and novel imaging techniques. (Stem cells have the capacity to differentiate into specific cell types, which gives them the potential to change damaged tissue in which they are placed.) These and other advances will lead to an improved quality of life for people with rheumatoid arthritis.


Occurrence and Impact of Rheumatoid Arthritis

Scientists estimate that over 2.1 million people, or between 0.5 and 1 percent of the U.S. adult population, have rheumatoid arthritis. Interestingly, some recent studies have suggested that the overall number of new cases of rheumatoid arthritis actually may be going down. Scientists are investigating why this may be happening.

Rheumatoid arthritis occurs in all races and ethnic groups. Although the disease often begins in middle age and occurs with increased frequency in older people, children and young adults also develop it. Like some other forms of arthritis, rheumatoid arthritis occurs much more frequently in women than in men. About two to three times as many women as men have the disease.

By all measures, the financial and social impact of all types of arthritis, including rheumatoid arthritis, is substantial, both for the Nation and for individuals. From an economic standpoint, the medical and surgical treatment for rheumatoid arthritis and the wages lost because of disability caused by the disease add up to billions of dollars annually.



Daily joint pain is an inevitable consequence of the disease, and most patients also experience some degree of:


depression
anxiety
feelings of helplessness

For some people, rheumatoid arthritis can interfere with normal daily activities, limit work opportunities, or disrupt the joys and responsibilities of family life. However, there are arthritis self-management programs that help people cope with the pain and other effects of the disease and help them lead independent and productive lives.

Rheumatoid Arthritis Diagnosis

Diagnosing and treating rheumatoid arthritis requires a team effort involving the patient and several types of health care professionals. A person can go to his or her family doctor or internist or to a rheumatologist. A rheumatologist is a doctor who specializes in arthritis and other diseases of the joints, bones, and muscles. As treatment progresses, other professionals often help. These may include:


nurses
physical therapists
occupational therapists
orthopaedic surgeons
psychologists
social workers

Studies have shown that patients who are well informed and participate actively in their own care have less pain and make fewer visits to the doctor than do other patients with rheumatoid arthritis.



Patient education and arthritis self-management programs, as well as support groups, help people to become better informed and to participate in their own care.


Self-management programs teach about rheumatoid arthritis and its treatments, exercise and relaxation approaches, communication between patients and health care providers, and problem solving. Research on these programs has shown that they help people:


understand the disease
reduce their pain while remaining active
cope physically, emotionally, and mentally
feel greater control over the disease and build a sense of confidence in the ability to function and lead full, active, and independent lives



Diagnosis

Rheumatoid arthritis can be difficult to diagnose in its early stages for several reasons. First, there is no single test for the disease. In addition, symptoms differ from person to person and can be more severe in some people than in others. Also, symptoms can be similar to those of other types of arthritis and joint conditions, and it may take some time for other conditions to be ruled out. Finally, the full range of symptoms develops over time, and only a few symptoms may be present in the early stages. As a result, doctors use a variety of the following tools to diagnose the disease and to rule out other conditions:

Medical history: This is the patient's description of symptoms and when and how they began. Good communication between patient and doctor is especially important here. For example, the patient's description of pain, stiffness, and joint function and how these change over time is critical to the doctor's initial assessment of the disease and how it changes over time.

Physical examination: This includes the doctor's examination of the joints, skin, reflexes, and muscle strength.

X rays: X rays are used to determine the degree of joint destruction. They are not useful in the early stages of rheumatoid arthritis before bone damage is evident, but they can be used later to monitor the progression of the disease.

Laboratory tests: One common test is for rheumatoid factor, an antibody that is present eventually in the blood of most people with rheumatoid arthritis. (An antibody is a special protein made by the immune system that normally helps fight foreign substances in the body.) Not all people with rheumatoid arthritis test positive for rheumatoid factor, however, especially early in the disease. Also, some people test positive for rheumatoid factor, yet never develop the disease. Other common laboratory tests include a white blood cell count, a blood test for anemia, and a test of the erythrocyte sedimentation rate (often called the sed rate), which measures inflammation in the body. C-reactive protein (CRP) is another common test that measures disease activity.


Rheumatoid Arthritis Treatment
Doctors use a variety of approaches to treat rheumatoid arthritis. These are used in different combinations and at different times during the course of the disease and are chosen according to the patient's individual situation. No matter what treatment the doctor and patient choose, however, the goals are the same:


to relieve pain
reduce inflammation
slow down or stop joint damage
improve sense of well-being and ability to function

Good communication between the patient and doctor is necessary for effective treatment. Talking to the doctor can help ensure that exercise and pain management programs are provided as needed, and that drugs are prescribed appropriately. Talking to the doctor can also help people who are making decisions about surgery.

Regular medical care is important to monitor the course of the disease, determine the effectiveness and any negative effects of treatment, and change therapies as needed.



Monitoring typically includes regular visits to the doctor. It also may include lab tests and x rays.




Healthy Behaviors

Certain activities can help improve a person's ability to function independently and maintain a positive outlook.

Rest

People with rheumatoid arthritis need a good balance between rest and exercise, with more rest when the disease is active and more exercise when it is not. Rest helps to reduce active joint inflammation and pain and to fight fatigue. The length of time for rest will vary from person to person, but in general, shorter rest breaks every now and then are more helpful than long times spent in bed.

Exercise

Exercise is important for:


maintaining healthy and strong muscles
preserving joint mobility
maintaining flexibility

Exercise can also help people sleep well, reduce pain, maintain a positive attitude, and lose weight. Exercise programs should take into account the person's physical abilities, limitations, and changing needs.



Joint care

Some people find using a splint for a short time around a painful joint reduces pain and swelling by supporting the joint and letting it rest. Splints are used mostly on wrists and hands, but also on ankles and feet. A doctor or a physical or occupational therapist can help a person choose a splint and make sure it fits properly. Other ways to reduce stress on joints include changes in the ways that a person carries out daily activities and assistive devices such as:


dressing/grooming aids
lift chairs
raised toilet seats
reacher aids

Stress reduction

People with rheumatoid arthritis face emotional challenges as well as physical ones. The emotions they feel because of the disease (fear, anger, and frustration) combined with any pain and physical limitations can increase their stress level. Although there is no evidence that stress plays a role in causing rheumatoid arthritis, it can make living with the disease difficult at times. Stress also may affect the amount of pain a person feels. Successful ways to reduce stress include:


rest periods
relaxation techniques i.e. distraction or visualization
exercise programs
participation in support groups
good communication with the health care team

Diet

With the exception of some specific types of oils, there is no scientific evidence that any specific food or nutrient helps or harms people with rheumatoid arthritis. However, an overall nutritious diet with enough-but not an excess of-calories, protein, and calcium is important. Some people may need to be careful about drinking alcohol because of the medications they take for rheumatoid arthritis. Those taking methotrexate may need to avoid alcohol altogether because of potential liver damage.

Climate

Some people notice that their arthritis gets worse when there is a sudden change in the weather. However, there is no evidence that a specific climate can prevent or reduce the effects of rheumatoid arthritis. Moving to a new place with a different climate usually does not make a long-term difference in a person's arthritis.



Natural therapies

Special diets, vitamin supplements, and other alternative approaches have been suggested for treating rheumatoid arthritis. Although many of these approaches may not be harmful in and of themselves, controlled scientific studies either have not been conducted on them or have found no definite benefit to these therapies. Some alternative or complementary approaches may help the patient cope or reduce some of the stress associated with living with a chronic illness. As with any therapy, patients should discuss the benefits and drawbacks with their doctors before beginning an alternative or new type of therapy. If the doctor feels the approach has value and will not be harmful, it can be incorporated into a patient's treatment plan. However, it is important not to neglect regular health care.


Medications Used To Treat Rheumatoid Arthritis / Surgery Options
Most people who have rheumatoid arthritis take medications. Some drugs are used only for pain relief. Other drugs are used to reduce inflammation. Other medications, called disease-modifying antirheumatic drugs (DMARDs), are used to try to slow the course of the disease. Important considerations in prescribing drugs for rheumatoid arthritis include the:


person's general condition
current and predicted severity of the illness
length of time he or she will take the drug
drug's effectiveness and potential side effects


Early Aggressive Treatment

For many years, doctors initially prescribed aspirin or other pain-relieving drugs for rheumatoid arthritis, as well as rest and physical therapy.



They usually prescribed more powerful drugs later only if the disease worsened.

Today, however, many doctors have changed their approach, especially for patients with severe, rapidly progressing rheumatoid arthritis. Studies show that early treatment with more powerful drugs, and the use of drug combinations instead of one medication alone, may be more effective in reducing or preventing joint damage. Once the disease improves or is in remission, the doctor may gradually reduce the dosage or prescribe a milder medication.




Drug Options

Medications currently used to treat rheumatoid arthritis include:


analgesics including acetaminophen
nonsteroidal anti-inflammatory drugs (NSAIDs) including:


salicylates (both acetylated such as aspirin and nonacetlyted)
traditional NSAIDs (i.e ibuprofen, ketoprofen, and naproxen)
COX-2 inhibitors

corticosteroids (i.e. methylprednisolone and prednisone)
disease-modifying antirheumatic drugs (DMARDs) including:

azathioprine
cyclosporine
hydroxychloroquine
gold sodium thiomalate
leflunomide
methotrexate
sulfasalazine

Biologic response modifiers (BRMs) including:


TNF blockers (etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira)
anakinra (Kineret)(interleukin1 inhibitor)
abatacept (Orencia)(T-cell co-stimulation modulator)
rituximab (Rituxan)(targets B-cells)



Biologic response modifiers are newer drugs used in the treatment of rheumatoid arthritis. They can help reduce inflammation and structural damage to the joints by blocking the action of cytokines, proteins of the body's immune system that trigger inflammation during normal immune responses.




Osteoporosis Prevention

People with rheumatoid arthritis may want to discuss preventing osteoporosis with their doctors as part of their long-term, ongoing care. Osteoporosis is a condition in which bones become weakened and fragile. Having rheumatoid arthritis increases the risk of developing osteoporosis for both men and women, particularly if a person takes corticosteroids. Such patients may want to discuss with their doctors the potential benefits of calcium and vitamin D supplements, hormone therapy, or other treatments for osteoporosis.



Surgery

Several types of surgery are available to patients with severe joint damage. The primary purpose of these procedures is to reduce pain, improve the affected joint's function, and improve the patient's ability to perform daily activities. Surgery is not for everyone, however, and the decision should be made only after careful consideration by patient and doctor. Together they should discuss the patient's overall health, the condition of the joint or tendon that will be operated on, and the reason for, as well as the risks and benefits of, the surgical procedure. Cost may be another factor. Common surgical procedures include:


joint replacement
tendon reconstruction
synovectomy



Joint replacement

This is the most frequently performed surgery for rheumatoid arthritis, and it is done primarily to relieve pain and improve or preserve joint function. Artificial joints are not always permanent and may eventually have to be replaced. This may be an important consideration for young people.

Tendon reconstruction

Rheumatoid arthritis can damage and even rupture tendons, the tissues that attach muscle to bone. This surgery, which is used most frequently on the hands, reconstructs the damaged tendon by attaching an intact tendon to it. This procedure can help to restore hand function, especially if the tendon is completely ruptured.

Synovectomy

In this surgery, the doctor actually removes the inflamed synovial tissue. Synovectomy by itself is seldom performed now because not all of the tissue can be removed, and it eventually grows back. Synovectomy is done as part of reconstructive surgery, especially tendon reconstruction.

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« Reply #15 on: October 06, 2006, 06:53:36 pm »

Spinal stenosis

Introduction
Spinal stenosis is a narrowing of one or more areas in your spine — most often in your upper or lower back. This narrowing can put pressure on the spinal cord or on the nerves that branch out from the compressed areas. This can lead to a number of problems, depending on which nerves are affected. In general, spinal stenosis can cause cramping, pain or numbness in your legs, back, neck, shoulders or arms; a loss of sensation in your extremities; and sometimes problems with bladder or bowel function.

Mild symptoms of spinal stenosis are often helped by pain relievers, physical therapy or a supportive brace. In more serious cases of spinal stenosis, doctors may recommend surgery to create additional space for the spinal cord or nerves. Although this usually provides some relief, it can't repair damaged nerves or stop the degenerative processes that often lead to spinal stenosis. Unfortunately, even after surgery, symptoms of spinal stenosis may recur or worsen over time.

Signs and symptoms
Spinal narrowing doesn't always cause problems. But if the narrowed areas compress the spinal cord or spinal nerves, you're likely to develop signs and symptoms. These often start gradually and grow worse over time. The most common include:

Pain or cramping in the legs.
Compressed nerves in your lower spine can lead to a condition called pseudoclaudication, false claudication or neurogenic intermittent claudication, which causes pain or cramping in your legs when you stand for long periods of time or when you walk. The discomfort usually eases when you bend forward or sit down, but it continues if you stand upright.

Another type of intermittent claudication (vascular claudication) occurs when there's a narrowing or blockage in the arteries in the legs.

Although both types of claudication cause similar symptoms, they differ in two important ways: Vascular claudication becomes worse when you walk uphill and improves when you stand still. Pseudoclaudication is usually worse when going downhill and gets better when you lean forward or sit down.

Radiating back and hip pain.
A herniated disk can compress nerves in your lumbar spine, leading to pain that starts in your hip or buttocks and extends down the back of your leg. The pain is worse when you're sitting and generally affects only one side.

You also may experience numbness, weakness or tingling in your leg or foot. For some people, the radiating pain is a minor annoyance, but for others, it can be debilitating.

Pain in the neck and shoulders.
This is likely to occur when the nerves in your neck are compressed. The pain may occur only occasionally or it may be chronic, and it sometimes can extend into your arm or hand.

You also may experience headaches, a loss of sensation or muscle weakness.
Loss of balance. Pressure on the cervical spinal cord can affect the nerves that control your balance, resulting in clumsiness or a tendency to fall.

Loss of bowel or bladder function (cauda equina syndrome). In severe cases, nerves to the bladder or bowel may be affected, leading to partial or complete urinary or fecal incontinence. If you experience either of these problems, seek medical care right away.
Causes


Knowing more about the anatomy of your spine makes it easier to understand how spinal stenosis develops and how it can lead to various problems. The main parts of the spine include:

Vertebrae.
 Your spine is made up of 24 bones stacked on top of one another, plus the sacrum and tailbone (coccyx).
Most adults have seven vertebrae in the neck (cervical vertebrae), 12 at the back wall of the chest (thoracic vertebrae) and five vertebrae at the inward curve of the lower back (lumbar vertebrae).

The sacrum consists of five fused vertebrae between the hip bones. The tailbone is composed of three to five fused bones at the very end of the spine.

Ligaments.
These tough, elastic bands of tissue help keep the vertebrae in place when you move.

Intervertebral disks.
These elastic pads of cartilage separate the vertebrae. They keep your spine flexible and act as shock absorbers to cushion the vertebrae when you move. Each disk consists of a ring of tough fibrous tissue (annulus fibrosis) surrounding a jelly-like center (nucleus pulposus).

Facet joints.
Located on the sides, top and bottom of each vertebra, these joints connect the vertebrae to one another and stabilize the spine while still allowing flexibility. The joints are coated with a lubricant so that they slide smoothly.
 
Spinal cord.
This long bundle of nerves extends from the brain stem at the base of your skull to the second lumbar vertebra in your lower back. When the spinal cord ends, another group of nerves (cauda equina) continues down the spinal canal.

The nerves within the spinal cord (upper motor neurons) carry messages between your brain and the nerves that go to all the parts of your body below your head. Two spinal nerves — one leading to the right side of your body and one to the left side — extend out from the spinal cord between each vertebra. The nerves exit through openings on either side of the vertebrae (intervertebral foramina).

In all, there are 31 pairs of spinal nerves in your neck and back. Some transmit information from your body to your brain, and others send messages from your brain to your muscles, skin and other organs.

Spinal canal.
The spinal cord passed through this channel in your spine. Normally, the spinal canal is spacious enough to accommodate the spinal cord, but degenerative changes in the spine can narrow the channel.

How spinal stenosis develops
Doctors categorize stenosis as either primary or acquired. Primary stenosis, which is relatively uncommon, is present at birth. But most people have acquired spinal stenosis, which develops later in life, usually as a result of degenerative changes in the spine that occur with aging.

The main cause of spinal degeneration is osteoarthritis, an arthritic condition that affects the cartilage that cushions the ends of bones in your joints. With time, the cartilage begins to deteriorate and its smooth surface becomes rough.
 
If it wears down completely, bone may rub painfully on bone. In an attempt to repair the damage, your body may produce bony growths called bone spurs. When these form on the facet joints in the spine, they narrow the spinal canal.

Other factors that can cause a narrowing of the spinal canal include:

Herniated disk.
By the time you're 30, your disks may start to show signs of deterioration. They begin to lose their water content, becoming flatter and more brittle. Eventually, the tough, fibrous outer covering of the disk may develop tiny tears, causing the jelly-like substance in the disk's center to seep out (herniation or rupture). The herniated disk presses on the surrounding nerves, causing pain in your back, leg or both. Sometimes you may also have numbness, tingling or weakness in the buttock, leg or foot on the affected side.

Ligament changes.
Ligaments in your back can undergo degenerative changes, becoming stiff and thick over time. This loss of elasticity may shorten the spine, narrowing the spinal canal and compressing the nerve roots.

Sometimes wear and tear on the disks and ligaments cause one lumbar vertebra to slip over another — a condition called spondylolisthesis. This often compresses the spinal nerves, leading to numbness, tingling and weakness in your legs, especially when you stand for long periods or when you walk.

Spinal tumors.
In the spine, abnormal growths can form inside the spinal cord, within the membranes (meninges) that cover the spinal cord, or in the space between the spinal cord and the vertebrae — the most common site.

Tumors may also spread (metastasize) to the spine or the spinal cord from other parts of the body. Primary or metastastic tumors can occur anywhere along the spine, including the sacrum and thoracic spine, where osteoarthritis is rare.

Growing tumors may compress the spinal cord and nerve roots. This can cause severe back pain that may extend to your hips, legs or feet; muscle weakness and a loss of sensation — especially in your legs; difficulty walking or even paralysis; and sometimes loss of bladder or bowel function.

Injury.
Car accidents and other trauma can profoundly affect the spine and spinal cord. Sometimes the spine or spinal canal may be dislocated, putting pressure on the cord and lower motor neurons.
In other cases, fragments of bone from a spinal fracture may penetrate the spinal canal. Swelling of tissue after back surgery can also put pressure on the spinal cord or nerves.
Paget's disease of bone.
Bone is living tissue engaged in a continuous process of renewal. During this remodeling process, old bone is removed and replaced by new bone. In Paget's disease, your body generates new bone at a faster-than-normal rate. This produces soft, weak bones that are prone to fractures. It can also create bones that are deformed or abnormally large.

When unusually large bones develop in the spine, they compress the spinal cord or the nerves exiting your brain and spinal cord. The resulting pain is often severe and may radiate from your lower back into your legs. You also may experience numbness, tingling or weakness in the legs or, in some cases, double vision.

Achondroplasia.
This genetic disorder slows the rate at which bone forms during fetal development and in early childhood. As a result, people with achondroplasia are of short stature — often no more than four feet tall when fully grown. They often have small hands and fingers and unusually short upper arms and thighs. They also have a narrow spinal canal, which puts pressure on the spinal cord.

This can cause severe back and leg pain and may even lead to paralysis of the legs. In some cases, babies or children with achondroplasia die suddenly — often in their sleep — when compression of the upper end of the spinal cord interferes with their breathing.

Risk factors
Age is the main known risk factor for spinal stenosis.

Also at risk are people with skeletal fluorosis, a sometimes crippling bone disease caused by high levels of fluoride in the body. Although the disease is rare in the United States, several million people worldwide have severe skeletal fluorosis.

When to seek medical advice
Many people ignore the symptoms of spinal stenosis, believing that the pain and stiffness they experience are a normal part of aging. But discomfort, especially if it interferes with your mobility, is never normal. Seek medical advice if you have pain, stiffness, numbness or weakness in your back, legs, neck or shoulders that's not related to exercise or overexertion.

Spinal stenosis is especially likely if you have leg pain that gets worse when you walk and improves when you sit or bend forward. Get immediate care if you suddenly have trouble controlling your bowels or bladder.

Screening and diagnosis
Spinal stenosis can be difficult to diagnose because its signs and symptoms are often intermittent and because they resemble those of many age-related conditions. To help diagnose spinal stenosis and rule out other disorders, your doctor will ask about your medical history and perform a physical exam that may include checking your peripheral pulses, range of motion, and leg reflexes.

You are also likely to have one or more of the following tests:

Spinal X-ray.
Although an X-ray isn't likely to confirm that you have spinal stenosis, it can help rule out problems that cause similar symptoms, including a fracture, bone tumor or inherited defect.

Magnetic resonance imaging (MRI).
In many cases, this is the imaging test of choice for diagnosing spinal stenosis. Instead of X-rays, an MRI uses a powerful magnet and radio waves to produce cross-sectional images of your back. The test can detect damage to your disks and ligaments, as well as the presence of tumors.

Computerized tomography (CT) scan.
This test uses a narrow beam of radiation to produce detailed, cross-sectional images of your body, including the shape and size of your spinal canal. Because you receive more radiation from a CT scan than from a regular X-ray, you should avoid this test if you're pregnant.
CT myelogram. This may be the most sensitive test for detecting spinal stenosis, but because it poses more risks than either MRI or CT, it may not be your doctor's first choice.

If you're contemplating surgery, however, your doctor may recommend a CT myelogram to assess the severity of the stenosis. In a myelogram, a contrast dye is injected in your spinal column. The dye then circulates around your spinal cord and spinal nerves. A myelogram can show herniated disks, bone spurs and tumors.

Bone scan.
In this test, a small amount of a radioactive material that attaches to bone is injected into vein in your arm. The material emits waves of radiation that are detected by a gamma camera. The camera then produces images of your bones. In a sense, a bone scan is the opposite of a standard X-ray, in which radiation passes through your body to create an image on film.
A bone scan can detect a number of bone disorders, but often can't distinguish among them. For that reason, it's usually performed with other tests.
 
Other diagnostic procedures. Sometimes your doctor may inject you with a spinal nerve block or epidural steroids. If your symptoms improve after the injection, spinal stenosis is likely the cause of your discomfort. The problem with this approach is that a negative finding doesn't mean you don't have spinal stenosis.

Complications
Depending on which nerves are compressed, spinal stenosis may cause a loss of feeling in your arms, hands, feet or legs. As a result, cuts or wounds may become seriously infected because you're not aware of them. In addition, spinal stenosis sometimes interferes with bowel or bladder function — a problem that can affect your quality of life.

Although treatment can relieve symptoms of spinal stenosis, it doesn't stop degenerative changes. Some of these changes, such as muscle atrophy, may be permanent, even after the pressure is relieved.

Treatment
Many people with spinal stenosis can be effectively treated with conservative measures. But if you have disabling pain or your ability to walk is severely impaired, your doctor may recommend spinal surgery. Acute loss of bowel or bladder function is usually considered a medical emergency and requires immediate surgical intervention.

Nonsurgical treatments
Before considering surgery, your doctor is likely to recommend trying one or more of the following for at least three months:

Nonsteroidal anti-inflammatory drugs (NSAIDs). These include over-the-counter and prescription medications such as aspirin, ibuprofen (Advil, Motrin, others) or indomethacin (Indocin) to reduce inflammation and pain. Although they can provide real relief, NSAIDs have a "ceiling effect" — that is, there's a limit to how much pain they can control.

If you have moderate to severe pain, exceeding the recommended dosage won't provide additional benefits. What's more, NSAIDS can cause serious side effects, including stomach ulcers that may bleed. If you take these medications, talk to your doctor so that you can be monitored for problems.

Analgesics.
This group of pain relievers includes acetaminophen (Tylenol, others). Analgesics don't reduce inflammation, but they can effectively treat pain. Yet chronic overuse of acetaminophen can cause kidney and liver damage. Drinking alcohol increases your risk of serious side effects.
 
Nonproprietary drugs.
Nonprescription supplements such as chondroitin sulfate and glucosamine, either alone or in combination, have shown positive effects on osteoarthritis. But it's not yet known whether they're effective at treating or preventing osteoarthritis of the spine. Talk to your doctor if you're interested in these supplements — they may interfere with other medications you're taking, especially warfarin (Coumadin).

Rest or restricted activity.
Moderate rest followed by a gradual return to activity may improve symptoms. Walking is usually the best exercise, especially for people with neurogenic claudication, but biking is also recommended because it keeps your back in a flexed position rather than in an extended one.
 
Physical therapy.
Working with a physical therapist can build up your strength and endurance and help maintain the flexibility and stability of your spine.

A back brace or corset.
This helps provide support and may especially benefit people who have weak abdominal muscles or degeneration in more than one area of the spine.
 
Epidural steroid injections.
In some cases, your doctor may inject a corticosteroid medication into the spinal fluid around your spinal cord and nerve roots.

Corticosteroids suppress inflammation and can be especially helpful in treating pain that radiates down the back of your leg — in fact, a single dose may provide significant relief. But because corticosteroids can cause a number of serious side effects, the number of injections you can receive is limited, usually to no more than three in one year.

Surgery
The goal of surgery is two-fold: to relieve pressure on the spinal cord or nerves, and to maintain the integrity and strength of your spine. This can be accomplished in several ways, depending on the cause of the problem. The most common surgical procedures include:

Decompressive laminectomy.
In this procedure, your surgeon removes all of the lamina — the back part of the bone over the spinal canal — to create more space for the nerves and to allow access to bone spurs or ruptured disks that may also be removed.
A laminectomy is often performed through a single incision in your back (open surgery), although in some cases, your surgeon may use a laparoscopic technique. In that case, a tiny camera and surgical instruments are inserted through several small incisions, and your surgeon views the operation on a video monitor.

Laparoscopic back surgery is complex and requires great skill and is not appropriate for many people with spinal stenosis. When done properly, however, you're likely to have less pain and to recover from surgery more quickly with this technique.
Risks of laminectomy include infection, a tear in the membrane that covers the spinal cord at the site of the surgery, bleeding, a blood clot in a leg vein, decreased intestinal function (paralytic ileus) and neurological deterioration.

Laminotomy.
In this procedure, just a portion of the lamina is removed to relieve pressure or to allow access to a disk or bone spur that's pressing on a nerve. The risks are the same as for laminectomy.
 
Fusion.
This procedure may be performed on its own or at the same time as laminectomy. It's used to permanently connect (fuse) two or more vertebral bones in your spine and may be especially indicated when one vertebra slips over another. To fuse the spine, small pieces of extra bone are needed to fill the space between two vertebrae. This may come from a bone bank or from your own body, usually your pelvic bone. Wires, rods, screws, metal cages or plates also may be used, especially if your spine is unstable or the operation takes place to correct a deformity
.
Back surgery can relieve pressure in your spine, but it's not a cure-all. You may have considerable pain immediately after the operation, and you might continue to have pain for a period of time. For some people, recovery can take weeks or months and may require long-term physical therapy. What's more, surgery won't stop the degenerative process, and symptoms may return — sometimes within just a few years.

Prevention
You can't always prevent age-related changes in your back, but the following steps can help keep your spine and joints as healthy as possible:

Exercise regularly. This helps maintain strength and flexibility in your spine, joints and ligaments. For the best results, combine aerobic activities such as walking and biking with weight training and stretching. Toning and stretching before exercise can help reduce wear and tear on your back. It also reduces your risk of injury by warming up your muscles and increasing your flexibility. Strength training can make your arms, legs and abdominal muscles stronger, which takes stress off your back.

If you're not used to exercise, start out gradually and increase the duration and intensity of your workout as you become stronger. Aim for at least 30 minutes of moderate exercise on most days.

Use good body mechanics. Being conscious of how you sit, stand, lift heavy objects and even how you sleep can go a long way toward keeping your back healthy.

To minimize stress when you sit, choose a seat that supports your lower back. If necessary, place a pillow or a rolled towel in the small of your back to maintain its normal curve.

When you drive, adjust your seat to keep your knees and hips level, and move the seat forward to avoid overreaching for the pedals.

Before you lift something heavy, decide where you'll place it and how you'll get there. Pushing is safer than pulling. Always bend your knees so that your arms are level with the object. Avoid lifting overhead.

For the best sleep posture, choose a firm mattress. Use pillows for support, but don't use one that forces your neck up at a severe angle.

Maintain a healthy weight. Extra weight puts additional stress on your joints and bones.
« Last Edit: October 09, 2006, 09:06:02 am by ♥ Supreme Queen Goddess ♥ » Logged


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« Reply #16 on: October 09, 2006, 07:41:04 pm »

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« Reply #17 on: October 12, 2006, 01:41:30 pm »

Questions to Ask Your Doctor About Arthritis and Other Disorders
Tips on Controlling Your Arthritis


 When you have a health problem, it's always important to understand what it is, what its course may be, and how it is treated. When you have a chronic disease such as arthritis, it's even more important. In chronic illness, you may not get all your questions answered right away - because you may not even think of them. But over time, you get an opportunity to develop an important partner relationship with your physician.

The day before every doctor visit, you should make time to sit down and make a list of anything that has been troubling you since your last visit - any changes in your symptoms, concerns about medications, or lifestyle issues, such as those related to exercise or sexuality - as well as any questions you have.

Early in the course of your relationship with your physician, you may want some or all of the following questions answered by your physician. Over time, you may want to ask some of these questions again - because the answers may change as your disease progresses or comes under control, as new therapies are developed, or as you age. You can use this list to develop your own question checklist for each doctor visit.

Your Diagnosis and General Treatment

What is my diagnosis? What kind of disease is this - and what do doctors know about its cause?
What are my treatment options? What are the goals for my treatment?
What are the risks of treatment - and the risks of not treating at all?
What is the likely course of my condition - the long-term outlook?
What complications could develop as a consequence of my condition? Could it affect other parts of my body - my eyes, heart, lungs, brain, kidneys, or gastrointestinal system? Is there anything I can do to help prevent this from happening?
Might surgery be of any help to me now or in the future?
I also have (any other chronic health problems). How will my arthritis or its treatment affect my other disorder(s) and their treatment?
Do I need any special dental care because of my condition?
Do I need any special adaptive devices, such as a cane, walker, built-up chair, etc., and if so, how should I obtain them?
Your Medications

Make sure your physician knows what medications and supplements, such as vitamins, you already take on a regular basis. Then, in addition to those guidelines, for each medication prescribed, you should know:

What are the brand and generic names?
What will it do and how long will it take to work?
How often do I take it, and what should I do if I miss a dose?
Are there any special instructions for taking it, such as with or without food, at bedtime, etc.)?
Are there any OTC drugs that I should avoid while taking this medication, such as antacids, laxatives, NSAIDs?
Are there any foods that I should avoid while taking this medication, such as grapefruit juice?
Is there a generic version of this medication and, if so, do you recommend it?
What side effects might I develop? What, if anything, should I call you about immediately?
How often should I come in for hidden side effects check-ups, such as blood pressure check or blood tests? Should I be checking my blood pressure at home?
Your Contact with Your Physician

If my symptoms change or I develop new symptoms, how should I contact you - by phone or by coming in for an appointment? What, if anything, should prompt an urgent, same day appointment with you?
In the absence of symptom change, how often should I come to you for a check-up for my condition?
When should I consult/see you, as opposed to my primary care physician?
What is the best time of day/week (if any) to call you?
Can I communicate with you by email?
Who covers for you when you are unavailable?
Are there other specialists whom I should be consulting about my condition, its possible complications, or medication side effects, such as a dermatologist, pulmonologist, cardiologist, gastroenterologist, gynecologist, opthalmologist, orthopaedist, or podiatrist?
Exercise and Physical Therapy

Do I need physical therapy? If so, will you give me a referral for physical therapy?
What exercise can I do - and how often? Will specific exercises help my condition? Are there specific exercises I should avoid? Is there a specific type or school of exercise that I should start, such as Pilates, yoga, aerobics, or strength training?
How can I know when I should persist exercising in spite of pain vs. when I should take a break for a few days?
Lifestyle and Family Issues

I do (type of work and/or hobbies). Will my condition impair my ability to do this in the future? (OR How can I get help from an occupational therapist or other sources because it is already impairing my ability to do it?)
What can be done to help the fact that my condition is impairing my ability to have sexual relations because (explain it - such as vaginal dryness, knee or hip pain, etc.)?
Will my condition or its treatment affect my ability to have children? Are my children likely to inherit this condition?
Are there any diet modifications that will help this condition?
Are there any alternative medicines or integrative medicine techniques (such as massage, relaxation therapy, or acupuncture) that will help my condition?
I am having emotional difficulties (depression, anxiety, etc.) because of my condition. Can you recommend a therapist to help me cope more effectively?
I have (or plan to have) special concerns (explain them). How will my condition and/or medication affect these concerns?
Learning More About Your Disease

What are the local support groups or foundations that are available to me?
What books, Websites, or other materials do you suggest I read about my condition?
Providing Feedback

Finally, remember that your relationship with your physician is a two-way street. You don't just ask questions and get answers. You have to provide information to your physician in order to assure your best care. Your physician-patient relationship needs and deserves nurturing just as any relationship does.

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« Reply #18 on: October 12, 2006, 01:43:13 pm »

How to Reduce Holiday Arthritis Flares
Tips on Controlling Your Arthritis


 

Many people with inflammatory types of arthritis, such as rheumatoid and lupus, report that their illness flares during and after the holidays. That should be no surprise because holidays can be stressful - and physical and emotional stress can increase the risk of flares.

Pace Yourself - If you're hosting the family get-together or throwing a party for friends, pace yourself. Start planning weeks ahead. Write down your plans, and set priorities - dates when you will do specific shopping, times when you will do advance cooking. Then relax - and build rest-times into your schedule. If you pace yourself and have lists so you know what you need to do when, you will be better able to get through.

Get Help - Don't be a martyr. Delegate tasks and ask for help. Those who love you will welcome an opportunity to help you - and to be an important part of the event. If you do it all yourself, you may find resentment building up - which will ruin your enjoyment of the party.

Set Aside Time for Yourself - Block out some solitary periods on your winter social calendar. You need time to recharge your batteries. All those candles should not be for parties. Light some for yourself to give you a light in the darkness - a place on which to focus for relaxation, meditation, or prayer - all great ways to recharge your batteries. Or light a candle in the bathroom while you relax in a warm tub - also great for achy joints. And don't forget your regular exercise regimen - because exercise keeps you conditioned and can replace fatigue with energy.

Don't Overspend - Set a budget, and do your best to stick to it - whether it's for party planning or gift-giving. If you overspend, worry will be your secret companion - and stressor - for months to come.

Practice Positive Self-Talk - Try to avoid worrying thoughts, such as "There's too much to do, I'll never be ready." If you've done your planning and arranged for friends and family to help, you really are ready. Think steadying thoughts, such as "Calm down and check your list, take one step at a time, and I'll be fine."

Don't Miss Your Meds - With all the holiday excitement, it's easy to miss your meds - whether that means ordering them on time or taking them on time. Put prescription order dates on your calendar. And if you don't already have one of those little boxes that keeps your pills in order by day of the week, that's a gift to get for yourself right now. Then keep it next to your toothbrush so you'll never forget - morning and evening.

If despite following this advice you start feeling signs of a flare, pay attention. Don't try denial hoping it will get better on its own. The sooner a flare is treated, the sooner it is controlled. Call your doctor promptly.

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« Reply #19 on: October 13, 2006, 10:28:16 am »

More than 20 percent U.S. adults have arthritis, CDC says

 More than 20 percent of U.S. adults have arthritis and more than a third of them have limited activity because of it, according to the U.S. Centers for Disease Control and Prevention.

Close to a third of people who are obese -- more than 31 percent -- have a diagnosis of arthritis, the CDC survey found. Women also are more likely to have arthritis.

Only 16 percent of people who are of normal weight or underweight have arthritis, the survey found.

The CDC looked at information in an annual survey of 30,000 people for its report, published in the agency's weekly summary of disease and death. The survey covered various forms of arthritis including rheumatoid arthritis, gout, lupus, and fibromyalgia.

"The findings in this report indicate that 21.6 percent (46.4 million) of U.S. adults reported doctor-diagnosed arthritis, and 8.3 percent (17.4 million) reported arthritis attributable activity limitation during 2003-2005," the CDC's report reads.

"Women, older adults, persons with little education, or those who are obese, overweight, or physically inactive are more likely affected," it said.

About 30 percent of the U.S. population is obese and 60 percent are overweight or obese. Exercise has been shown to help prevent arthritis but only 22 percent of Americans surveyed by experts said they exercised at least 30 minutes per day five or more times a week, as recommended by several groups.

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« Reply #20 on: October 17, 2006, 08:52:40 am »

October 17, 2006
For Young and Active, a Hip Replacement Alternative

At 40, Jeff Gaynor barely resembled the young man who, in his early 20’s, ran half-marathons and performed martial arts.

Mr. Gaynor, who lives in Champaign, Ill., was so sleep deprived from pain in his hip that he had not had one good night’s sleep in seven years, he said. His body was so twisted and his gait so peculiar that children ran in the other direction when they saw him.

Unable to stand and barely able to walk, he resigned from his job as a mathematics professor at the University of Illinois. His young sons became accustomed to a father who could not run, play or even go to the mall without a lot of planning. He gained weight — 70 pounds — because although he was sedentary, he still ate like an athlete.

But Mr. Gaynor, now 45, has been able to resume some of his former activities because of a new surgical implant called the Birmingham Hip Resurfacing System, an alternative to total hip replacement.

The device was developed by Dr. Derek McMinn, a hip surgeon in Birmingham, England, and approved in May by the Food and Drug Administration for use in the United States.

Unlike hip replacement, in which the entire hip joint is replaced, hip resurfacing involves shaping and capping, with an implant, a few centimeters of bone within the hip joint. The implant, made from cobalt chrome, has the potential to last longer than traditional hip implants, experts say, making it an especially attractive option for younger, more active patients.

The technique also offers other advantages over the traditional hip replacements performed in the United States, the experts said. The resurfacing implant is larger than the femoral head used in total hip replacements, offering greater stability and reducing the risk of dislocation, the most common cause of hip replacement failures. It also offers greater range of motion after surgery.

“This is one of the major advances in orthopedics in recent years, at least in this country,” said Dr. Robert Barrack, chief of staff for orthopedic surgery at Barnes-Jewish Hospital in St. Louis, who said he had no financial ties to the company making the implant.

Dr. Barrack, with Dr. McMinn at his side, performed the first Birmingham resurfacing in this country in June and said there was a great deal of enthusiasm about the device. “There were many patients leaving the country to have it done,” Dr. Barrack said, “or having it done with devices that were not F.D.A.-approved, and that’s not optimal.”

Dr. McMinn said he had performed 2,763 hip resurfacing operations in England since developing the technique in 1997.

Dr. James C. Kudrna, a surgeon at Evanston Northwestern Healthcare in Illinois, said he was cautiously optimistic about the technique.

“You always need to be reasonably reserved about these devices because we don’t have 50 years of follow-up,” Dr. Kudrna said. “But we do have excellent 10-year follow-up. From what we have seen, we are certainly optimistic, but there will be no promises for decades and decades.”

Both hip replacements and hip resurfacing require about a five- to six-inch incision, an hour of surgery and about six to eight weeks to return to normal activities. Patients can usually resume more vigorous sports and exercise in six to nine months, Dr. Kudrna said.

But, he said, the big difference between total hip replacement and hip resurfacing is that resurfacing conserves bone and has the potential to last longer.

“There is an identical healing period for both surgeries,” Dr. Kudrna said. “The difference is that with resurfacing, there is a feeling that the hip is more natural. Patients feel like it’s their own hip a bit quicker.”

He added that hip resurfacing was not suitable for patients who were morbidly obese or who had childhood hip deformities, osteoporosis, cysts on the femur or an allergy to metal. Dr. Kudrna has no financial interest in the procedure, he said.

Dr. Steven Stuchin, director of orthopedic surgery at New York University Hospital for Joint Diseases, said one concern with the procedure was the possibility of a fracture of the neck of the hip bone, caused by increased force from the implant. When such a fracture occurs, a traditional hip replacement is done instead.

“Hip resurfacing is the right procedure for somebody, not the right procedure for everybody,” Dr. Stuchin said.

Dr. Michael Goone, a 49-year-old dentist from Buffalo Grove, Ill., learned of the resurfacing technique from Dr. Kudrna.

Dr. Goone had suffered pain from osteoarthritis for almost 10 years. But he had reached a point where after a 45-minute commute to work, his hip would stiffen so badly that he could barely get out of his car. He had made an appointment to have a total hip replacement in June and was attending a preoperative class, when his surgeon, Dr. Kudrna, passed him a note about hip resurfacing.

“He said I was a good candidate and that the larger ball and socket were better for me, with lower risk of dislocation and greater range of motion than a conventional replacement,” Dr. Goone said.

The resurfacing was performed on June 23, Dr. Goone said, and he is now walking one to two miles a day and riding for 10 minutes on a stationary bike with no pain.

Mr. Gaynor, the former math professor, learned about the procedure on Surfacehippy, an Internet forum devoted to hip resurfacing. At the time, the Birmingham technique was not yet approved in the United States.

Mr. Gaynor developed severe osteoarthritis of the right hip at 32, probably caused by a slight congenital hip deformity made worse by running, he was told.

The doctors he consulted said he was not a candidate for traditional hip replacement — he was too young and too active, and there was a chance he would have to repeat the surgery later on if the replacement did not last, risking unacceptable complications.

“They told me to hang on in grim determination as long as I possibly could,” Mr. Gaynor said.

Desperate for another solution, he inquired about hip resurfacing. He underwent the procedure in England in 2001, with Dr. McMinn performing the surgery.

Since then, he said, he has resumed martial arts training, runs on an elliptical trainer and works out with weights. He is taking lessons in tango and swing dancing, and he often takes his sons horseback riding, kayaking and white-water rafting.

“It’s very much like having your entire life handed back to you again,” Mr. Gaynor said. “Before surgery I was handicapped, and people treated me very differently.”

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« Reply #21 on: October 20, 2006, 06:52:19 am »

BOSTON, October 19 -- Exercise in the six weeks before a hip or knee replacement led to significant improvements in preoperative muscle strength and a 73% lower-risk of needing care at a rehab facility after arthroplasty, reported researchers here.
Action Points

Explain to patients that this study suggests that a six-week program of water- and land-based exercises before a total-knee or hip replacement significantly reduced the chance that joint recipients would need inpatient rehabilitation. Preoperative exercise did not appear to affect clinical outcomes, however.
Patients who were randomized to the six-week preoperative regimen of water- and land-based exercise also had significant improvements in muscle strength compared with controls, found Daniel S. Rooks, Sc.D., of Beth Israel Deaconess Medical Center, New England Baptist Hospital, in Boston.


Men and women who exercised prior to getting new joints were also more likely to walk more than 50 feet in the early post-op period, the investigators noted in the October issue of Arthritis Care & Research.


But while both hip and knee replacement candidates improved their lower-extremity muscle strength preoperatively, there were pre-op improvements in function only in patients slated for a total hip.


"Exercise is a cornerstone of rehabilitation following total joint arthroplasty and other surgical procedures," the investigators wrote. "Little attention, however, has been placed on the potential role exercise might play in preparation for surgery."


The investigators randomized 108 patients scheduled for total-hip or total-knee arthroplasty to a six-week exercise program or to receive educational materials (controls).


The exercise protocol included water and land-based exercise for 30 to 60 minutes three times weekly over the six weeks immediately prior to surgery. The exercises were tailored to the fitness levels of the individual patients, and were performed in groups under at a community fitness center under supervision.


Pool exercises, performed during the first three weeks, focused on single planar motion of the cervical spine, shoulders, elbows, wrists, hands, hips, knees, and ankles. During weeks four through six, exercise sessions involved a total body fitness program of cardiovascular, strength, and flexibility training.


The investigators assessed outcomes with questionnaires and performance measures, including the Western Ontario and McMaster Universities Osteoarthritis Index for disease-specific assessment, and the Short Form 36 physical function index for assessment of general function.


Fifty-nine total-hip replacement candidates (25 in the exercise group and 24 in the control group) and 29 total-knee replacement candidates (14 exercisers and 15 controls) completed the study. The groups were evaluated during the preoperative and immediate post-op periods, and again at eight and 26 weeks following joint replacement surgery.


The authors found that for the patients scheduled for hip replacement, the exercise intervention was associated with a 2.2 point improvement in the preoperative Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index function score. In contrast, controls had 3.9 point decline (P= 0.02), with negative changes in both pain and function scales.


On the Short Form 36 physical function index, hip candidates, both exercisers and controls, experienced a decline, but the decrease in function was significantly more pronounced among controls compared with exercisers (-0.4 in exercisers versus -14.3 in controls; P =0.003).


There were no significant differences between groups of patients scheduled for total-knee replacement.


The investigators also found that exercise increased preoperative muscle by 18% in hip-replacement patients and by 20% in knee-replacement patients, while controls showed no significant changes in strength.


Exercise also was a good predictor of which patients could be discharged home after surgery rather than to a rehab facility. In all 65% of exercisers (hip and knee recipients combined) were discharged directly home after their inpatient stay, and 35% went to an inpatient rehab facility. In contrast, 44% of controls went home, and 56% went to rehab after surgery.


Two-thirds (76%) of pre-op exercisers were also able to walk at least 50 feet on the third hospital day, compared with 61% of controls.


In stepwise logistic regression models, the odds ratio for discharge to rehabilitation for exercisers vs. controls was 0.27 (95% confidence interval, 0.074-0.998).


The adjusted odds ratio for exercisers being able to walk more than 50 feet on day 3 was 3.2 (95% CI, 1.2-8.9).


Preoperative exercise did not, however, have any effects on outcomes at either eight- or 26-week follow-up, the authors noted.


"Our findings show that an appropriately designed program of water and land-based exercise involving cardiovascular, strength training, and flexibility activities can be a safe, well tolerated, and effective approach to improving function and muscle strength in middle-aged and older adults with severe osteoarthritis of the hip and knee," they wrote.


The investigators suggested that the strength-training component of the exercise protocol, which was shorter than that normally required for significant strength gains, may have worked through a combination of increased neuromuscular coordination and "a reduction in fear of anticipated pain associated with increased muscular effort."


"Our most striking finding," the authors wrote, "was that regardless of affected joint, participating in the exercise intervention reduced the odds of discharge to a rehabilitation facility by 73%. A greater proportion of nonexercisers (54%) went to inpatient rehabilitation facilities compared with exercisers (33%)."


The findings conflict with those of a 1998 study showing the patients scheduled for total knee arthroplasty who exercised preoperatively were more likely to need inpatient rehabilitation on hospital discharge.


Nevertheless, "the potential economic implication of this finding is noteworthy and should be examined in future studies, particularly with the rise in inpatient rehabilitation use," they added.


The authors acknowledged study limitations that included a low recruitment rate (only 12% of eligible patients), and dropouts (some due to the inconvenience of traveling to the fitness center), which could have reduced the evidence for the efficacy of exercise by eliminating those patients who could have benefited most from the intervention.

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« Reply #22 on: October 31, 2006, 06:04:20 am »

Reported October 30, 2006
Curry for Arthritis
(Ivanhoe Newswire) -- A spice commonly used in curries and other South Asian dishes may help treat arthritis.

A new report from the National Institutes of Health reveals turmeric -- a flowering plant in the ginger family -- has anti-arthritic benefits. 

Researchers used an experimental compound containing turmeric that was similar to over the counter turmeric dietary supplements.

Study results reveal the dose they gave to rats blocked a protein that leads to inflammation and also blocked other key genes that cause inflammation. Researchers also found turmeric could prevent acute and chronic arthritis, block the destruction of joints due to arthritis, and prevent an increase in the cells that break down bone in joints.

The authors say the turmeric dietary supplements seem to work in the same way as drugs that are currently being developed to target the same protein to treat arthritis. And because of the chemical complexity of turmeric, it may also block other causes of inflammation.

“In summary, just as the willow bark provided relief for arthritis patients before the advent of aspirin, it would appear that the underground stem (rhizome) of a tropical plant [turmeric] may also hold promise for the treatment of joint inflammation and destruction,” write the authors.

They say more studies are needed before turmeric supplements can be recommended as a treatment for arthritis.

More than 40 percent of arthritis patients in the United States use complementary and alternative medicine, including dietary supplements. The use has gone up since the FDA warned consumers about the dangers of anti-inflammatory drugs such as Celebrex.

Thank you Karyl, as always!
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« Reply #23 on: November 16, 2006, 08:56:59 am »

Marker Identifies High-Risk Ankylosing Spondylitis Patients
 
University of California, San Francisco
November 15, 2006
   

This study was published as an abstract and presented orally at a conference. These data and conclusions should be considered to be preliminary as they have not yet been reviewed and published in a peer-reviewed publication.
   

WASHINGTON, Nov. 15 -- A simple lab test can predict most of the patients at risk for progression of ankylosing spondylitis and should be part of clinical practice, a Canadian researcher said here.

Serum matrix metalloproteinase-3 (MMP-3) -- a biomarker associated with damage to joint matrix -- is elevated in two-thirds of ankylosing spondylitis patients who go on to the more severe forms of the disease, according to Walter Maksymowych, M.D., of the University of Alberta in Edmonton.


"Testing for MMP-3 is cheap and readily available," Dr. Maksymowych told a press conference at the American College of Rheumatology meeting.


"This is a test that should be done in patients with ankylosing spondylitis," he said. "It is essentially our only predictor."


The finding emerged from a continuing study of ankylosing spondylitis patients at four centers on Europe. Researchers analyzed blood samples from 100 patients for a panel of eight biomarkers associated with other forms of inflammatory disease, including rheumatoid arthritis.


Of the eight, only MMP-3 was significantly associated (P=0.004) with two-year radiological progression in ankylosing spondylitis, as measured by the modified Stoke Ankylosing Spondylitis Spinal Score, Dr. Maksymowych said.


He said the finding may make it easier for physicians to decide which patients should get new biologic treatments for the disease, which are both more toxic and more expensive than standard anti-inflammatory medications.


Also, he said, the result may help improve the design of clinical trials.


Physicians now have "highly effective" treatments for the disease, he said, but resource constraints in many countries mean that the medications aren't easily available. Being able to target the drugs to specific patients at high risk may break down such barriers, Dr. Maksymowych said.


That's not a serious concern in the U.S., said Eric Ruderman, M.D., of Northwestern University in Chicago, who was not involved in the study. By and large, he said, U.S. payers are covering biologics for ankylosing spondylitis if physicians make a case for the drugs on the basis of on clinical signs and symptoms.


He said the "missing piece of the puzzle" is evidence that early treatment of patients with high levels of MMP-3, using biologics such as Remicade (infliximab), would prevent future damage. Currently, a patient with minimal clinical symptoms probably would not be offered the drugs because of the expense and toxicity.


On the other hand, "if I knew that I could give a patient something that is going to prevent damage, even in the absence of clinical signs right now, I would encourage that," he said. "And that's where this is going."

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« Reply #24 on: November 22, 2006, 08:45:01 pm »

HANOVER, N.H., Nov. 21 -- For patients with a herniated lumbar disk, surgery and usual care appeared equally effective in reducing pain and disability over two years, according to two studies.


It was essentially a draw in the first randomized trial of lumbar diskectomy or to nonoperative individualized treatment for patients with lumbar disk intervertebral herniation, said investigators here. Action Points

Explain to interested patients that those with sciatica and a herniated lumbar disk treated with surgery or with nonoperative care both improved substantially over two years.


Recognize that both of these studies had serious methodological flaws which make meaningful comparisons between treatments extremely difficult.
Irrespective of the therapy, patients improved substantially and for the most part equally, James Weinstein, D.O., of Dartmouth Medical School here, and colleagues reported in the Nov. 22/29 issue of the Journal of the American Medical Association.


In a companion observational study of patients who declined to be randomized in the first trial but chose their own treatment, the results were similar, giving a slight edge to surgery, found a second report in the same issue of JAMA.


However, according to the researchers, a similar group in both studies, and two editorial writers, both studies had unavoidable methodological flaws, making it difficult to reach firm conclusions.


In the randomized controlled trial, The Spine Patient Outcomes Research Trial (SPORT), 501 surgical candidates were enrolled from 2000 to 2004 from 13 multidisciplinary spine clinics in 11 states. Patients (mean age, 42 years; 42% women) had imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least six weeks.


Of the patients, 232 were randomized to standard open diskectomy, while 240 were assigned to nonoperative treatment. The latter protocol included physical therapy (44%), education and counseling with home exercise instruction (93%), nonsteroidal anti-inflammatory drugs if tolerated (61%), opiates (46%), epidural steroid injections (more than 50%), and activity restriction (29%).


Intent-to-treat analysis measured regularly for up to two years from enrollment found substantial improvements for all primary and secondary outcomes in both treatment groups, the researchers reported.


Primary outcomes included changes from baseline for pain and physical function as measured by the Medical Outcomes Study Short-Form Health Survey and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version).


Secondary outcomes included sciatic severity (Sciatica Bothersome Index), satisfaction with symptoms, self-reported improvement, and employment status.


Differences between the groups for reduction in pain and disability consistently favored surgery. Specifically, the results were small and not statistically significant in the primary measures, but not in the secondary measures of sciatica severity and self-rated improvement, the researchers reported.


There was little evidence of harm from either treatment, the researchers said. No patient in either group developed cauda equina syndrome, and 95% of the surgical patients had no intraoperative complications. The most common complication, dural tear, occurred in 4%, similar to results in other studies.


However, the study had a major methodological problem because adherence to the assigned treatment was limited, the researchers wrote. In the randomized trial, only 50% of the patients assigned to surgery received diskectomy within three months of enrollment, while 30% of those assigned to non-operative treatment also decided to have surgery in the same period.


Considering the differential risk of the two strategies, the researchers were not surprised, and they prepared for it by developing a parallel observational study of patients who qualified for the trial but refused randomization.


Those more likely to cross over to surgery, they said, tended to have lower incomes, worse baseline symptoms, more disability, and were more likely to rate their symptoms as getting worse, compared with the other usual-care patients.


Those more likely to switch from surgery to usual care were older, had higher incomes, were more likely to have had an upper-lumbar herniation, had less pain, better physical function, and were more likely to rate their symptoms as getting better compared with the other surgical patients.


Because of the large number of patients who crossed over in both directions, the researchers said, conclusions about the superiority or equivalence of the treatment are not warranted on the basis of the intent-to-treat analysis.


However, they noted the large effects seen in their as-treated analysis and the characteristics of the cross-over patients suggest that the intent-to-treat analysis underestimated the true effect of surgery.


Discussing the study's other limitations, the researchers noted that the choice of nonoperative treatments was at the discretion of the treating physician and the patient. However, given the limited evidence for most of these usual-care treatments, creating a fixed protocol of treatment was neither clinically feasible nor generalizable.


Still another limitation of SPORT was its potential lack of representativeness of the patients who agreed to be randomized.


Finally, Dr. Weinstein said that given the degree of crossover in both directions, it is unlikely that the analysis can form the basis of a valid estimate of the true effect of surgery.


For this reason, Dr. Weinstein and a partly overlapping group of researchers undertook the observational study of 743 SPORT patients who had declined randomization. Of these, 528 had surgery during the first two years, and 191 received nonoperative care.


At three months. patients who chose surgery had greater improvement in:

Pain measures (mean change: surgery, 40.9 versus nonoperative care, 26.0; treatment effect, 14.8; 95% confidence interval, 10.8-18.9);
Physical function (mean change: surgery, 40.7 versus nonoperative care, 25.3; treatment effect, 15.4; CI, 11.6-19.2),
Disability Index (mean change: surgery, −36.1 versus nonoperative care, −20.9; treatment effect, −15.2; CI, −18.5. to −11.8).

These differences narrowed somewhat between three months and two years but remained significant at all periods, the researchers said.


At two years patients who chose surgery had greater improvement in:


Pain measures (mean change: surgery, 42.6 versus nonoperative care, 32.4; treatment effect, 10.2; CI, 5.9-14.5),
Physical function (mean change: surgery, 43.9 versus nonoperavtive care 31.9; treatment effect, 12.0; CI, 7.9-16.1),
Disability Index (mean change: surgery −37.6 versus nonoperative care −24.2; treatment effect, −13.4; CI, −17.0 to −9.7).

Study limitations included the fact that strict eligibility criteria may have limited the generalizability of the SPORT results (patients unable to tolerate symptoms for six weeks or those who preferred early surgical intervention were not included).


Also, the investigators said, to the degree that some nonoperative treatments were ineffective or inappropriate, the benefits of surgery may have been overestimated. However, the one-year improvement in the usual-care group was excellent.


An important limitation in the study design and in all such interventions is that when measuring subjective outcomes, differences in motivation and even in care may affect the results. In addition, people who elected to have surgery may have been different in unmeasured ways, including burden of disease, the researchers said.


In this nonrandomized evaluation, patients with persistent sciatica from lumbar disk herniation improved in both the operated and usual-care groups. However, those who chose surgery reported significantly greater improvements than patients who elected nonoperative care, the researchers reported.


However, they emphasized, nonrandomized comparisons of self-reported outcomes are subject to potential confounding and must be interpreted cautiously.


In an accompanying editorial, David Flum, M.D., of the University of Washington in Seattle, and a JAMA contributing editor, said that although the findings from the observational study suggest that surgery is more beneficial than usual care, this interpretation may be flawed.


Patients who elected to have surgery were different in many ways from those who declined. A higher level of disease severity among operative-care patients might be considered a conservative bias in that treatment effects among patients with similar disability might be even greater, he said.


But if anything has been learned from the legacy of sham-controlled trials, he said, these differences may also include a greater expectation of success among patients having the more invasive intervention.


How much of the observed difference in outcome in the SPORT trial is the result of these raised expectations can only be determined by studying the placebo effect through sham-controlled trials, Dr. Flum said.


Because of limitations in the design of the SPORT study, "the proper role and benefits of these competing interventions are still unclear. Given the large number of patients potentially exposed to the risks of these strategies, a sham surgical trial may be the only effective and ethical next step," Dr. Flum concluded.


In another editorial in the same issue, Eugene Carragee, M.D., of Stanford University wrote that these two studies "represent a colossal research effort and provide a fascinating snapshot of both modern patient preferences and clinical outcomes for this common clinical problem."


However, he said, in a study in which only half of those in the surgery group underwent the procedure three months after entry, these findings are difficult to evaluate.


Nonetheless, Dr. Carragee said, it is clear that both surgical and nonoperative treatment were associated with clinically significant improvement over time and that the differences between the two approaches, as has been shown in previous studies, decreased over time.


Among several important questions that remain, he said, is the need to establish the cost effectiveness of surgery and the role of pharmacologic treatments aimed at local inflammatory processes. Furthermore, technical advances allow less extensive procedures to decompress the nerve roots, and whether these approaches will lead to improvements or increase complications is unclear.


"The fear of many patients and surgeons that not removing a large disk herniation will likely have catastrophic neurologic consequences is simply not borne out," Dr. Carragee said. "Thus, these data help both clinicians and patients make better informed decision based on each patient's needs and expectations," he concluded.

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« Reply #25 on: November 22, 2006, 09:00:54 pm »



November 22, 2006
Study Questions Need to Operate on Disk Injuries
People with ruptured disks in their lower backs usually recover whether or not they have surgery, researchers are reporting today. The study, a large trial, found that surgery appeared to relieve pain more quickly but that most people recovered eventually and that there was no harm in waiting.
And that, surgeons said, is likely to change medical practice.

The study, published in The Journal of the American Medical Association, is the only large and well-designed trial to compare surgery for sciatica with waiting.

The study was controversial from the start, with many surgeons saying they knew that the operation worked and that it would be unethical for their patients to participate in such a study.

In the end, though, neither waiting nor surgery was a clear winner, and most patients could safely decide what to do based on personal preference and level of pain. Although many patients did not stay with their assigned treatment, most fared well with whatever treatment they had.

Patients who had surgery often reported immediate relief. But by three to six months, patients in both groups reported marked improvement.

After two years, about 70 percent of the patients in the two groups said they had a “major improvement” in their symptoms. No one who waited had serious consequences, and no one who had surgery had a disastrous result.

Many surgeons had long feared that waiting would cause severe harm, but those fears were proved unfounded.

“I think this will have an impact,” said Dr. Steven R. Garfin, chairman of the department of orthopedic surgery at the University of California, San Diego. “It says you don’t have to rush in for surgery. Time is usually your ally, not your enemy,” Dr. Garfin added.

As many as a million Americans suffer from sciatica, said Dr. James Weinstein, a professor of orthopedic surgery at Dartmouth who led the study. The condition is characterized by an often agonizing pain in the buttocks or leg or weakness in a leg.

It is caused when a ruptured disk impinges on the root of the sciatic nerve, which runs down the back of the leg. And an estimated 300,000 Americans a year have surgery to relieve the symptoms, Dr. Weinstein said.

Patients are often told that if they delay surgery they may risk permanent nerve damage, perhaps a weakened leg or even losing bowel or bladder control. But nothing like that occurred in the two-year study comparing surgery with waiting in nearly 2,000 patients.

The study did not include people who had just lower back pain, which can have a variety of causes. Nor did it include people with conditions that would require immediate surgery like losing bowel or bladder control.

Instead, they were typical of a vast majority of people with sciatica who are made miserable by searing pain. For such patients, fear that delaying an operation could be dangerous “was the 800-pound gorilla in the room,” said Dr. Eugene J. Carragee, professor of orthopedic surgery at Stanford.

Dr. Carragee said that he had never believed it himself, but that the concern was widespread among patients and doctors.

“The worry was not knowing,” he added. “If someone had a big herniated disk, can you just say, ‘Well, if it’s not bothering you that much, you can wait?’ It’s kind of like walking on eggshells. What if something terrible did happen?”

With the new results, it is clear that the risk of waiting “is, if not extraordinarily small, at least off the radar screen,” Dr. Carragee said.

The study involved 13 spine clinics in 11 states. All the participants had pain from herniated disks and leg pain. The patients were asked whether they would allow the researchers to decide their treatment at random. Those who did not have surgery generally received physical therapy, counseling and anti-inflammatory drugs.

In the end, the study could not provide definitive results on the best course of treatment because so many patients chose not to have the treatment that they had been randomly assigned.

About 40 percent of those assigned to surgery decided not to have it, often because their conditions improved while they awaited the operations. A third of patients assigned to wait decided to have operations, often because their pain was so bad that they could not endure it any longer.

Others asked not to be assigned at random and were followed to see what treatment they chose and how they fared.

The researchers are also conducting a separate analysis on the cost effectiveness of surgery compared with waiting. Although that analysis has not been published, Dr. Anna N. A. Tosteson of Dartmouth, an author of the study, said that Medicare paid a total of $5,425 for the operation and that private insurers might pay three to four times that.

Although the results answered one question, about the safety of waiting, they were also, in a sense, disappointing, said Dr. David R. Flum, a contributing editor at The Journal of the American Medical Association and an associate professor of surgery at the University of Washington.

“Everyone was hoping the study would show which was better,” Dr. Flum said.

“And everyone was surprised by the tremendous number of crossovers in both directions,” he added, referring to the large number of participants who changed from surgery to waiting and vice versa.

That muddied the data.

Sciatica tends to run in families and occurs when the soft gel-like material inside a spinal disk protrudes through the outer lining of the disk like a bubble on a bicycle tire. That compresses and inflames a nerve root that forms the sciatic nerve.

The resulting pain can feel like a burning fork in the buttocks, Dr. Weinstein said. Or it can be a searing pain down the back of a leg. The pain can be so intense that some people cannot walk. Some cannot sit. Some, Dr. Weinstein said, “can barely crawl.”

The operation is quick and generally effective, Dr. Garfin said. It involves gently pushing the compressed nerve root away from the herniated disk. Then the surgeon makes an incision in the disk and deflates it. The nerve returns to its normal position, the inflammation goes away, and the pain often disappears.

The Journal of the American Medical Association published two papers on the study, one reporting on the randomized trial and the other on the patients who chose not to be randomized. It also published editorials by Dr. Carragee and Dr. Flum.

The reason for all the attention, Dr. Flum explained, was that the study was large and well designed, that its authors had no conflicts of interest, and, “We can learn a lot.”

The message, in the end, Dr. Weinstein said, was that no matter which treatment a patient received, “nobody got worse.”

He added, “We never knew that until we did the study.”

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« Reply #26 on: December 26, 2006, 07:52:33 pm »

Heartburn Drugs May Lead To Broken Hips


 December 26, 2006

CHICAGO -- Taking such popular heartburn drugs as Nexium, Prevacid or Prilosec for a year or more can raise the risk of a broken hip markedly in people over 50, a large study in Britain found.

The study raises questions about the safety of some of the most widely used and heavily promoted prescription drugs on the market, taken by millions of people.

The researchers speculated that when the drugs reduce acid in the stomach, they also make it more difficult for the body to absorb bone-building calcium. That can lead to weaker bones and fractures.

Hip fractures in the elderly often lead to life-threatening complications. As a result, doctors should make sure patients have good reason to stay on heartburn drugs long term, said study co-author Dr. Yu-Xiao Yang of the University of Pennsylvania School of Medicine.

"The general perception is they are relatively harmless," Yang said. "They often are used without a clear or justified indication for the treatment."

Some people find relief from heartburn with over-the-counter antacids such as Tums, Rolaids and Maalox. But for others, those medicines do not work well. Moreover, heartburn can be more than a source of discomfort. People with chronic heartburn can develop painful ulcers in the esophagus, and in rare cases, some can end up with damage that can lead to esophageal cancer.

Dr. Sandra Dial of McGill University in Montreal, who was not involved in the study but has done similar research, said patients should discuss the risks and benefits with their doctors and taper off their use of these medicines if they can.

Nexium, Prevacid and Prilosec are members of a class of drugs known as proton pump inhibitors. The study found a similar but smaller risk of hip fractures for another class of acid-fighting drugs called H2 blockers. Those drugs include Tagamet and Pepcid.

The study, published in Wednesday's Journal of the American Medical Association, looked at medical records of more than 145,000 patients in England, where a large electronic database of records is available for research. The average age of the patients was 77.

The patients who used proton pump inhibitors for more than a year had a 44 percent higher risk of hip fracture than nonusers. The longer the patients took the drugs, the higher their risk.

The biggest risk was seen in people who took high doses of the drugs for more than a year. That group had a 2½ times greater risk of hip fractures than nonusers.

Yang said that for every 1,262 elderly patients treated with the drugs for more than a year, there would be one additional hip fracture a year attributable to the drugs. For every 336 elderly patients treated for more than a year with high doses, there would be one extra hip fracture a year attributable to the drugs.

Dr. Doug Levine of AstraZeneca PLC, which makes Nexium and Prilosec, said the study does not prove that proton pump inhibitors cause hip fractures. It merely suggests a potential association, he said. Doctors need to monitor their patients for proper dosage and watch how long they take the drugs, Levine said.

Julia Ellwanger, a spokeswoman for TAP Pharmaceutical Products Inc., which markets Prevacid, said proton pump inhibitors' safety has been well-established by rigorous studies, and the new study does not prove or disprove a connection to hip fractures.

Dr. Alan Buchman of Northwestern University, who was not involved in the research, said the study should not change medical practice, since doctors already should be monitoring the bone density of elderly people taking the drugs and recommending calcium-rich diets to all patients.

"Most people are not taking enough calcium to start with," he said. He also wondered if a similar result would have been found in a sunny climate, because vitamin D from sunshine helps with calcium absorption.

Also, Buchman said it not known whether the acid-fighting drugs prevent esophageal cancer. He said the risk of esophageal cancer has been exaggerated in the marketing of these drugs.

"I think the risk has been overplayed and scared the community," Buchman said.

Heartburn medicines are heavily are advertised in "Ask your doctor about ..." commercials in this country, particularly during the evening news.

Nexium is the second biggest selling drug in the world, behind the cholesterol medicine Lipitor, with global sales totaling $4.6 billion last year, according to IMS Health, which tracks drug sales.

Yang and his co-authors disclosed in the paper that they have worked as consultants and received speaking fees from companies making acid-fighting drugs. The study was funded by the National Institutes of Health and the American Gastroenterological Association/GlaxoSmithKline Glaxo Institute for Digestive Health.

Men in the study had a higher drug-associated risk of hip fracture than women, possibly because women may be more aware of osteoporosis and may get more calcium in their diets, Yang said. He plans more research on whether calcium-rich diets or calcium supplements can prevent the problem.

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« Reply #27 on: December 31, 2006, 09:22:13 am »


December 30, 2006

The Spine as Profit Center

Spinal-fusion surgery is one of the most lucrative areas of medicine. An estimated half-million Americans had the operation this year, generating billions of dollars for hospitals and doctors.

But there have been serious questions about how much the surgery actually helps patients with back pain and whether surgeons’ generous fees might motivate them to overuse the procedure. Those concerns are now heightened by a growing trend among some surgeons to profit in yet another way — by investing in companies that make screws and other hardware they install.

The parts can be highly profitable. A single screw that goes into the spine, for example, sells for about $1,000 — at least 10 times the cost of making it.

Within the medical device industry, it has been well chronicled how companies use consulting ties and other financial relationships to try to gain favor with the surgeons using their devices. But critics are especially troubled by the emerging trend in spinal devices, which so far has occurred largely under the radar.

Doctors’ taking significant ownership stakes in spinal parts makers, critics say, provides an extra financial incentive for a doctor to recommend a surgery. It may be one of the most distinct examples yet of the way monetary considerations can play a role in the way doctors practice medicine.

Such doctors face “an awfully pernicious conflict of interest,” said Dr. Richard A. Deyo, a physician and health services professor at the University of Washington in Seattle.

Patricia Kennedy had a disk-replacement operation that she said was unsuccessful. She is suing the surgeon and the maker of the artificial disk.

About 30 start-up companies have begun selling spinal devices, including screws, in the last couple of years. And industry experts say about a dozen companies have doctors among their investors. Because most of the companies are private and the relationships are not publicly disclosed, there is no way to know how many spine surgeons around the country are partial owners of device makers.

Typically, patients are not aware of the doctor’s financial interests. One patient who is suing her surgeon for malpractice learned only during the legal discovery process that her surgeon had a financial interest in the maker of the artificial disk he installed in her spine.

Federal regulators have voiced concerns about the growing popularity of the investment arrangements, which would potentially violate antikickback laws if doctors receive stock or are otherwise compensated to use or recommend certain devices.

“This is an area that is new and growing,” Vicki L. Robinson, a senior attorney in the Office of Inspector General at the Department of Health and Human Services, said in an interview. In a recent letter to a device industry trade group, Ms. Robinson wrote that the “ventures should be closely scrutinized under the fraud and abuse laws.”

Some spine surgeons are also concerned about whether they and their colleagues should enter into such arrangements. “These are, I believe, unethical and bias the doctors’ choice for what is best for the patient,” said Dr. Charles D. Rosen, a spine surgeon at the University of California at Irvine, who is the president of the newly formed Association of Ethical Spine Surgeons. The group has about 75 members so far, who have agreed not to invest in companies whose devices they use.

But doctors who do sometimes use the products of companies in which they invest say they do not let financial interests influence their medical judgment. Some surgeons and companies say that patients can even benefit because the collaboration means the devices have been better designed to meet their needs.

But industry experts say that that doctors’ financial needs may be also be a big motive.

As surgeon fees have fallen over the years, doctors have been increasingly attracted to other sources of revenue, said Dr. John Cherf, an orthopedic surgeon in Chicago who also advises hospitals about health care trends. That is why many surgeons have invested in specialty hospitals, he said.

And now, devices “are the low-hanging fruit,” he said. “There’s a lot of money in devices.”

One of the fastest growing companies is Allez Spine, of Irvine, Calif. It was founded on a business model that called for the 120 doctors who invested in Allez to serve as “its customer base,” according to a lawsuit filed by a former chief executive last April. Those doctors, who pay $50,000 or more to become investors, own two-thirds of the company, according to legal filings.

Selling the company’s screws to its “investor-doctors” was a way to “generate more profits for the company” according to a related lawsuit involving the former executive.

At one midsize Nevada hospital, a surgeon who performs many spinal fusions is an Allez investor who uses the company’s screws, said an administrator. He spoke on condition of anonymity because the hospital fears alienating its surgeons. While some doctors at the hospital who invested in Allez choose not to use its screws, others seem “financially driven” to select them, he said.

The identities of most of the surgeons who invest in Allez are not publicly disclosed. And the doctors who could be identified and were called for comment did not return repeated telephone calls.

Dr. Edward Geehr, president of Allez Spine, said that many of his surgeon-investors did not use the company’s products, although he declined to say how much of the company’s sales came from surgeons who were not also investors.

The company offers hospitals products at lower prices than the competition, Dr. Geehr said, although he declined to discuss specific pricing.

The spinal device market, which has doubled in the last three years, is particularly attractive to newcomers, said Stan Mendenhall, the editor of Orthopedic Network News, an industry newsletter. Spinal screws are relatively simple to develop and cost only $65 to $100 to make, he said, often by a supplier that handles the production of screws for a variety of companies.

There are about 100 companies in the spinal devices field, and some of the newest and fastest growing have some level of doctor ownership, Mr. Mendenhall said.

Patients who find out about these ties can be upset, as was Patricia Kennedy, whose disk-replacement operation in September 2002 was performed by Dr. Richard A. Balderston, a spine surgeon in Philadelphia.

Ms. Kennedy says the surgery was unsuccessful and made her condition even worse. She is now suing Dr. Balderston for malpractice, and the maker of the artificial disk, Spine Solutions, for product liability.

Ms. Kennedy says she did not fully understand that the disk was experimental. She discovered only later that Dr. Balderston was an investor in a venture capital fund that owned Spine Solutions at the time of the surgery. A lawyer for the company declined to comment.

The company and the doctor “failed to disclose that Dr. Balderston had a significant financial interest in the outcome of the experiment,” according to the lawsuit.

“I’ve really been guinea pigged and betrayed,” Ms. Kennedy said in an interview.

A lawyer from the firm representing Dr. Balderston said the firm had a policy of not commenting on pending litigation. The case is expected to go to trial in March, according to Ms. Kennedy.

Even hospitals where spinal-fusion surgeries are performed may not know when doctors own a piece of a device maker. A few hospitals, though, require the device makers and doctors to tell them about the arrangements.

At Hoag Memorial Hospital Presbyterian in Newport Beach, Calif., several doctors are investors in Allez, including Dr. William Dobkin, a surgeon at the hospital. He did not return repeated calls for comment.

“We use heavy disclosure practices with our vendors and our physicians to understand these relationships,” said Jennifer Mitzner, the chief financial officer for Hoag.

At the Tenet Healthcare hospital chain, the California hospitals it owns have signed a contract with Allez that calls, among other things, for the doctors to agree to disclose any ownership interests to their patients.

Allez says physicians who invest in the company and use its products in California disclose those ties to patients. “All our relationships are disclosed,” Dr. Geehr said.

Some of the new companies aim to recruit surgeons who perform a high volume of back operations, according to doctors who have been approached. The exact nature of the investment opportunity is left vague in the discussions, the doctors say, with details made available only to those who agree to become investors.

One surgeon described being contacted by Globus Medical, a start-up company in Audubon, Pa. The surgeon said he was not persuaded to use Globus screws and other hardware, despite the sales representative’s mention of the “good opportunities” available if he were to become a large user.

The policies of Globus forbid its representatives from offering stock to reward surgeons who use their products, said Dave Demski, chief financial officer of Globus.

The doctors who do invest, Mr. Demski said, are doing so because they are interested in owning stock in businesses they understand, like Globus. “It’s really based on their enthusiasm for what we’re doing,” he said.

At Alphatec Holdings, a company in Carlsbad, Calif., doctors are shareholders because they have either invested directly or are paid in stock for consulting, according to filings by Alphatec, which is one of the few publicly held companies among the small start-ups.

The chairman of Alphatec’s scientific advisory board is Dr. Stephen J. Hochschuler, a prominent surgeon who helped start the Texas Back Institute, one of the largest spine clinics in the country.

For his work as an adviser, Dr. Hochschuler received a restricted stock grant that was worth about $640,000 when Alphatec went public in June, according to the company’s public filings. Because the share price has fallen, the grant — which vests over five years — is currently now worth only about $270,000.

Dr. Hochschuler, in a written response to an interview request, said doctors should work closely with device companies like Alphatec. “Surgeon involvement in the development of surgical devices is paramount in the creation of these devices and techniques that allow our patients to return to their lives in a more timely fashion, with less pain,” he wrote.

Dr. Hochschuler’s ties to the company do not influence his choice of devices, he said in a follow-up e-mail message. He said he had used the Alphatec implants “probably less than 5 times so that I thoroughly know and understand the pros and cons.”

An Alphatec spokesman also said physicians played an important role in developing new products. “There is a critical relationship between physicians and engineers at Alphatec,” said the spokesman, David Schull.

Some surgeons who have bought Alphatec stock argue that their holdings are no different than their investments in any other company.

Dr. E. Claiborne Irby Jr., a surgeon in Richmond, Va., who invested in Alphatec before it went public, says he uses its devices, but not exclusively. “I don’t change anything I do because of any kind of investment,” he said.

But federal regulators and law-enforcement officials are on the lookout for surgeons who step over the line.

Doctors “are supposed to make the decision based on the best interest of the patient,” said Peter Winn, a lawyer in the United States attorney’s office in Seattle, who has aired his concerns in a speech to spine surgeons.

To do otherwise, he said in an interview, “is a violation of the ethical rules, and it has been since the time of Hippocrates.”

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« Reply #28 on: January 02, 2007, 09:47:44 am »


chronic disease called Psoriatic Arthritis.

What Is It?
Psoriatic (sore-EE-AA-tick) arthritis causes pain and swelling in some joints and scaly skin patches on some areas of the body. It is related to the skin condition psoriasis.
What Are the Symptoms?

About 95% of those with psoriatic arthritis have swelling in joints outside the spine, and more than 80% of people with psoriatic arthritis have nail lesions. The course of psoriatic arthritis varies, with most doing reasonably well.

Symptoms include:
Silver or grey scaly spots on the scalp, elbows, knees and/or lower end of the spine.
Pitting of fingernails/toenails
Pain and swelling in one or more joints
Swelling of fingers/toes that gives them a "sausage" appearance. What Causes It?
The cause is not yet known. It may be partly inherited and environment might play a role.
How Is It Diagnosed?
May involve X-rays, blood tests and joint fluid tests.

Treatment Options
Skin care
Light treatment (UVB or PUVA)
Corrective cosmetics
Medications: glucocorticoids, NSAIDs, DMARDs (disease-modifying anti-rheumatic drugs) such as methotrexate, sulfasalazine, gold, cyclosporine
Exercise
Rest
Heat and cold
Splints

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« Reply #29 on: January 25, 2007, 11:36:04 am »

One Bone Scan Predicts Fracture Risk as Well as Two
 
 
January 25, 2007


PORTLAND, Ore. -- A single bone mineral density scan to predict future fracture risk may be good for life for healthy older women, according to a large study.
Action Points

Explain to interested patients that a bone mineral density test predicts the risk of fracturing a bone in the future, but additional bone mineral density scans may not add any predictive value.


**Point out to patients that repeat bone mineral density scans may still be helpful for women who may have accelerated rates of bone mineral density change because of illness, substantial weight loss, and new medication use (such as glucocorticoids).

Repeat measurement of bone mineral density eight years after the initial scan yielded no improvement in prediction of fractures, reported Teresa A. Hillier, M.D., M.S., of Kaiser Permanente Northwest/Hawaii here, and colleagues, in the Jan. 22 issue of the Archives of Internal Medicine.

Although repeat bone mineral density scans are common in clinical practice, the findings weigh heavily against the scanty evidence for their benefit in evaluating fracture risk, the researchers said.
"The lack of overall additional benefit…does not contradict the importance of bone mineral density, and bone mineral density loss, in the disease etiology of osteoporosis," they wrote.

"However, our results do suggest that, for the average healthy older woman 65 years or older, a repeat bone mineral density measurement has little or no value in classifying risk for future fracture -- even for the average older woman who has osteoporosis by initial bone mineral density measure or high bone mineral density loss," the investigators added.

They noted that repeat scans may still be useful for women who may have accelerated rates of bone mineral density change because of illness, substantial weight loss, and new medication use (such as glucocorticoids).

The Study of Osteoporotic Fractures included 8,141 community-dwelling women ages 65 years or older at baseline (mean 72) who underwent an initial bone mineral density scan using dual-energy x-ray absorptiometry and then a second scan eight years later, on average.

Initial bone mineral density findings were typically in the low bone-mass range (mean t score -1.37 where 0 is "normal"). The average bone mineral density loss per year was -0.59% for an average t score of -1.64 at eight years of follow-up. Initial and repeat measurements were significantly correlated (r=0.92, P<0.0001).
Participants were followed for incident fractures over an average of five years after the repeat scan. They were contacted by postcard three times a year and fractures were verified through radiology reports and X-ray films. During this five year period, 877 women experienced an incident, nontraumatic, nonspine fracture, of which 275 were hip fractures, and 340 women had a spine fracture.

The researchers used four different methods to predict age- and weight change-adjusted fracture risk for each standard deviation lower bone mineral density.
The hazard ratios for incident nonspine fractures were:
1.55 using initial bone mineral density only (95% confidence interval 1.43 to 1.67, area under the curve 0.65%),
1.61 using repeat bone mineral density only (95% CI 1.49 to 1.74, AUC 0.65%),
1.26 using change in bone mineral density (95% CI 1.17 to 1.35, AUC 0.61%), and
1.18 using initial plus change in bone mineral density (95% CI 1.10 to 1.26, AUC 0.65%).
The hazard ratios for incident hip fractures and morphometric spine fractures (fractures diagnosed based on vertebral shape) followed a similar pattern with high correlations between initial and repeat measurements in predicting fracture risk (P<0.001 for all models).
Change in bone mineral density was a weaker predictor than initial or repeat measurement alone and the only one that was significantly worse than any other (P<0.05 versus initial for all fracture types).
The results were unchanged by stratification for initial t scores, high bone loss, bisphosphonate use, or hormone therapy.

Repeat bone mineral density measurements are often done in two- to five-year intervals in clinical practice rather than the eight-year interval in the study. However, Dr. Hillier and colleagues said the longer interval they used would tend to overestimate any potential benefit of more frequent testing.
They cautioned that the study did not evaluate repeat testing to monitor osteoporosis treatment response and may not be generalizable to men, other ethnic groups (more than 99% of the women were non-Hispanic whites), or younger women entering menopause. They said more research would be needed to confirm the results in these other populations.

The investigators emphasized that the findings confirmed the value of bone mineral density measurement in screening older women for fracture though not an incremental improvement in prediction compared with a single scan alone.

"Our results indicate that, although bone mineral density is highly predictive of fracture risk, for the average postmenopausal woman 65 years or older who has not yet developed a fracture, repeat bone mineral density measurement provides little additional benefit as a screening tool," they wrote.



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www.LupusMCTD.com Represents:
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