Eric Thomas

Motor cortical dysfunction disclosed by single and double magnetic stimulation in patients with fibromyalgia

OBJECTIVE To investigate the motor cortex by single and double magnetic stimulation, in patients with fibromyalgia. METHODS Thirteen patients with fibromyalgia and 13 age-matched healthy subjects were examined. We evaluated, in both limbs, motor evoked potential (MEP) latency and amplitude and the MCA/MPA ratio, i.e. MEP cortical amplitude (MCA) /maximal peripheral amplitude of the M response (MPA), the central conduction time (TCC) and the length of the silent period (SP). With double magnetic stimulation, different time intervals between shocks were used: with delays between shocks of 4, 25, 55 and 85 ms, the intensities of the conditioning shock were 80% the relaxed threshold. With delays between shocks of 55, 85, 100, 155, 200, 255 and 355 ms, the intensities of the conditioning shocks were set at 150% the relaxed threshold. In all cases, the intensity of the test shock was 150% the relaxed threshold. The results were also compared with those obtained in 5 women affected by rheumatoid arthritis (RA). RESULTS As compared to control, the cortical relaxed threshold was enhanced on both sides and limbs (P<0.05). The cortical silent period recorded with single magnetic stimulation was reduced in the upper limbs (P = 2.7x10(-11)) and lower limbs (both sides P = 3.6x10(-5)). The other parameters investigated were normal. With double magnetic stimulation, facilitatory phenomena were absent in fibromyalgic patients and the inhibitory responses recorded with a delay of 155 ms were reduced (P = 0.0052). No significant differences were noted between FM and RA patients. CONCLUSION This study demonstrated motor cortical dysfunction in patients with fibromyalgia involving excitatory and inhibitory mechanisms. This indicates motor cortical involvement and supports the hypothesis of aberrant central pain mechanisms. The absence of differences between FM and RA suggest that the lesions were not specific and could be related to chronic pain disorders within the central nervous system.

Aerobic exercise in fibromyalgia: a practical review

The objective of the study was to determine the current evidence to support guidelines for aerobic exercise (AE) and fibromyalgia (FM) in practice, and to outline specific research needs in these areas. Data sources consisted of a PubMed search, 2007 Cochrane Data Base Systematic review, 2008 Ottawa panel evidence-based clinical practice guidelines, as well as additional references found from the initial search. Study selection included randomized clinical trials that compared an aerobic-only exercise intervention (land or pool based) with an untreated control, a non-exercise intervention or other exercise programs in patients responding to the 1990 American College of Rheumatology criteria for FM. The following outcome data were obtained: pain, tender points, perceived improvement in FM symptoms such as the Fibromyalgia Impact Questionnaire total score (FIQ), physical function, depression (e.g., Beck Depression Inventory, FIQ subscale for depression), fatigue and sleep were extracted from 19 clinical trials that considered the effects of aerobic-only exercise in FM patients. Data synthesis shows that there is moderate evidence of important benefit of aerobic-only exercise in FM on physical function and possibly on tender points and pain. It appears to be sufficient evidence to support the practice of AE as a part of the multidisciplinary management of FM. However, future studies must be more adequately sized, homogeneously assessed, and monitored for adherence, to draw definitive conclusions.

Osteoporosis in Persons With Spinal Cord Injury: The Need for a Targeted Therapeutic Education

OBJECTIVES To identify circumstances surrounding the onset of fracture and common risk factors in persons with spinal cord injury (SCI) and to suggest an alternative or complement to the pharmacologic approach by evaluating the need for a prospective study based on the impact of a targeted therapeutic education on risk management of fractures in this population. DESIGN Retrospective study. SETTING Hospital and Rehabilitation Center Setting. PARTICIPANTS Women (n=7) and men (n=25; N=32; with ≥1 fracture after the initial SCI that occurred at home or in a hospital setting; mean ± SD age, 53±12y at the time of clinical review) with bone mineral density (BMD) measurements. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Demographics, main circumstances of onset, and complications of fractures, as well as transversal bone mineral density evaluation. RESULTS Nine patients had more than 1 fracture and 23 patients had only 1 fracture (total, 43 fractures; mean age at onset of fracture, 49±12y; median time since injury, 13.9y; mean delay in diagnosis, 6.5±15d). Fractures occurred mostly in the lower limbs. The circumstances of onset of these fractures were different and very stereotyped. In 3 cases, no trauma was reported. The most frequent mechanisms identified were forced maneuvers by the patient or a third party and falls. In 10 cases, the fracture occurred during a wheelchair transfer with forced maneuver or a fall from the wheelchair. Twenty-five patients were confined to bed after the fracture (mean duration of bed confinement, 18±28d; range, 0-120d). Postfracture follow-up showed that for 43 cases of fractures, 19 had at least 1 orthopedic complication, 15 had local complications, and 23 had general complications. Patients (23 of 32) benefited from dual-energy X-ray absorptiometry to assess BMD a few months or years after the fracture (mean femoral neck BMD, 0.574±0.197g/cm²; mean femoral neck T score, -3.8±1.5). CONCLUSION With this retrospective analysis of common risk factors and circumstances of onset of secondary fractures, there is a clear future for a prospective study to evaluate the impact of targeted therapeutic education on risk factors for secondary fractures in patients with SCI.

Appendicular skeletal muscle mass is the strongest independent factor associated with femoral neck bone mineral density in adult and older men.

The relationship between bone mass and muscle mass may be due to the site-specific effects of loading on bone in adults and to lifestyle, nutritional, and hormonal factors. Another hypothesis is that the maintenance with aging of both appendicular muscle and bone mass may be determined by factors independent of all these previous factors, including genetic factors. In 160 healthy men aged 20 to 72years, we recorded femoral neck bone mineral density (FN BMD), relative appendicular skeletal muscle mass [RASM; appendicular skeletal muscle mass (kg)/height (cm)], age, body mass, maximum grip and knee extension strength, lifetime physical activities, calcium intake, tobacco smoking, and serum parathyroid hormone (PTH), estradiol (E2), free testosterone, dehydroepiandrosterone sulphate (DHEAS), insulin-like growth factor (IGF-I), sex hormone-binding globulin (SHBG), calcium, 25(OH) vitamin D, albumin, and creatinine clearance. The correlation between FN BMD and RASM (that includes upper and lower limb muscle mass) was of slightly greater magnitude than that between FN BMD and the relative upper limb muscle mass and between FN BMD and the relative leg muscle mass (r=0.39; p< or =0.001 versus r=0.36; p< or =0.001 and r=0.34; p< or =0.001, respectively). The stepwise multiple linear regression model showed that FN BMD was significantly associated with RASM (15% of FN BMD variance, p<0.0001), age (10% of FN BMD variance, p<0.0001), physical activities from age 11-20years (5% of FN BMD variance, p<0.01), and blood PTH, IGF-I, and creatinine clearance, (2%, 2%, and 1% of FN BMD variance, respectively, p<0.05). These results show that RASM, with ASM measured by DXA, is the strongest factor associated with FN BMD in men. It remains to be determined whether assessing RASM by anthropometric methods would help screening adult men at risk of low FN BMD. Furthermore, since RASM is associated with FN BMD independently of appendicular skeletal loads and other lifestyle, nutritional, and hormonal factors, this suggests that common factors, possibly genetic factors, might also influence the coupled maintenance of appendicular muscle mass and FN BMD in adult men.

Role of Sclerostin and Dickkopf-1 in the Dramatic Alteration in Bone Mass Acquisition in Adolescents and Young Women With Recent Anorexia Nervosa

BACKGROUND The nutritional deprivation of adolescent girls with anorexia nervosa (AN) reduces bone mass acquisition. A better understanding of this process would improve the medical treatment of bone alteration and its long-term consequences. OBJECTIVE The first aim was to model the bone mass acquisition in young women with AN. The second aim was to identify the clinical and biological factors associated with bone demineralization and investigate the potential role of sclerostin and dickkopf-1 protein (DKK-1). POPULATION AND METHODS Ninety-eight AN patients (mean age 18.2 ± 2.6 years) and 63 age-matched controls were enrolled in this study. Areal bone mineral density (aBMD) was determined by dual-energy x-ray absorptiometry. Calciotropic hormones, bone turnover markers, sclerostin, DKK-1, and growth factors were concomitantly evaluated. RESULTS The aBMD was significantly reduced at all bone sites in AN patients vs controls (range, -3.3% at the radius to -12.1% for total proximal femur). Bone formation markers IGF-1 and DKK-1 were significantly decreased in AN patients, whereas PTH, sclerostin, and the bone resorption markers were increased. In patients, the AN duration, amenorrhea, weight, body mass index, fat mass, and fat-free soft tissue were negatively correlated with aBMD, whereas the age of AN onset was positively correlated. Multiple regression analysis revealed that the duration of amenorrhea was the independent factor most negatively associated with aBMD at all bone sites except the radius. CONCLUSION This case-control study demonstrated a dramatic reduction in aBMD, reinforced for the first time by our models, and indicates the need for early, systematic, and adapted bone mass monitoring. Moreover, appropriate treatment should be started early in patients with AN. Increased secretion of sclerostin suggests that it may be a target for pharmacological action.

Are antidepressants effective in fibromyalgia

Amitriptyline and other imipramine antidepressants are the cornerstone of drug therapy in fibromyalgia. However, some patients fail to respond to antidepressant therapy, and in responders the beneficial effects wear off after some time. The effect on fibromyalgia seems independent from the effects on depression.

Normal Vertebral Body Dimensions: A New Measurement Method Using MRI

Abstract:Much clinical research on osteoporosis is aimed at documenting a reduction in vertebral fracture rates, but there is considerable disagreement about defining normality. Most methods for measuring vertebral body dimensions use lateral radiographs. In the present paper, we investigate the reliability of magnetic resonance imaging (MRI) for normal reference determination. A validation study was performed on a cadaver by comparing vertebral body volume measured both with MRI (sagittal acquisition in T1 weighted sequence) and with immersion. MRI was then performed with the same protocol from T4 to L5 in a standard population of 80 women with no history of vertebral fractures. Then all vertebral measurements were standardized relative to each other, and means and standard deviations were calculated using a statistical fitting procedure derived from volume and medial area. The validation study confirmed the reproducibility and accuracy of MRI (intraclass correlation coefficient 0.95). There was a strong correlation between volume and medial area of vertebral bodies (Pearson correlation coefficient 0.95) and a constant relationship between the medial area of vertebral bodies for each subject (coefficient of variation 5.6%). The variations in vertebral body dimensions will allow comparison with pathologic vertebral fractures in further studies. This could be useful for monitoring osteoporosis treatments.

Osteoporotic fracture of the sacrum: sacroplasty and physical medecine.

CONTEXT Traditional treatment of sacrum osteoporotic fractures is mainly based on antalgics and rest in bed. But complications are frequent, cutaneous, respiratory, thrombotic or digestive and mortality at 1 year significant. THE AIMS We wanted to define the interest of sacroplasty when treating osteoporotic fracture of sacrum. METHOD We reviewed literature while studying a clinical case in an elderly patient. RESULTS Sacroplasty was efficient at short and mean delay to control the pain due to osteoporotic sacrum fracture. Rate of complications is low in the centers mastering the procedure. CONCLUSION Sacroplasty is of evident interest for elderly patients suffering of an osteoporotic fracture of sacrum. It reduces decubitus complications, secondary effects of antalgics and allows an early reeducation.