Karen Walker-Bone

Neonatal Bone Mass: Influence of Parental Birthweight, Maternal Smoking, Body Composition, and Activity During Pregnancy

Evidence is accumulating that intrauterine growth and development may influence an individuals risk of osteoporosis in later adult life. To examine maternal and paternal influences on intrauterine skeletal growth, we used dual‐energy X‐ray absorptiometry to measure the neonatal bone mineral content (BMC) and bone mineral density (BMD) of 145 infants born at term. Independently of the infants duration of gestation at birth, the birthweights of both parents and the height of the father were positively correlated with neonatal whole body BMC. Women who smoked during pregnancy had infants with a lower whole body BMC and BMD; overall, there was a 7.1‐g (11%) average difference between whole body BMC of infants whose mothers did and did not smoke during pregnancy (p = 0.005). Women with thinner triceps skinfold thicknesses (reflecting lower fat stores) and those who reported a faster walking pace and more frequent vigorous activity in late pregnancy also tended to have infants with a lower BMC and BMD (p values for BMC; 0.02, 0.03, and 0.05, respectively). Maternal thinness and faster walking pace but not maternal smoking or parental birthweight also were associated with lower bone mineral apparent density (BMAD). The influences on skeletal growth and mineralization were independent of placental weight, a marker of the placental capacity to deliver nutrients to the fetus. These observations point to a combination of genetic and intrauterine environmental influences on prenatal skeletal development and suggest that environmental modulation, even at this early stage of life, may reduce the risk of osteoporosis in adulthood.

Medical management of osteoarthritis

Osteoarthritis is a common, chronic, musculoskeletal disorder. Symptomatic osteoarthritis, particularly of the knee and hip, is the most common cause of musculoskeletal disability in elderly people. In the Western world it ranks fourth in health impact among women and eighth among men.1 Given this high prevalence, therapeutic approaches to treatment will have to be shared between primary and secondary care. A range of non-surgical interventions has been proposed as components of such a therapeutic strategy. #### Summary points Osteoarthritis is a major cause of pain and disability in Western populations The prevalence of osteoarthritis necessitates a “shared care” approach to management between general practitioners and hospital specialists Several non-surgical interventions to alleviate pain and disability in lower limb osteoarthritis are now available: Non-pharmacological measures (education, social support, physiotherapy, and occupational therapy) Pharmacological measures (simple analgesics, non-steroidal anti-inflammatory drugs, COX-2 inhibitors, topical non-steroidal anti-inflammatory drugs, and capsaicin) Intra-articular therapy: corticosteroids, hyaluronic acid derivatives, and tidal irrigation These interventions have been evaluated to varying degrees, but they can be incorporated into an algorithm for the management of osteoarthritis #### Therapeutic options in osteoarthritis ##### Non-pharmacological treatment Education (patient and spouse or family) Social support (telephone contact) Physiotherapy (aerobic exercises, muscle strengthening, and patellar strapping) Occupational therapy (aids and appliances, joint protection) Weight loss Acupuncture Transcutaneous electrical nerve stimulation (TENS) ##### Pharmacological treatment Simple analgesia Non-steroidal anti-inflammatory drugs COX-2 inhibitors (cyclo-oxygenase-2 selective non-steroidal anti-inflammatory drugs) Topical (non-steroidal anti-inflammatory drugs, capsaicin) Chondroprotective agents ##### Intra-articular treatment Corticosteroids Hyaluronans Tidal irrigation Systematic reviews and controlled clinical trials were located through Medline and BIDS 1991-9, searching under the key words: osteoarthritis; guidelines; glucosamine; capsaicin; physiotherapy, occupational therapy, acupuncture, drug therapy, education, intra-articular injection, heat, cold, rehabilitation, epidemiology, therapy. When available, the most recent reviews or meta-analyses are cited; if not available, individual controlled trials were included and methodological shortcomings discussed. We did not perform assessments of quality of individual reviews. Semiquantitative estimates …

The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the upper limb

OBJECTIVES Following a consensus statement from a multidisciplinary UK workshop, a structured examination schedule was developed for the diagnosis and classification of musculoskeletal disorders of the upper limb. The aim of this study was to test the repeatability and the validity of the newly developed schedule in a hospital setting. METHOD 43 consecutive referrals to a soft tissue rheumatism clinic (group 1) and 45 subjects with one of a list of specific upper limb disorders (including shoulder capsulitis, rotator cuff tendinitis, lateral epicondylitis and tenosynovitis) (group 2), were recruited from hospital rheumatology and orthopaedic outpatient clinics. All 88 subjects were examined by a research nurse (blinded to diagnosis), and everyone from group 1 was independently examined by a rheumatologist. Between observer agreement was assessed among subjects from group 1 by calculating Cohens κ for dichotomous physical signs, and mean differences with limits of agreement for measured ranges of joint movement. To assess the validity of the examination, a pre-defined algorithm was applied to the nurses examination findings in patients from both groups, and the sensitivity and specificity of the derived diagnoses were determined in comparison with the clinics independent diagnosis as the reference standard. RESULTS The between observer repeatability of physical signs varied from good to excellent, with κ coefficients of 0.66 to 1.00 for most categorical observations, and mean absolute differences of 1.4°–11.9° for measurements of shoulder movement. The sensitivity of the schedule in comparison with the reference standard varied between diagnoses from 58%–100%, while the specificities ranged from 84%–100%. The nurse and the clinic physician generally agreed in their diagnoses, but in the presence of shoulder capsulitis the nurse usually also diagnosed shoulder tendinitis, whereas the clinic physician did not. CONCLUSION The new examination protocol is repeatable and gives acceptable diagnostic accuracy in a hospital setting. Examination can feasibly be delegated to a trained nurse, and the protocol has the benefit of face and construct validity as well as consensus backing. Its performance in the community, where disease is less clear cut, merits separate evaluation, and further refinement is needed to discriminate between discrete pathologies at the shoulder.

Soft-Tissue Rheumatic Disorders of the Neck and Upper Limb: Prevalence and Risk Factors

OBJECTIVES To review the epidemiologic literature concerning the occurrence of and the risk factors for pain and specific soft-tissue rheumatic conditions that affect the neck and upper limbs. METHODS An extensive search of the literature, including a search of Medline and EMBASE, authoritative recent reviews, and relevant textbooks, was performed. Studies that furnished data about the occurrence of or risk factors for regional pain or specific soft-tissue entities were extracted. RESULTS Numerous epidemiologic studies among different populations suggest a high prevalence of pain in the neck (10% to 19%), shoulder (18% to 26%), elbow (8% to 12%), and wrist/hand (9% to 17%) at any point in time. Less clear is the proportion of pain caused by specific upper-limb disorders as compared with nonspecific pain; however, as many as 6% of adults may have carpal tunnel syndrome. Significant risk factors for these disorders include age, female gender, obesity, and association with mechanical exposures (eg, posture, force, repetition, vibration) in the workplace. Also implicated are psychologic well-being and psychosocial workplace factors such as high levels of demand, poor control, and poor support. CONCLUSION Pain and soft-tissue rheumatic disorders of the neck and upper limb are common. It appears that individual, mechanical, and psychosocial factors all contribute to upper-limb disorders, suggesting that future strategies for prevention will need to address each of these factors if they are to be successful.

The anatomical pattern and determinants of pain in the neck and upper limbs: an epidemiologic study

&NA; Little is known about the distribution and determinants of pain at multiple sites in the neck and upper limb. To investigate the prevalence, pattern, and clustering of such pains and the association of extensive involvement with putative risk factors, we mailed a questionnaire to a community sample of 9696 working‐aged adults. Age–sex specific prevalence rates for pain were estimated and the frequency of bilateral involvement, pairwise overlap at different sites, and extent to which reports clustered within individuals were explored. Associations of multi‐site involvement with age, gender, psychological health, smoking, and employment status were assessed by logistic regression. Among 6038 responders, 2657 reported at least a day of neck or upper limb pain in the past 7 days, including 1843 whose symptoms rendered normal activities difficult or impossible. Pain was frequently bilateral or in the dominant arm. Significant associations were seen for pain at anatomically adjacent sites. Pain affecting every site considered (neck, shoulders, elbows, wrists/hands) was far more common than might be expected if each site were statistically independent (observed/expected ratio 8750). Being female, unemployed, a blue‐collar worker, or a smoker were independent risk factors for such extensive pain, but the strongest association was with psychological ill‐health (odds ratio for worst vs. best third of the SF‐36 low vitality score, 30.3, 95% CI 7.1–129.0). Neck and upper limb pain commonly cluster, and frequently display symmetry and adjacent patterns of involvement. Extensive neck and upper limb pain is far more strongly associated with poor mental vitality than localised pain.

Occupation and epicondylitis: a population-based study

OBJECTIVE To explore the relationship between occupational exposures and lateral and medial epicondylitis, and the effect of epicondylitis on sickness absence in a population sample of working-aged adults. METHODS This was a cross-sectional study of 9696 randomly selected adults aged 25-64 years involving a screening questionnaire and standardized physical examination. Age- and sex-specific prevalence rates of epicondylitis were estimated and associations with occupational risk factors explored. RESULTS Among 6038 respondents, 636 (11%) reported elbow pain in the last week. Of those surveyed, 0.7% were diagnosed with lateral epicondylitis and 0.6% with medial epicondylitis. Lateral epicondylitis was associated with manual work [odds ratio (OR) 4.0, 95% CI 1.9, 8.4]. In multivariate analyses, repetitive bending/straightening elbow >1 h day was independently associated with lateral (OR 2.5, 95% CI 1.2, 5.5) and medial epicondylitis (OR 5.1, 95% CI 1.8, 14.3). Five per cent of adults with epicondylitis took sickness absence because of their elbow symptoms in the past 12 months (median 29 days). CONCLUSION Repetitive exposure to bending/straightening the elbow was a significant risk factor for medial and lateral epicondylitis. Epicondylitis is associated with prolonged sickness absence in 5% of affected working-aged adults.

Descriptive Epidemiology of Somatising Tendency: Findings from the CUPID Study

Somatising tendency, defined as a predisposition to worry about common somatic symptoms, is importantly associated with various aspects of health and health-related behaviour, including musculoskeletal pain and associated disability. To explore its epidemiological characteristics, and how it can be specified most efficiently, we analysed data from an international longitudinal study. A baseline questionnaire, which included questions from the Brief Symptom Inventory about seven common symptoms, was completed by 12,072 participants aged 20–59 from 46 occupational groups in 18 countries (response rate 70%). The seven symptoms were all mutually associated (odds ratios for pairwise associations 3.4 to 9.3), and each contributed to a measure of somatising tendency that exhibited an exposure-response relationship both with multi-site pain (prevalence rate ratios up to six), and also with sickness absence for non-musculoskeletal reasons. In most participants, the level of somatising tendency was little changed when reassessed after a mean interval of 14 months (75% having a change of 0 or 1 in their symptom count), although the specific symptoms reported at follow-up often differed from those at baseline. Somatising tendency was more common in women than men, especially at older ages, and varied markedly across the 46 occupational groups studied, with higher rates in South and Central America. It was weakly associated with smoking, but not with level of education. Our study supports the use of questions from the Brief Symptom Inventory as a method for measuring somatising tendency, and suggests that in adults of working age, it is a fairly stable trait.

Reliability of the Southampton examination schedule for the diagnosis of upper limb disorders in the general population

Background: Epidemiological research in the field of soft tissue neck and upper limb disorders has been hampered by the lack of an agreed system of diagnostic classification. In 1997, a United Kingdom workshop agreed consensus definitions for nine of these conditions. From these criteria, an examination schedule was developed and validated in a hospital setting. Objective: To investigate the reliability of this schedule in the general population. Methods: Ninety seven adults of working age reporting recent neck or upper limb symptoms were invited to attend for clinical examination consisting of inspection and palpation of the upper limbs, measurement of active and passive ranges of motion, and clinical provocation tests. A doctor and a trained research nurse examined each patient separately, in random order and blinded to each others findings. Results: Between observer repeatability of the schedule was generally good, with a median κ coefficient of 0.66 (range 0.21 to 0.93) for each of the specific diagnoses considered. Conclusion: As expected, the repeatability of tests is poorer in the general population than in the hospital clinic, but the Southampton examination schedule is sufficiently reproducible for epidemiological research in the general population.

Criteria for assessing pain and nonarticular soft-tissue rheumatic disorders of the neck and upper limb

OBJECTIVE To critically review the criteria used to diagnose nonarticular soft-tissue rheumatic disorders of the neck and upper limb. METHODS An extensive search of the literature, including a search of Medline and EMBASE, authoritative recent reviews, and relevant textbooks, was completed. The diagnostic criteria used in epidemiologic studies were compared and the reliability and validity of these criteria were assessed. RESULTS Altogether, the search identified 117 relevant research articles, among which 69 included a physical examination component, but few specified diagnostic criteria. Evidence supported respectable levels of between-observer repeatability regarding: symptom questionnaires (kappa, 0.52 to 0.79); measurement of shoulder range of motion with a goniometer (intraclass coefficients > 0.70); tests for carpal tunnel syndrome (Tinels and Phalens kappa, 0.53 to 0.80); and demonstration of neck tenderness (kappa = 0.43). The Katz hand diagram, and combinations of physical signs of carpal tunnel syndrome, show reasonable sensitivity and specificity for that diagnosis but only among patients referred to specialists with that putative diagnosis; no such validity has been shown among the general population. Only 1 diagnostic examination schedule has published data on both the reliability and the validity of its criteria and diagnoses. For the remaining soft-tissue upper-limb disorders, diagnostic criteria rely apparently on face and content validity and reliability data have not been published. CONCLUSION Classification of specific disorders of the neck and upper limb requires a back to basics approach. At present, the diagnosis of most of these conditions relies heavily on the clinical opinions of investigators and there are insufficient data to indicate that these criteria are repeatable, sensitive, or specific. Recent European initiatives offer scope to follow a more disciplined approach, but more work is urgently required.

Prevalence of and risk factors for chronic arthralgia and rheumatoid-like polyarthritis more than 2 years after infection with chikungunya virus

Objectives Chikungunya virus (CHIKV), transmitted to humans from infected mosquitoes, causes acute fever, arthralgia and rash. There is increasing evidence that it also causes longer-term rheumatic symptoms. In a circumscribed part of Mauritius where infectivity was high, a cohort of inhabitants was surveyed with the objectives of assessing the prevalence of and risk factors for chronic musculoskeletal symptoms and for a rheumatoid arthritis-like condition at 27.5 months after initial infection. Methods Participants were recruited May–November 2008 and invited to complete a questionnaire. CHIKV was diagnosed clinically. The primary outcomes for the analyses were (a) self-reported ongoing musculoskeletal symptoms and (b) fulfilment of modified diagnostic criteria for rheumatoid arthritis. Risk factors for these outcomes were explored in univariate analyses using logistic regression. Subsequently, multivariate logistic regression was used to identify factors that were independently associated with the outcomes. Results 173 individuals were identified with CHIKV, of whom 136 (78.6%) reported persisting musculoskeletal symptoms 27.5 months after infection. Persistent symptoms were associated with older age at time of infection, female gender and baseline symmetrical distribution of joint symptoms. We found that 5% of those infected with CHIKV fulfilled a modified version of the American College of Rheumatology criteria for rheumatoid arthritis 27.5 months after infection. Conclusions CHIKV is associated with a high prevalence of persistent rheumatic symptoms. Physicians need to be aware of CHIKV as a cause of acute and chronic rheumatic symptoms.