M. Revel

Impact of digital ulcers on disability and health-related quality of life in systemic sclerosis.

Objective: To assess the impact of digital ulcers (DUs) on disability and health-related quality of life (HRQoL) in systemic sclerosis (SSc). Methods: Two hundred and thirteen patients with SSc were evaluated at four annual meetings of a patient society between 2004 and 2007 (nu200a=u200a177) or during hospital stay (nu200a=u200a36). HRQoL was assessed by the SF-36, global disability by the health assessment questionnaire (HAQ), hand disability by the Cochin Hand Function Scale (CHFS) and global hand and wrist mobility by the Kapandji index. Results: Sixty-seven patients (31.4%) had at least one DU at the time of evaluation. Patients with DUs showed significantly more pitting scars (p<0.001) and calcinosis (p<0.0001) than others. Patients with DU had significantly greater HAQ (mean (SD) 1.218 (0.723) vs 0.930 (0.717), pu200a=u200a0.008), CHFS (mean (SD) 27.38 (20.68) vs 16.73 (18.19), p<0.0001) and aesthetic prejudice (mean (SD) 6.1 (2.2) vs 3.9 (2.5), p<0.0001) scores than others. Hand and wrist mobility were significantly diminished in patients with DU (mean (SD) Kapandji score 75.3 (22.8) vs 81.7 (19.2), p<0.0001). The presence of a DU did not significantly alter the physical component but influenced the mental component (mean (SD) 43.38 (12.53) vs 39.58 (9.54), pu200a=u200a0.026) of the SF36. Conclusion: Patients with SSc with DUs have reduced wrist and hand mobility, increased global and hand disabilities and decreased mental component of HRQoL.

Clinical practice guidelines for rest orthosis, knee sleeves, and unloading knee braces in knee osteoarthritis.

OBJECTIVEnTo develop clinical practice guidelines concerning the use of bracing--rest orthosis, knee sleeves and unloading knee braces--for knee osteoarthritis.nnnMETHODSnThe French Physical Medicine and Rehabilitation Society (SOFMER) methodology, associating a systematic literature review, collection of everyday clinical practice, and external review by multidisciplinary expert panel, was used.nnnRESULTSnFew high-level studies of bracing for knee osteoarthritis were found. No evidence exists for the effectiveness of rest orthosis. Evidence for knee sleeves suggests that they decrease pain in knee osteoarthritis, and their use is associated with subjective improvement. These actions do not appear to depend on a local thermal effect. The effectiveness of knee sleeves for disability is not demonstrated for knee osteoarthritis. Short- and mid-term follow-up indicates that valgus knee bracing decreases pain and disability in medial knee osteoarthritis, appears to be more effective than knee sleeves, and improves quality of life, knee proprioception, quadriceps strength, and gait symmetry, and decreases compressive loads in the medial femoro-tibial compartment. However, results of response to valgus knee bracing remain inconsistent; discomfort and side effects can result. Thrombophlebitis of the lower limbs has been reported with the braces. Braces, whatever kind, are infrequently prescribed in clinical practice for osteoarthritis of the lower limbs.nnnCONCLUSIONnModest evidence exists for the effectiveness of bracing--rest orthosis, knee sleeves and unloading knee braces--for knee osteoarthritis, with only low level recommendations for its use. Braces are prescribed infrequently in French clinical practice for osteoarthritis of the knee. Randomized clinical trials concerning bracing in knee osteoarthritis are still necessary.

Patient preference disability questionnaire in systemic sclerosis: A cross-sectional survey

OBJECTIVEnTo assess patient priorities concerning disability in systemic sclerosis (SSc).nnnMETHODSnA total of 150 SSc patients (22 men) fulfilling the American College of Rheumatology and/or LeRoy and Medsger criteria for SSc were evaluated by the McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR), Karnofsky performance status (KPS), Cochin Hand Function Scale, Health Assessment Questionnaire (HAQ), Hospital Anxiety and Depression Scale, Mouth Handicap in SSc (MHISS) scale, and global perception regarding their health status. Correlations between scores were analyzed using Spearmans coefficient. Logistic regression analysis was used to determine factors associated with patients global perception of their health.nnnRESULTSnOf the patients investigated, 81 (54%) had limited cutaneous SSc, 65 (43.3%) diffuse SSc, and 4 (2.7%) limited SSc. The 3 disability domains most often cited were walking (82 patients [54.6%]), housekeeping (67 patients [44.6%]), and sport activities (59 patients [39.3%]). The MACTAR score correlated moderately with KPS (r = 0.58) but only weakly with the HAQ score (r = 0.38). In multivariate analysis, 2 factors were associated with patients negative global perception of their health status: KPS (odds ratio [OR] 1.07, 95% confidence interval [95% CI] 1.00-1.15) and MHISS score (OR 0.93, 95% CI 0.88-0.99).nnnCONCLUSIONnFor assessing SSc patient priorities concerning disability, the MACTAR has acceptable construct validity. Its weak correlation with the HAQ suggests that it adds useful information on disability.

Reliability of a modified Modic classification of bone marrow changes in lumbar spine MRI

OBJECTIVEnThe purpose of this study was to determine the intra- and interobserver reliability of a modified Modic classification for bone marrow changes seen on lumbar spine magnetic resonance imaging (MRI), taking into consideration mixed signals.nnnMETHODSnLumbar MRI scans from 94 patients with low back pain were assessed independently by 2 spine specialists (senior [senior1], junior) and a radiologist (senior2). One reviewer (senior1) assessed the MR images twice at a three-week interval for evaluation of intraobserver reliability. Senior2 and junior reviewers assessed the MR images once. Pure edema endplate signal changes were classified as Modic type I, and pure fatty endplate changes as Modic type II. A mixture of types I and II but predominantly edema signal changes was classified as Modic I-2 and a mixture of types I and II but predominantly fatty changes was classified as Modic II-1.nnnRESULTSnThe intraobserver agreement was excellent (weighted kappa 0.85). The interobserver agreement was moderate to substantial (weighted kappa range 0.56-0.74). Interobserver reliability depended on the experience of the observer, thus highlighting the importance of a learning curve.nnnCONCLUSIONnThis study shows that the modified Modic classification is reliable and easy to apply for observers with different clinical experience. The inclusion of mixed marrow changes in the modified classification may have clinical and therapeutic implications.

Association of Gender with Clinical Expression, Quality of Life, Disability, and Depression and Anxiety in Patients with Systemic Sclerosis

Objectives To assess the association of gender with clinical expression, health-related quality of life (HRQoL), disability, and self-reported symptoms of depression and anxiety in patients with systemic sclerosis (SSc). Methods SSc patients fulfilling the American College of Rheumatology and/or the Leroy and Medsger criteria were assessed for clinical symptoms, disability, HRQoL, self-reported symptoms of depression and anxiety by specific measurement scales. Results Overall, 381 SSc patients (62 males) were included. Mean age and disease duration at the time of evaluation were 55.9 (13.3) and 9.5 (7.8) years, respectively. One-hundred-and-forty-nine (40.4%) patients had diffuse cutaneous SSc (dcSSc). On bivariate analysis, differences were observed between males and females for clinical symptoms and self-reported symptoms of depression and anxiety, however without reaching statistical significance. Indeed, a trend was found for higher body mass index (BMI) (25.0 [4.1] vs 23.0 [4.5], pu200a=u200a0.013), more frequent dcSSc, echocardiography systolic pulmonary artery pressure >35 mmHg and interstitial lung disease in males than females (54.8% vs 37.2%, pu200a=u200a0.010; 24.2% vs 10.5%, pu200a=u200a0.003; and 54.8% vs 41.2%, pu200a=u200a0.048, respectively), whereas calcinosis and self-reported anxiety symptoms tended to be more frequent in females than males (36.0% vs 21.4%, pu200a=u200a0.036, and 62.3% vs 43.5%, pu200a=u200a0.006, respectively). On multivariate analysis, BMI, echocardiography PAP>35 mmHg, and anxiety were the variables most closely associated with gender. Conclusions In SSc patients, male gender tends to be associated with diffuse disease and female gender with calcinosis and self-reported symptoms of anxiety. Disease-associated disability and HRQoL were similar in both groups.

Employment status and socio-economic burden in systemic sclerosis: a cross-sectional survey

OBJECTIVEnTo assess employment status and socio-economic burden in SSc patients.nnnMETHODSnEighty-seven SSc patients (72 females), fulfilling the ACR or the Leroy and Medsger criteria, or both, were evaluated for employment status, socio-economic burden and handicap. Statistical analysis involved Mann-Whitney U-test and Fishers exact test and backward stepwise regression analysis.nnnRESULTSnIn total, 60.9% of the SSc patients were on full-time sick leave and 35.6% were receiving a disability pension. On univariate analysis, myalgia was the only clinical manifestation more frequently encountered in sick-leave patients than others (73.6 vs 47.1%; P = 0.012). Karnofsky performance status (KPS) was lower in SSc patients who were on sick leave or were receiving a disability pension than others [78.5 (10.6) vs 85.8 (9.0); P = 0.004 and 78.1 (8.7) vs 83.1 (11.2); P = 0.016, respectively]. In addition, greater global, hand and mouth handicaps and depression were observed in patients on sick leave [HAQ 0.9 (0.7) vs 0.6 (0.5); P = 0.021; Cochin Hand Function Scale 21.7 (18.9) vs 10.7 (12.1); P = 0.003; mouth handicap scale 20.2 (10.8) vs 14.6 (10.0); P = 0.014; and depression dimension of the hospital anxiety and depression scale 7.1 (3.9) vs 4.8 (3.4); P = 0.003]. On multivariate analysis, factors associated with sick leave were KPS [odds ratio (OR) 0.92; 95%CI 0.88, 0.98] and myalgias (OR 3.19; 95% CI 1.19, 8.58), and the factor associated with receiving a disability pension was decreased income (OR 8.19; 95% CI 2.67, 25.12).nnnCONCLUSIONSnSSc patients commonly have to take full-time sick leave from work. Despite such patients receiving disability pensions, the socio-economic burden is considerable.

Frequency and Interrelations of Risk Factors for Chronic Low Back Pain in a Primary Care Setting

Introduction Many risk factors have been identified for chronic low back pain (cLBP), but only one study evaluated their interrelations. We aimed to investigate the frequency of cLBP risk factors and their interrelations in patients consulting their general practitioners (GPs) for cLBP. Methods A cross-sectional, descriptive, national survey was performed. 3000 GPs randomly selected were asked to include at least one patient consulting for cLBP. Demographic, clinical characteristics and the presence of cLBP risk factors were recorded. The frequency of each cLBP risk factor was calculated and multiple correspondence analysis (MCA) was performed to study their interrelations. Results A total of 2068 GPs (68.9%) included at least 1 patient, for 4522 questionnaires analyzed. In the whole sample of patients, the 2 risk factors most commonly observed were history of recurrent LBP (72.1%) and initial limitation of activities of daily living (66.4%). For working patients, common professional risk factors were beliefs, that LBP was due to maintaining a specific posture at work (79.0%) and frequent heavy lifting at work (65.5%). On MCA, we identified 3 risk-factor dimensions (axes) for working and nonworking patients. The main dimension for working patients involved professional risk factors and among these factors, patients job satisfaction and job recognition largely contribute to this dimension. Discussion Our results shed in light for the first time the interrelation and the respective contribution of several previously identified cLBP risk factors. They suggest that risk factors representing a “work-related” dimension are the most important cLBP risk factors in the working population.

Scheuermann's disease: An update

Scheuermanns disease is a juvenile osteochondrosis of the spine. It is a disease of the growth cartilage endplate, probably due to repetitive strain on the growth cartilage weakened by a genetic background. The radiographic aspects are related to the vertebral endplate lesions and include vertebral wedging, irregularity of the vertebral endplate, and Schmorls node (intraossous disk herniation). Disc alterations are frequent and may be secondary to dysfunction of the disc-vertebra complex. The definitions of Scheuermanns disease are varied; it can refer to the classical form of juvenile kyphosis, described by Scheuermann as well as asymptomatic radiographic abnormalities. Lumbar involvement is probably as frequent as the thoracic form and might be more painful. The first-line treatment is medical and includes rehabilitation and bracing. The earlier the start of treatment, the better the outcome, which highlights the importance of early diagnosis. Surgery is uncommon and must be limited to severe involvement after failure of conservative treatment. The natural history of Scheuermanns disease is unknown, but it might be associated with increased risk of back pain. The evolution of thoracolumbar and lumbar disease is unknown.

Traduction et validation dˈune échelle algofonctionnelleadaptée aux cervicalgies

Resume Objectifsxa0: Traduction en francais et validation du Neck Pain and Disability Scale (NPDS), echelle algofonctionnelle adaptee aux cervicalgies. Patients et methodesxa0: Etude prospective non randomisee proposee aux patients souffrant de cervicalgies communes. Les mesures cliniques comprenaient lˈevaluation de la deficience (par lˈEVA douleur, la mobilite cervicale, la sensibilite a la palpation, le score radiologique de Kellgren), de lˈincapacite (par le score du NPDS et lˈEVA de la gene fonctionnelle), du handicap (par lˈEVA du handicap) et de lˈetat anxio-depressif du patient par lˈechelle HAD. La repetabilite a ete evaluee en utilisant le coefficient de correlation intraclasse et la methode de Bland et Altman, la validite de construit (validites de convergence et de divergence) a ete evaluee a lˈaide du coefficient de correlation non parametrique de Spearman, et dˈune analyse factorielle suivie de rotation orthogonale. Resultatsxa0: Cent-un patients ont participe a cette etude. La traduction a ete obtenue par la methode de «xa0translation/back-translationxa0». La repetabilite est excellente a 0,91. Des adaptations ont ete necessaires apres lˈetude pilote. Les correlations du score de lˈindice avec lˈEVA douleur (rxa0=xa00,51), lˈEVA de gene fonctionnelle (rxa0=xa00,63), lˈEVA handicap (rxa0=xa00,67), le sore anxiete et depression du HAD (rxa0=xa00,39 et rxa0=xa00,49 respectivement), sensibilite a la palpation (rxa0=xa00,31), la mobilite (rxa0=xa0–xa00,45 et 0,28), et le score de Kellgren (rxa0=xa00,04) suggerent une bonne validite de construit (validites convergente et divergente). La methode de Bland et Altman montre une moyenne des differences centree et lˈabsence dˈeffet systematique. Lˈanalyse factorielle a permis dˈextraire trois facteurs expliquant 78xa0% de la variance totale. Conclusionxa0: Le NPDS traduit en francais a de bonnes qualites metrologiques. Son utilisation simple permettra lˈevaluation de lˈincapacite fonctionnelle des cervicalgiques et la normalisation de cette evaluation.

Lombalgie chronique et réentraînement à l'effort : application de la notion de niveau de douleur cliniquement acceptable

OBJECTIVESnTo search for predictors of reduced low back pain under the patient acceptable symptom state (PASS) at the end of a functional restoration program (FRP) in chronic low back pain, and then to compare the effectiveness of FRP depending on the rate of people returning to work, the acceptability threshold of pain has been reached or not at the end of the program.nnnMETHODnOpen prospective study on 303 patients with chronic low back pain included in a FRP. An assessment of the deficiencies (finger-tip-to-floor (cm) and Schöber tests (cm), VO2max (l/min), Shirado and Sorensen tests (seconds), lumbar and radicular VAS (0-100), the functional disability (Wadell and Quebec scales (0-9 and 0-100), and the psychological status (Beck and Hamilton scale (0-35 and 0-30), HAD scale (0-21), FABQ (0-42 and 0-24)) was conducted at the beginning and end of the program. Data on the work were also collected (arduous physical labor, work-related accident or not, sick leaves or not and length, return to work at the end of the program). The variables associated with a PASS at the end of the FRP and a correlation between the level of pain and the return to work were sought.nnnRESULTSnThe parameters were significantly improved: finger-tip-to-floor test (-17.5+/-16.2), Schöber test (-0.5+/-5.4), lumbar VAS(-6.3+/-23.6), VO2max (0.14+/-0.4), Wadell (-1.3+/-2.4), Quebec (-10.5+/-17), Beck D (-3.1+/-4.5), Beck A (-2.5+/-4.3), HAD D (-2.4+/-4.7), HAD A (-1.3+/-3.8) et FABQ1 (-5.7+/-11.6), FABQ2 (-3.9+/-9.6) scores, endurance of the flexor (35+/-63.83) and extensor (44.8+/-112) spine. Patients reaching the PASS for pain level return significantly more to work (73% versus 52%). Five parameters indicative of a reduction of back pain under the PASS were identified : lumbar VAS and endurance of the flexor spine at the beginning, changes in finger-tip-to-floor test, radicular VAS and Beck score for anxiety.nnnCONCLUSIONnThe PASS appears to be a relevant concept associated with a successful return to work for patients with chronic low back pain and severe disability after a program of FRP.