Robert A. Kalish

A Randomized Trial of Tai Chi for Fibromyalgia

BACKGROUND Previous research has suggested that tai chi offers a therapeutic benefit in patients with fibromyalgia. METHODS We conducted a single-blind, randomized trial of classic Yang-style tai chi as compared with a control intervention consisting of wellness education and stretching for the treatment of fibromyalgia (defined by American College of Rheumatology 1990 criteria). Sessions lasted 60 minutes each and took place twice a week for 12 weeks for each of the study groups. The primary end point was a change in the Fibromyalgia Impact Questionnaire (FIQ) score (ranging from 0 to 100, with higher scores indicating more severe symptoms) at the end of 12 weeks. Secondary end points included summary scores on the physical and mental components of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). All assessments were repeated at 24 weeks to test the durability of the response. RESULTS Of the 66 randomly assigned patients, the 33 in the tai chi group had clinically important improvements in the FIQ total score and quality of life. Mean (+/-SD) baseline and 12-week FIQ scores for the tai chi group were 62.9+/-15.5 and 35.1+/-18.8, respectively, versus 68.0+/-11 and 58.6+/-17.6, respectively, for the control group (change from baseline in the tai chi group vs. change from baseline in the control group, -18.4 points; P<0.001). The corresponding SF-36 physical-component scores were 28.5+/-8.4 and 37.0+/-10.5 for the tai chi group versus 28.0+/-7.8 and 29.4+/-7.4 for the control group (between-group difference, 7.1 points; P=0.001), and the mental-component scores were 42.6+/-12.2 and 50.3+/-10.2 for the tai chi group versus 37.8+/-10.5 and 39.4+/-11.9 for the control group (between-group difference, 6.1 points; P=0.03). Improvements were maintained at 24 weeks (between-group difference in the FIQ score, -18.3 points; P<0.001). No adverse events were observed. CONCLUSIONS Tai chi may be a useful treatment for fibromyalgia and merits long-term study in larger study populations. (Funded by the National Center for Complementary and Alternative Medicine and others; ClinicalTrials.gov number, NCT00515008.)

Tai Chi is Effective in Treating Knee Osteoarthritis: A Randomized Controlled Trial

OBJECTIVE To evaluate the effectiveness of Tai Chi in the treatment of knee osteoarthritis (OA) symptoms. METHODS We conducted a prospective, single-blind, randomized controlled trial of 40 individuals with symptomatic tibiofemoral OA. Patients were randomly assigned to 60 minutes of Tai Chi (10 modified forms from classic Yang style) or attention control (wellness education and stretching) twice weekly for 12 weeks. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score at 12 weeks. Secondary outcomes included WOMAC function, patient and physician global assessments, timed chair stand, depression index, self-efficacy scale, and quality of life. We repeated these assessments at 24 and 48 weeks. Analyses were compared by intent-to-treat principles. RESULTS The 40 patients had a mean age of 65 years and a mean body mass index of 30.0 kg/m(2). Compared with the controls, patients assigned to Tai Chi exhibited significantly greater improvement in WOMAC pain (mean difference at 12 weeks -118.80 mm [95% confidence interval (95% CI) -183.66, -53.94; P = 0.0005]), WOMAC physical function (-324.60 mm [95% CI -513.98, -135.22; P = 0.001]), patient global visual analog scale (VAS; -2.15 cm [95% CI -3.82, -0.49; P = 0.01]), physician global VAS (-1.71 cm [95% CI -2.75, -0.66; P = 0.002]), chair stand time (-10.88 seconds [95% CI -15.91, -5.84; P = 0.00005]), Center for Epidemiologic Studies Depression Scale (-6.70 [95% CI -11.63, -1.77; P = 0.009]), self-efficacy score (0.71 [95% CI 0.03, 1.39; P = 0.04]), and Short Form 36 physical component summary (7.43 [95% CI 2.50, 12.36; P = 0.004]). No severe adverse events were observed. CONCLUSION Tai Chi reduces pain and improves physical function, self-efficacy, depression, and health-related quality of life for knee OA.

Persistence of Immunoglobulin M or Immunoglobulin G Antibody Responses to Borrelia burgdorferi 10–20 Years after Active Lyme Disease

The interpretation of serological results for patients who had Lyme disease many years ago is not well defined. We studied the serological status of 79 patients who had had Lyme disease 10-20 years ago and did not currently have signs or symptoms of active Lyme disease. Of the 40 patients who had had early Lyme disease alone, 4 (10%) currently had IgM responses to Borrelia burgdorferi, and 10 (25%) still had IgG reactivity to the spirochete, as determined by a 2-test approach (enzyme-linked immunosorbent assay and Western blot). Of the 39 patients who had had Lyme arthritis, 6 (15%) currently had IgM responses and 24 (62%) still had IgG reactivity to the spirochete. IgM or IgG antibody responses to B. burgdorferi may persist for 10-20 years, but these responses are not indicative of active infection.

Evaluation of Study Patients with Lyme Disease, 10–20-Year Follow-up

To determine the long-term impact of Lyme disease, we evaluated 84 randomly selected, original study patients from the Lyme, Connecticut, region who had erythema migrans, facial palsy, or Lyme arthritis 10-20 years ago and 30 uninfected control subjects. The patients in the 3 study groups and the control group did not differ significantly in current symptoms or neuropsychological test results. However, patients with facial palsy, who frequently had more widespread nervous system involvement, more often had residual facial or peripheral nerve deficits. Moreover, patients with facial palsy who did not receive antibiotics for acute neuroborreliosis more often now had joint pain and sleep difficulty and lower scores on the body pain index and standardized physical component sections of the Short-Form 36 Health Assessment Questionnaire than did antibiotic-treated patients with facial palsy. Thus, the overall current health status of each patient group was good, but sequelae were apparent primarily among patients with facial palsy who did not receive antibiotics for acute neuroborreliosis.

Lyme Arthritis: Pathogenesis, Clinical Presentation, and Management

Arthritis is one of the most prominent features of Lyme disease, the tick-borne illness caused by Borrelia burgdorferi. Although the pathogenesis of Lyme arthritis is complex and still under study, the clinical presentation and natural history have been established by long-term observation of untreated and treated patients. This review addresses the clinical presentation of Lyme arthritis as a mono- or oligoarticular relapsing/remitting arthritis primarily affecting the large joints and describes presentations in which arthralgias rather than arthritis are seen. Strategies for diagnosis and treatment are discussed, and methods are reviewed for addressing treatment-refractory Lyme arthritis and arthralgias that may occur after treatment of Lyme disease (sometimes as a component of what is known as the post-Lyme disease syndrome).

Tai Chi for treating knee osteoarthritis: Designing a long-term follow up randomized controlled trial

BackgroundKnee Osteoarthritis (KOA) is a major cause of pain and functional impairment among elders. Currently, there are neither feasible preventive intervention strategies nor effective medical remedies for the management of KOA. Tai Chi, an ancient Chinese mind-body exercise that is reported to enhance muscle function, balance and flexibility, and to reduce pain, depression and anxiety, may safely and effectively be used to treat KOA. However, current evidence is inconclusive. Our study examines the effects of a 12-week Tai Chi program compared with an attention control (wellness education and stretching) on pain, functional capacity, psychosocial variables, joint proprioception and health status in elderly people with KOA. The study will be completed by July 2009.Methods/DesignForty eligible patients, age > 55 yr, BMI ≤ 40 kg/m2 with tibiofemoral osteoarthritis (American College of Rheumatology criteria) are identified and randomly allocated to either Tai Chi (10 modified forms from classical Yang style Tai Chi) or attention control (wellness education and stretching). The 60-minute intervention sessions take place twice weekly for 12 weeks. The study is conducted at an urban tertiary medical center in Boston, Massachusetts. The primary outcome measure is the Western Ontario and McMaster Universities (WOMAC) pain subscale at 12 weeks. Secondary outcomes include weekly WOMAC pain, function and stiffness scores, patient and physician global assessments, lower-extremity function, knee proprioception, depression, self-efficacy, social support, health-related quality of life, adherence and occurrence of adverse events after 12, 24 and 48 weeks.DiscussionIn this article, we present the challenges of designing a randomized controlled trial with long-term follow up. The challenges encountered in this design are: strategies for recruitment, avoidance of selection bias, the actual practice of Tai Chi, and the maximization of adherence/follow-up while conducting the clinical trial for the evaluation of the effectiveness of Tai Chi on KOA.Trial registrationClinicalTrials.gov identifier: NCT00362453

Sweet's syndrome in association with Crohn's disease.

A case of Sweets syndrome in association with Crohns disease in a young woman is reported. Sweets syndrome is a rare extraintestinal manifestation of Crohns disease and ulcerative colitis.

Factors associated with blood hydroxychloroquine level in lupus patients: renal function could be important:

Sir, We describe the possible association of blood hydroxychloroquine (HCQ) level and renal function in patients with systemic lupus erythematosus (SLE) from a pilot study at a single academic rheumatology clinic. HCQ is a critically important medication in the management of patients with SLE as it is safe and effective in preventing flares. However, the pharmacokinetics of HCQ are not fully understood, and only a few studies have explored the factors associated with variation in blood HCQ concentration in individual patients. We conducted a cross-sectional study to explore the relationship of various factors to blood HCQ levels in SLE patients. The study population consisted of 30 patients with SLE, who were seen between December 2009 and April 2010 in the Rheumatology clinic at Tufts Medical Center in Boston, Massachusetts. Inclusion criteria were any SLE patients aged 18 years or older who fulfilled the American College of Rheumatology criteria, had been on oral HCQ for at least two months and were willing to provide blood samples. Written informed consent was obtained from each participant. The study was approved by the Institutional Review Board of Tufts Medical Center. Whole blood HCQ levels were quantified by high-performance liquid chromatography (HPLC) with fluorescence detection. From a total of 30 participants, three were excluded in data analysis due to undetectable HCQ levels. The characteristics of subjects are listed in Table 1. Four out of 27 had abnormal estimated glomerular filtration rate (GFR) ranging from 3 to 71mL/min/1.73m using the chronic kidney disease-epidemiology collaboration (CKDEPI) equation. Self-completed questionnaires indicated relative quiescence of disease activity. Ethnicity, age, gender, smoking status, HCQ dose, HCQ dose per weight, abnormal liver function tests were not associated with blood HCQ level. However, GFR was significantly related to blood HCQ level(r 1⁄4 –0.558, p 1⁄4 .002 by Spearman correlation). When subjects were dichotomized into two groups of normal and abnormal GFR, two groups were significantly different from HCQ level (p1⁄4 .002) (Table 1, Figure 1). Our study was one of the few studies that measured blood HCQ level in SLE patients, and even though we were not able to correlate HCQ level with most of the variables in this small stable SLE group, we did find a relationship between renal function and the level of blood HCQ. Though our study is limited by its lack of power and its inability to determine medication compliance, the finding of high blood HCQ level in patients with decreased renal function may have an important clinical significance. Although HCQ is mainly excreted in urine there currently is no guideline for dose adjustment in SLE patients with renal dysfunction. Previous studies suggested that significant impairment of renal function could result in increased tissue retention of HCQ and constitute a risk factor for retinopathy. In addition renal failure was suggested as a predisposing factor for neuromyotoxicity among patients taking HCQ. Therefore, further studies are needed in SLE patients with renal insufficiency to confirm our findings and to examine the relationship of blood HCQ level, drug efficacy, and toxicity.

Preworkshop Knowledge of Musculoskeletal Anatomy of Rheumatology Fellows and Rheumatologists of Seven North, Central, and South American Countries

To report the baseline knowledge of clinical anatomy of rheumatology fellows and rheumatologists from Argentina, Chile, Ecuador, El Salvador, Mexico, the US, and Uruguay.

Clinical Anatomy of the Ankle and Foot

This paper emphasizes the anatomical substrate of several foot conditions that are seldom discussed in this context. These include the insertional and non-insertional Achilles tendinopathies, plantar fasciopathy, inferior and posterior heel spurs, foot compartment syndromes, intermetatarsal bursitis and Mortons neuroma. It is a rather superficial anatomical review of an organ that remains largely neglected by rheumatologists. It is our hope that the cases discussed and the cross examination by instructors and participants will stimulate study of the foot and the attention it deserves.