prof speed newsletter september 2015

Musculoskeletal Matters News and Research

From Professor Cathy Speed

Bone Health Growth Hormone Supplementation in Postmenopausal Women

More on bones Hopping for bones (p2)

Resistance exercise for bones (p2)

Others Immunity & the seasons (p5)

Shock wave (p6)

ACL Reconstruction (p8)

Anabolic Steroids (p8)

Arthritis & Spinal Pain

OA Hands (p3)

Arthroplasty & MI (p3)

Gout (p 4)

Back and Neck pain (p 6,7)

Professor Cathy Speed September 2015

A recent Swedish study involved 80 postmenopausal women with osteoporosis (aged 50-70yrs), randomised to receive daily injections of placebo, 1 unit of growth hormone or a 2.5-unit dose of growth hormone. After 18 months, the placebo group halted the injections, while the growth hormone recipients continued treatment for another 18 months. The women were then followed for a further seven years, with their bone density, fractures and quality of life monitored.

A decade after the study began, it was shown that the women who received the larger dose of growth hormone had persistently higher bone mineral density levels than those receiving the lower dose or the placebo. Rates of fractures in the treated women who had osteoporosis declined by 50 per cent during the study period, whereas fractures rose fourfold in the control group.

Undoubtedly more studies will be performed using this treatment, which may prove to be one more therapy available to patients with established osteoporosis.

Journal of Clinical Endocrinology & Metabolism 2015.

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Professor Cathy Speed www.chap.uk.com

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A recent study has shown that regular high impact exercise can help counteract the effect of ageing on bone. The study measured the effect of short bouts of daily hopping on bone density. The study involved 34 men over the age of 65 who hopped for 2 minutes a day for one year. The men hopped only on one leg, so the other leg could be used for comparison.

Bone mass increased by up to 7% in parts of the exercised hip's cortex. The results also showed increases in the density of the trabecular bone. These effects were also seen in the thinnest areas of the hip - the parts that are most likely to suffer a fracture during a fall.

Allison et al, Journal of Bone and Mineral Research, 2015.

High intensity resistance training for bone health

Current guidelines for osteoporosis suggest ‘moderate-intensity exercise’, due to concerns about injuries from higher intensity loading. A recent study assessed the safety and efficacy of brief, bone-targeted, high-intensity progressive resistance training for patients in post-menopausal women.

Subjects were randomised to a twice-weekly 30-minute supervised high-intensity resistance training and impact loading sessions, or a low-intensity home-based exercise programme of the same duration and dose. Bone, muscle and fat mass were assessed as well as functional performance at baseline, and at eight months.

28 women completed the study, with the high-intensity resistance training and impact loading shown to improve height, functional performance and bone mineral density at the femoral neck and lumbar spine. No injuries were reported in either group.

Osteoporosis International, 2015

Hopping for bones Website for patients and professionals

www.chap.uk.com

Professor Cathy Speed regularly updates this website.

Colleagues and patients can find information on a range of topics relating to Rheumatology, Sport & Exercise Medicine. There are information sheets that can be downloaded for patients. Further information is also provided about Professor Speed’s practice.

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Osteoarthritis

Effectiveness of treatments: debate continues

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Chondroitin… again

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Arthroplasty and Risk of MI Total knee or hip arthroplasty (TKA or THA) for osteoarthritis is linked to substantially increased risk for myocardial infarction (MI) in the immediate postoperative period, according to a cohort study from the USA. Unlike the risk for venous thromboembolism that remains years after this surgery however, there was no overall long-term negative effect of arthroplasty on the incidence of MI.

Arthritis Rheum. August, 2015.

Hydroxychloroquine for OA Hands A recent trial has shown that hydroxychloroquine may not be as effective for patients with hand OA as previously thought. 202 patients with primary hand OA were randomly assigned to receive either oral hydroxychloroquine 400mg once a day (n=100) or placebo (n=102) for 24 weeks. Results showed that 24 weeks of treatment with hydroxychloroquine did not significantly reduce pain when compared to placebo. In addition, hydroxychloroquine showed no overall effect on pain, disability and joint stiffness, and no overall change was observed in physical, social and emotional wellbeing scores. More research is needed to clarify the issue, and in the meantime the medication may still be considered in some cases.

Basoski et al, EULAR Annual Congress Presentation, 2015.

Ten percent of the world’s population have osteoarthritis, and 20-30% of these have hand OA, rising to 50% of those after age 60 years. A randomised placebo controlled trial from Switzerland of 162 patients with hand OA reports that chondroitin sulphate (800mg) significantly decreased pain and stiffness and improved hand function, compared to placebo. The evidence for benefit at other sites of OA is lacking.

Gabay et al, Arthritis Rheumatism 2011.

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Gout triggers

NSAIDs versus other analgesics

in soft tissue injuries

A recent Cochrane Review has assessed the effects (benefits and harms) of NSAIDs compared with other oral analgesics for treating acute soft tissue injuries. They concluded that there is generally low quality but consistent evidence of no clinically important difference in analgesic efficacy between NSAIDs and other oral analgesics. There is low-quality evidence of more gastrointestinal adverse effects with non-selective NSAID compared with paracetamol. There is low- or very low-quality evidence of better function and fewer adverse events with NSAIDs compared with opioid-containing analgesics; however, one study dominated this evidence using a now unavailable COX-2 selective NSAID and is of uncertain applicability. Further research is required to determine whether there is any difference in return to function or adverse effects between both non-selective and COX-2 selective NSAIDs versus paracetamol.

Cochrane Rev, 2015

Arthritis

Tomatoes are commonly cited as triggers of gout and yet there is little evidence to support this. A recent New Zealand study addressed the question by surveying 2,051 people with gout, of whom 71% reported having one or more food triggers. Tomatoes were cited as a trigger in 20 per cent of cases, making them the fourth most common trigger after seafood, alcohol and red meat. Data from 12,720 subjects also showed that uric acid levels are higher in those who have a higher tomato intake.

BMC Musculoskeletal Disorders. 2015

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Immune Function

Changes in the Immune System with the Seasons

A new UK based study has identified seasonal changes in genetic and immune system activity that may explain why some diseases vary according to the time of year. Researchers examined blood and adipose tissue samples from more than 16,000 people living in both the northern and southern hemispheres in order to profile this trend.

The study indicated that almost a quarter of the 22,822 genes tested differed according to the time of year, with some more active in winter and others more active in summer.

These seasonal changes also affected the immune cells and the composition of the blood and adipose tissue, with the differences present across mixed populations in geographically and ethnically diverse locations, while displaying opposing patterns in the northern and southern hemispheres.

One inflammation-suppressing gene, ARNTL, was found to be more active in the summer than the winter, offering an explanation why inflammatory conditions (e.g. rheumatoid arthritis) are more active or prevalent during the colder months of the year. Meanwhile, a set of genes associated with vaccination responses were more active in winter, suggesting that immunisation programmes might be better deployed during these times. The reasons for these trends are unclear, but may be due to environmental cues such as daylight and ambient temperature.

Arthritis research UK and Nature Communications, 2015

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Neck Pain in Rugby Players

A French study of 101 professional rugby players and 85 control subjects used clinical assessment and MRI to assess the prevalence of cervical spine complaints compared to the general population. 10% of the players (0% of controls) had had surgery for disc herniation and radiculopathy. Complaints of chronic neck pain and reduced neck mobility were reported significantly more often in the former rugby player group (50.5%) than in the control group (31.8%). However, when these symptoms were evaluated using a neck pain visual analogue scale and the Neck Disability Index there was no statistically significant difference in the level of pain reported by the former rugby players and the level of pain reported by the volunteers. Rugby players had more central canal stenosis and foraminal stenosis but also significantly greater neck muscle mass (and less fat) than the volunteers. The researchers hypothesize that the stronger paraspinal muscles found in former rugby players may aid in controlling the level of spinal pain in this group. Brauge et al. Journal of Neurosurgery: Spine, 2015

Shockwave therapy (ESWT)

Shockwave therapy is now commonly used in musculoskeletal conditions, including some tendinopathies. Many mechanisms of action are proposed but few studies have been performed on humans. A study of the effects of a single dose of ESWT on patients with Achilles tendinosis showed increases in cytokines (IL-6 and IL-8) and catabolic enzymes (MMPs) from a dialysate sampled from around the tendon. These products are seen in tendon remodeling and indicate that the ESWT may act to accelerate tendon remodeling responses. Waugh et al. European Cells and Materials 2015

Sport & Injuries

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Back Pain

A recent study in the USA has shown that early appropriate physical therapy following an episode of acute lower back pain (LBP) results in substantially lower costs and reduced use of health care resources over a 2-year period.

122,723 patients who went to a GP following an initial episode of LBP and received physical therapy within 90 days were included. Of these, 24% received early physical therapy (within 14 days) that adhered to guidelines for active treatment. During a 2-year time period, these patients made significantly less use of advanced imaging, lumbar spinal injections, lumbar spine surgery, and opioids than did patients in other combinations of timing and adherence. Early physical therapy patients also had 60% lower LBP-related costs as compared to the 33.5% (23,993) of patients who had delayed and adherent physical therapy (between 14 and 90 days).

Childs et al, BMC Health Services Research, 2015

A prospective longitudinal study of 36 subjects with whiplash injury has shown that muscle fatty infiltrates in the cervical multifidi muscles occurs soon after whiplash injury, and seems to be associated with those who do poorly longer term. Other negative predictors include older age, pain-related disability, and post-traumatic stress disorder.

Elliott et al, Spine 2015.

Whiplash

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Anabolic Steroids and Tendon Ruptures

Anabolic-androgenic steroids (AAS) abuse is a common problem with many potential adverse health effects. Tendon ruptures are well described in case reports but the first case control study relating to this issue has only recently been published.

Of 88 male bodybuilders who abused AAS, 22% reported at least one tendon rupture vs 6% of 54 bodybuilders who did not abuse AAS. Several men reported 2 or more tendon ruptures.

Interestingly, upper-body tendon ruptures occurred exclusively in the AAS group (17% of AAS users vs 0 nonusers), whereas there was no significant difference between users and nonusers in risk for lower-body ruptures. Of 31 individual tendon ruptures assessed, only 19% occurred while weightlifting, with the majority occurring during other sports activities. 26% ruptures followed prodromal symptoms of nonspecific pain in the region. Virtually all ruptures were treated surgically, with complete or near-complete ultimate restoration of function.

Kanayama et al, Am J Sports Med 2015

Patellofemoral Pain after Hamstrings graft ACL Reconstruction

Patellofemoral pain can be a troublesome complication following anterior cruciate ligament reconstruction (ACLR), irrespective of graft source. A recent study of the factors associated with patellofemoral pain following hamstring-tendon ACLR noted that 30% of patients reported patellofemoral pain after ACLR. The study indicated that older age at the time of ACLR was a predictor of post-operative patellofemoral pain but co-existing knee pathologies or gender were not. Those with patellofemoral pain after ACLR had a higher body mass index, and worse physical performance, quality of life, kinesiophobia and return to sport attitudes.

Culvenor et al. J Sci Med Sport 2015

Professor Cathy Speed BMedSci, Dip Sports Med, MA, PhD, FRCP, FFSEM(I)(UK)

Professor Cathy Speed is a Consultant in Rheumatology, Sport & Exercise Medicine. She also acts as a Senior Physician to the English Institute of Sport and is Chief Medical Officer to GB Badminton and Middlesex County Cricket Club at the Lords Ground, London.

She has a clinical practice based in Cambridge and in London. She draws from her expertise in both specialty areas to provide holistic and customised care. She sees patients of all ages and from a broad range of backgrounds, from those with arthritis and fatigue syndromes to high performance athletes.

Contact details CAMBRIDGE

Progress, The Cambridge Centre for Health and Performance

Conqueror House, Vision Park, Chivers Way,

Histon, Cambridge. CB24 9ZR

[email protected]

LONDON

The Fortius Clinic, 17 Fitzhardinge St,

London W1H 6EQ

[email protected]

www.chap.uk.com

www.chap.uk.com Professor Cathy Speed

prof speed newsletter september 2015

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