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Spinal Cord Stimulation Promising for Chronic Back, Leg Pain
TOPLINE:
Spinal cord stimulation (SCS) therapies for chronic back and/or leg pain is superior to conventional medical management (CMM) for reduced pain intensity and functional disability, new research suggests.
METHODOLOGY:
- Researchers performed a systematic review and network meta-analysis of 13 randomized clinical trials that compared conventional and novel SCS therapies with CMM.
- More than 1500 adults with chronic back and/or leg pain and no past history of receiving SCS therapies were included.
- Novel therapies included high frequency, burst, differential target multiplexed, and closed-loop SCS; conventional therapies included tonic SCS wave forms.
- Study outcomes included pain intensity in the back and in the leg, proportion of patients achieving at least 50% pain reduction in the back and in the leg, quality of life as measured by the EuroQol-5 Dimensions (EQ-5D) index, and functional disability on the Oswestry Disability Index.
- The analysis included data from multiple follow-up points at 3, 6, 12, and 24 months, with 6-month data being those from the longest mutually reported timepoint across all outcomes.
TAKEAWAY:
- Both conventional and novel SCS therapies demonstrated superior efficacy vs CMM in pain reduction, but the novel SCS therapies were more likely to provide ≥ 50% reduction in back pain (odds ratio, 8.76; 95% credible interval [CrI], 3.84-22.31).
- Both SCS therapies showed a significant reduction in pain intensity, with novel SCS providing the greatest mean difference (MD) for back pain (–2.34; 95% CrI, –2.96 to –1.73) and lower leg pain (MD, –4.01; 95% CrI, –5.31 to –2.75).
- Quality of life improved with both types of SCS therapies, with novel SCS therapies yielding the highest MD (0.17; 95% CrI, 0.13-0.21) in EQ-5D index score.
- Conventional SCS showed greater improvement in functionality vs CMM, yielding the lowest MD (–7.10; 95% CrI, –10.91 to –3.36) in Oswestry Disability Index score.
IN PRACTICE:
“We found that SCS was associated with improved pain and QOL [quality of life] and reduced disability, compared with CMM, after 6 months of follow-up. These findings highlight the potential of SCS therapies as an effective and valuable option in chronic pain management,” the investigators wrote.
SOURCE:
The study was led by Frank J.P.M. Huygen, PhD, MD, Erasmus Medical Center, Rotterdam, the Netherlands. It was published online in JAMA Network Open.
LIMITATIONS:
The lack of randomized clinical trials with long-term follow-up data restricted the inclusion of extended outcome assessments. Most included studies showed a high risk for bias. Safety estimates could not be evaluated as adverse events were only reported as procedure-related outcomes, which are not applicable for CMM. Additionally, the network meta-analytical approach, which combined evidence from studies with varying patient eligibility criteria, may have introduced bias because of between-study heterogeneity.
DISCLOSURES:
This study was funded by Medtronic. Huygen reported receiving personal fees from Abbott, Saluda, and Grunenthal outside the submitted work. The four other authors reported receiving funding from Medtronic.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
TOPLINE:
Spinal cord stimulation (SCS) therapies for chronic back and/or leg pain is superior to conventional medical management (CMM) for reduced pain intensity and functional disability, new research suggests.
METHODOLOGY:
- Researchers performed a systematic review and network meta-analysis of 13 randomized clinical trials that compared conventional and novel SCS therapies with CMM.
- More than 1500 adults with chronic back and/or leg pain and no past history of receiving SCS therapies were included.
- Novel therapies included high frequency, burst, differential target multiplexed, and closed-loop SCS; conventional therapies included tonic SCS wave forms.
- Study outcomes included pain intensity in the back and in the leg, proportion of patients achieving at least 50% pain reduction in the back and in the leg, quality of life as measured by the EuroQol-5 Dimensions (EQ-5D) index, and functional disability on the Oswestry Disability Index.
- The analysis included data from multiple follow-up points at 3, 6, 12, and 24 months, with 6-month data being those from the longest mutually reported timepoint across all outcomes.
TAKEAWAY:
- Both conventional and novel SCS therapies demonstrated superior efficacy vs CMM in pain reduction, but the novel SCS therapies were more likely to provide ≥ 50% reduction in back pain (odds ratio, 8.76; 95% credible interval [CrI], 3.84-22.31).
- Both SCS therapies showed a significant reduction in pain intensity, with novel SCS providing the greatest mean difference (MD) for back pain (–2.34; 95% CrI, –2.96 to –1.73) and lower leg pain (MD, –4.01; 95% CrI, –5.31 to –2.75).
- Quality of life improved with both types of SCS therapies, with novel SCS therapies yielding the highest MD (0.17; 95% CrI, 0.13-0.21) in EQ-5D index score.
- Conventional SCS showed greater improvement in functionality vs CMM, yielding the lowest MD (–7.10; 95% CrI, –10.91 to –3.36) in Oswestry Disability Index score.
IN PRACTICE:
“We found that SCS was associated with improved pain and QOL [quality of life] and reduced disability, compared with CMM, after 6 months of follow-up. These findings highlight the potential of SCS therapies as an effective and valuable option in chronic pain management,” the investigators wrote.
SOURCE:
The study was led by Frank J.P.M. Huygen, PhD, MD, Erasmus Medical Center, Rotterdam, the Netherlands. It was published online in JAMA Network Open.
LIMITATIONS:
The lack of randomized clinical trials with long-term follow-up data restricted the inclusion of extended outcome assessments. Most included studies showed a high risk for bias. Safety estimates could not be evaluated as adverse events were only reported as procedure-related outcomes, which are not applicable for CMM. Additionally, the network meta-analytical approach, which combined evidence from studies with varying patient eligibility criteria, may have introduced bias because of between-study heterogeneity.
DISCLOSURES:
This study was funded by Medtronic. Huygen reported receiving personal fees from Abbott, Saluda, and Grunenthal outside the submitted work. The four other authors reported receiving funding from Medtronic.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
TOPLINE:
Spinal cord stimulation (SCS) therapies for chronic back and/or leg pain is superior to conventional medical management (CMM) for reduced pain intensity and functional disability, new research suggests.
METHODOLOGY:
- Researchers performed a systematic review and network meta-analysis of 13 randomized clinical trials that compared conventional and novel SCS therapies with CMM.
- More than 1500 adults with chronic back and/or leg pain and no past history of receiving SCS therapies were included.
- Novel therapies included high frequency, burst, differential target multiplexed, and closed-loop SCS; conventional therapies included tonic SCS wave forms.
- Study outcomes included pain intensity in the back and in the leg, proportion of patients achieving at least 50% pain reduction in the back and in the leg, quality of life as measured by the EuroQol-5 Dimensions (EQ-5D) index, and functional disability on the Oswestry Disability Index.
- The analysis included data from multiple follow-up points at 3, 6, 12, and 24 months, with 6-month data being those from the longest mutually reported timepoint across all outcomes.
TAKEAWAY:
- Both conventional and novel SCS therapies demonstrated superior efficacy vs CMM in pain reduction, but the novel SCS therapies were more likely to provide ≥ 50% reduction in back pain (odds ratio, 8.76; 95% credible interval [CrI], 3.84-22.31).
- Both SCS therapies showed a significant reduction in pain intensity, with novel SCS providing the greatest mean difference (MD) for back pain (–2.34; 95% CrI, –2.96 to –1.73) and lower leg pain (MD, –4.01; 95% CrI, –5.31 to –2.75).
- Quality of life improved with both types of SCS therapies, with novel SCS therapies yielding the highest MD (0.17; 95% CrI, 0.13-0.21) in EQ-5D index score.
- Conventional SCS showed greater improvement in functionality vs CMM, yielding the lowest MD (–7.10; 95% CrI, –10.91 to –3.36) in Oswestry Disability Index score.
IN PRACTICE:
“We found that SCS was associated with improved pain and QOL [quality of life] and reduced disability, compared with CMM, after 6 months of follow-up. These findings highlight the potential of SCS therapies as an effective and valuable option in chronic pain management,” the investigators wrote.
SOURCE:
The study was led by Frank J.P.M. Huygen, PhD, MD, Erasmus Medical Center, Rotterdam, the Netherlands. It was published online in JAMA Network Open.
LIMITATIONS:
The lack of randomized clinical trials with long-term follow-up data restricted the inclusion of extended outcome assessments. Most included studies showed a high risk for bias. Safety estimates could not be evaluated as adverse events were only reported as procedure-related outcomes, which are not applicable for CMM. Additionally, the network meta-analytical approach, which combined evidence from studies with varying patient eligibility criteria, may have introduced bias because of between-study heterogeneity.
DISCLOSURES:
This study was funded by Medtronic. Huygen reported receiving personal fees from Abbott, Saluda, and Grunenthal outside the submitted work. The four other authors reported receiving funding from Medtronic.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
Oxidative Stress Marker May Signal Fracture Risk in T2D
TOPLINE:
Elevated levels of plasma F2-isoprostanes, a reliable marker of oxidative stress, are associated with an increased risk for fractures in older ambulatory patients with type 2 diabetes (T2D) independently of bone density.
METHODOLOGY:
- Patients with T2D face an increased risk for fractures at any given bone mineral density; oxidative stress levels (reflected in circulating F2-isoprostanes), which are elevated in T2D, are associated with other T2D complications, and may weaken bone integrity.
- Researchers analyzed data from an observational cohort study to investigate the association between the levels of circulating F2-isoprostanes and the risk for clinical fractures in older patients with T2D.
- The data included 703 older ambulatory adults (baseline age, 70-79 years; about half White individuals and half Black individuals ; about half men and half women) from the Health, Aging and Body Composition Study, of whom 132 had T2D.
- Plasma F2-isoprostane levels were measured using baseline serum samples; bone turnover markers were also measured including procollagen type 1 N-terminal propeptide, osteocalcin, and C-terminal telopeptide of type 1 collagen.
- Incident clinical fractures were tracked over a follow-up period of up to 17.3 years, with fractures verified through radiology reports.
TAKEAWAY:
- Overall, 25.8% patients in the T2D group and 23.5% adults in the non-diabetes group reported an incident clinical fracture during a mean follow-up period of 6.2 and 8.0 years, respectively.
- In patients with T2D, the risk for incident clinical fracture increased by 93% for every standard deviation increase in the log F2-isoprostane serum levels (hazard ratio [HR], 1.93; 95% CI, 1.26-2.95; P = .002) independently of baseline bone density, medication use, and other risk factors, with no such association reported in individuals without T2D (HR, 0.98; 95% CI, 0.81-1.18; P = .79).
- In the T2D group, elevated plasma F2-isoprostane levels were also associated with a decrease in total hip bone mineral density over 4 years (r = −0.28; P = .008), but not in the non-diabetes group.
- No correlation was found between plasma F2-isoprostane levels and circulating advanced glycoxidation end-products, bone turnover markers, or A1c levels in either group.
IN PRACTICE:
“Oxidative stress in T2D may play an important role in the decline of bone quality and not just bone quantity,” the authors wrote.
SOURCE:
This study was led by Bowen Wang, PhD, Rensselaer Polytechnic Institute, Troy, New York. It was published online in The Journal of Clinical Endocrinology & Metabolism.
LIMITATIONS:
This study was conducted in a well-functioning elderly population with only White and Black participants, which may limit the generalizability of the findings to other age groups or less healthy populations. Additionally, the study did not assess prevalent vertebral fracture risk due to the small sample size.
DISCLOSURES:
This study was supported by the US National Institute on Aging and the Intramural Research Program of the US National Institutes of Health and the Dr and Ms Sands and Sands Family for Orthopaedic Research. The authors reported no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
Elevated levels of plasma F2-isoprostanes, a reliable marker of oxidative stress, are associated with an increased risk for fractures in older ambulatory patients with type 2 diabetes (T2D) independently of bone density.
METHODOLOGY:
- Patients with T2D face an increased risk for fractures at any given bone mineral density; oxidative stress levels (reflected in circulating F2-isoprostanes), which are elevated in T2D, are associated with other T2D complications, and may weaken bone integrity.
- Researchers analyzed data from an observational cohort study to investigate the association between the levels of circulating F2-isoprostanes and the risk for clinical fractures in older patients with T2D.
- The data included 703 older ambulatory adults (baseline age, 70-79 years; about half White individuals and half Black individuals ; about half men and half women) from the Health, Aging and Body Composition Study, of whom 132 had T2D.
- Plasma F2-isoprostane levels were measured using baseline serum samples; bone turnover markers were also measured including procollagen type 1 N-terminal propeptide, osteocalcin, and C-terminal telopeptide of type 1 collagen.
- Incident clinical fractures were tracked over a follow-up period of up to 17.3 years, with fractures verified through radiology reports.
TAKEAWAY:
- Overall, 25.8% patients in the T2D group and 23.5% adults in the non-diabetes group reported an incident clinical fracture during a mean follow-up period of 6.2 and 8.0 years, respectively.
- In patients with T2D, the risk for incident clinical fracture increased by 93% for every standard deviation increase in the log F2-isoprostane serum levels (hazard ratio [HR], 1.93; 95% CI, 1.26-2.95; P = .002) independently of baseline bone density, medication use, and other risk factors, with no such association reported in individuals without T2D (HR, 0.98; 95% CI, 0.81-1.18; P = .79).
- In the T2D group, elevated plasma F2-isoprostane levels were also associated with a decrease in total hip bone mineral density over 4 years (r = −0.28; P = .008), but not in the non-diabetes group.
- No correlation was found between plasma F2-isoprostane levels and circulating advanced glycoxidation end-products, bone turnover markers, or A1c levels in either group.
IN PRACTICE:
“Oxidative stress in T2D may play an important role in the decline of bone quality and not just bone quantity,” the authors wrote.
SOURCE:
This study was led by Bowen Wang, PhD, Rensselaer Polytechnic Institute, Troy, New York. It was published online in The Journal of Clinical Endocrinology & Metabolism.
LIMITATIONS:
This study was conducted in a well-functioning elderly population with only White and Black participants, which may limit the generalizability of the findings to other age groups or less healthy populations. Additionally, the study did not assess prevalent vertebral fracture risk due to the small sample size.
DISCLOSURES:
This study was supported by the US National Institute on Aging and the Intramural Research Program of the US National Institutes of Health and the Dr and Ms Sands and Sands Family for Orthopaedic Research. The authors reported no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
Elevated levels of plasma F2-isoprostanes, a reliable marker of oxidative stress, are associated with an increased risk for fractures in older ambulatory patients with type 2 diabetes (T2D) independently of bone density.
METHODOLOGY:
- Patients with T2D face an increased risk for fractures at any given bone mineral density; oxidative stress levels (reflected in circulating F2-isoprostanes), which are elevated in T2D, are associated with other T2D complications, and may weaken bone integrity.
- Researchers analyzed data from an observational cohort study to investigate the association between the levels of circulating F2-isoprostanes and the risk for clinical fractures in older patients with T2D.
- The data included 703 older ambulatory adults (baseline age, 70-79 years; about half White individuals and half Black individuals ; about half men and half women) from the Health, Aging and Body Composition Study, of whom 132 had T2D.
- Plasma F2-isoprostane levels were measured using baseline serum samples; bone turnover markers were also measured including procollagen type 1 N-terminal propeptide, osteocalcin, and C-terminal telopeptide of type 1 collagen.
- Incident clinical fractures were tracked over a follow-up period of up to 17.3 years, with fractures verified through radiology reports.
TAKEAWAY:
- Overall, 25.8% patients in the T2D group and 23.5% adults in the non-diabetes group reported an incident clinical fracture during a mean follow-up period of 6.2 and 8.0 years, respectively.
- In patients with T2D, the risk for incident clinical fracture increased by 93% for every standard deviation increase in the log F2-isoprostane serum levels (hazard ratio [HR], 1.93; 95% CI, 1.26-2.95; P = .002) independently of baseline bone density, medication use, and other risk factors, with no such association reported in individuals without T2D (HR, 0.98; 95% CI, 0.81-1.18; P = .79).
- In the T2D group, elevated plasma F2-isoprostane levels were also associated with a decrease in total hip bone mineral density over 4 years (r = −0.28; P = .008), but not in the non-diabetes group.
- No correlation was found between plasma F2-isoprostane levels and circulating advanced glycoxidation end-products, bone turnover markers, or A1c levels in either group.
IN PRACTICE:
“Oxidative stress in T2D may play an important role in the decline of bone quality and not just bone quantity,” the authors wrote.
SOURCE:
This study was led by Bowen Wang, PhD, Rensselaer Polytechnic Institute, Troy, New York. It was published online in The Journal of Clinical Endocrinology & Metabolism.
LIMITATIONS:
This study was conducted in a well-functioning elderly population with only White and Black participants, which may limit the generalizability of the findings to other age groups or less healthy populations. Additionally, the study did not assess prevalent vertebral fracture risk due to the small sample size.
DISCLOSURES:
This study was supported by the US National Institute on Aging and the Intramural Research Program of the US National Institutes of Health and the Dr and Ms Sands and Sands Family for Orthopaedic Research. The authors reported no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
Shoulder Pain Pointers for Primary Care
The causes of shoulder pain may be as common as a traumatic injury or as rare as a systemic inflammatory condition, according to the American Academy of Orthopaedic Surgeons. The combination of joints, tendons, and muscles that make up the shoulder can present diagnostic and clinical challenges, but several experts shared their tips for management.
Evaluation and Diagnosis
Rotator cuff tendinopathy/tendinitis and subacromial bursitis are typically the most common causes of shoulder pain presenting to a primary care provider, said Jason Kolfenbach, MD, a rheumatologist at UC Health, Denver, Colorado, in an interview. “Other causes of shoulder pain may include acromioclavicular osteoarthritis, biceps tendinitis (often a secondary process in the setting of rotator cuff disease), and true glenohumeral joint osteoarthritis,” he said.
Experts estimate that as much as 80% of shoulder pain involves the muscles, tendons, and ligaments surrounding the joint, rather than true arthritis, said Kolfenbach, who was a co-author of a Medscape slideshow on evaluating shoulder pain. In the slideshow, the authors noted that proper evaluation is needed for successful pain management. Some patients may do well with nonsteroidal anti-inflammatory drugs (NSAIDs), rest, ice, and physical therapy, but more serious conditions may require steroids, disease-modifying antirheumatic drugs, or surgery.
If a patient’s joint pain with active range of motion is relieved when an examiner supports the affected limb (passive range of motion), the cause is more likely related to muscles, tendons, or ligaments, Kolfenbach said.
Primary care providers may not be familiar with examination maneuvers to diagnose shoulder pain, although they are often tasked with evaluating and managing these patients, said Kolfenbach.
Education focused on practical aspects of these maneuvers may help improve primary care confidence in utilizing them and lead to more appropriate ordering of imaging testing and better pain management plans for patients, he said.
However, “If there is concern for a true intra-articular process, plain radiographs are recommended to determine if there is loss of cartilage space and/or other anatomic drivers of pain,” he noted. “Even in conditions of documented intra-articular arthritis, such as osteoarthritis, weakness, and atrophy of the surrounding musculature can contribute to joint disability and pain,” he said. For these patients, referral to physical therapy for periarticular strengthening can provide pain relief, he added.
Pinning Down the Pain Point
The many different structures within the shoulder that can cause pain make diagnosis a challenge, Nicole Angelo, DO, MS, a physiatrist at the Hospital for Special Surgery, New York City, said in an interview.
Potential sources of pain include the joint of the shoulder itself, the structures within it (labrum, capsule, and ligaments), and the surrounding rotator cuff muscles and tendons, she said. Patients also may experience overlapping pain referred from the neck (cervical spine) related to nerve irritation (cervical radiculopathy) or arthritis, she noted.
“A patient’s history, including mechanism and acuity of injury, as well as exam, specifically weakness in certain movements,” can help determine whether advanced imaging and surgical intervention may be required,” Angelo told this news organization.
Frozen shoulder is the most missed diagnosis of shoulder pain in primary care, Brian Feeley, MD, chief of sports medicine and shoulder surgery at the University of California, San Francisco (UCSF), said in an interview.
Frozen shoulder, also known as adhesive capsulitis, can mimic many other conditions including rotator cuff problems, shoulder arthritis, and biceps problems, Feeley said. “When people have a loss of active and passive range of motion and no evidence of arthritis on x-rays, their diagnosis is most likely frozen shoulder,” he said.
Another challenge for primary care providers is identifying the severity of rotator cuff problems, Feeley said. “I like to think of rotator cuff problems along a spectrum — impingement is inflammation above the rotator cuff and suggests an imbalance between rotator cuff strength and deltoid strength,” said Feeley. “Partial thickness tears are often normal age-related problems but can be a source of pain,” he added.
However, full-thickness tears encompass a range of problems, from very small asymptomatic holes in the rotator cuff to massive tears that require shoulder replacement, Feeley explained. “Tendinopathy, or changes in the collagen organization in the tendon of the rotator cuff, sounds problematic, but most often is either incidental or part of aging,” he added.
When Shoulder Pain Isn’t Caused by the Shoulder
Primary care patients presenting with shoulder pain may in fact have a neck or spine problem instead, Feeley told this news organization. “Pain that is in the shoulder blade area or down the arm and into the fingers is usually coming from the neck/cervical spine,” he said.
In some cases, shoulder pain stems from the joints below the shoulder, including the elbow, because of arthritis, tennis elbow (lateral epicondylopathy), or golfer’s elbow (medial epicondylopathy), said Angelo. “Conditions of the elbow and neck can also affect shoulder mechanics or cause someone to use the joint more or less frequently,” she said. The interconnections between the neck and joints of the upper extremity, including referral patterns, complicate the diagnosis of shoulder pain; therefore, careful history-taking and examination of joints both above and below the shoulder are essential, she added.
Conservative Care
Shoulder problems often can be managed conservatively with therapeutic exercise focused on maintaining range of motion of the shoulder and strengthening the musculature around the shoulder, Angelo said. “Often, working with a physical therapist to address the mechanics of how the shoulder is moving and how the muscles are firing can help decrease pain and help patients meet their functional goals,” said Angelo. “Injections into the joint, the bursa adjacent to the rotator cuff, and, at times, into the tendons themselves can also be beneficial in relieving pain and improving function,” she said.
In some cases, a short, consistent course of anti-inflammatory medications can be part of a conservative strategy for the management of shoulder pain, Angelo noted.
“Utilizing these medications on an as-needed basis can also help patients improve their ability to sleep, perform their daily activities, and participate in physical therapy,” she said. A course of physical therapy that promotes maintaining shoulder range of motion, strengthening of the rotator cuff musculature, and working on the mechanics between the scapula and humerus is a good first step for most shoulder conditions, Angelo told this news organization.
“If there is concern due to recent trauma, significant weakness, or new/persistent numbness, referral to a specialist should be considered,” she said. If conservative measures including analgesics and exercise have failed to improve shoulder pain, advanced imaging and further interventional treatment may be necessary, Angelo added.
Most shoulder problems can and should be managed nonoperatively, Feeley said. Surgery should be reserved for patients whose shoulder pain has not improved with nonoperative care in most situations, he said. “It is often surprising for patients to hear, but most things in the shoulder actually get better without surgery, and changes on MRI are often normal for age,” Feeley noted. For example, more than 80% of individuals older than 50 will show signs of a labral tear or arthritis in the acromioclavicular joint, he said. “These are incidental findings that don’t need treatment,” he added.
More research is needed to develop more medications to manage pain for all musculoskeletal conditions, including shoulder pain, said Feeley. “But for now, for patients with shoulder pain, I tend to recommend a combination of Tylenol and an NSAID to improve inflammation and reduce pain, and a guided [physical] therapy program at home or in person. The combination of both usually will be successful,” he said.
Postsurgical Shoulder Pain
“For patients who have shoulder surgery, the techniques to manage pain around surgery have improved tremendously over the last decade, particularly with multimodal pain management and nerve blocks,” Feeley told this news organization. These advances have tremendously reduced the need for narcotics for pain management beyond the first 72 hours after surgery, he said. “I strongly recommend patients and primary care doctors to stop all narcotics as soon as possible after shoulder surgery, since they are not nearly as effective for management of pain after the first few days, and they should never be used as a sleep aid,” he emphasized.
Managing pain during recovery from shoulder surgery also involves about 6 weeks in a sling to protect the repair, followed by 6 weeks of active motion but no strengthening, then 3 months of strengthening exercises, he said.
Shoulder pain resources for patients: https://www.hss.edu/condition-list_shoulder-pain-causes.asp
Feeley’s 10-minute video on shoulder examination and pain assessment at the UCSF 14th Annual Primary Care Sports Medicine Conference, 2019: Video on the Essential Shoulder Exam
Kolfenbach disclosed receiving royalties from Elsevier for being the editor of Rheumatology Secrets and Wolters Kluwer for authoring several articles on UpToDate. Feeley and Angelo had no relevant financial conflicts to disclose.
A version of this article appeared on Medscape.com.
The causes of shoulder pain may be as common as a traumatic injury or as rare as a systemic inflammatory condition, according to the American Academy of Orthopaedic Surgeons. The combination of joints, tendons, and muscles that make up the shoulder can present diagnostic and clinical challenges, but several experts shared their tips for management.
Evaluation and Diagnosis
Rotator cuff tendinopathy/tendinitis and subacromial bursitis are typically the most common causes of shoulder pain presenting to a primary care provider, said Jason Kolfenbach, MD, a rheumatologist at UC Health, Denver, Colorado, in an interview. “Other causes of shoulder pain may include acromioclavicular osteoarthritis, biceps tendinitis (often a secondary process in the setting of rotator cuff disease), and true glenohumeral joint osteoarthritis,” he said.
Experts estimate that as much as 80% of shoulder pain involves the muscles, tendons, and ligaments surrounding the joint, rather than true arthritis, said Kolfenbach, who was a co-author of a Medscape slideshow on evaluating shoulder pain. In the slideshow, the authors noted that proper evaluation is needed for successful pain management. Some patients may do well with nonsteroidal anti-inflammatory drugs (NSAIDs), rest, ice, and physical therapy, but more serious conditions may require steroids, disease-modifying antirheumatic drugs, or surgery.
If a patient’s joint pain with active range of motion is relieved when an examiner supports the affected limb (passive range of motion), the cause is more likely related to muscles, tendons, or ligaments, Kolfenbach said.
Primary care providers may not be familiar with examination maneuvers to diagnose shoulder pain, although they are often tasked with evaluating and managing these patients, said Kolfenbach.
Education focused on practical aspects of these maneuvers may help improve primary care confidence in utilizing them and lead to more appropriate ordering of imaging testing and better pain management plans for patients, he said.
However, “If there is concern for a true intra-articular process, plain radiographs are recommended to determine if there is loss of cartilage space and/or other anatomic drivers of pain,” he noted. “Even in conditions of documented intra-articular arthritis, such as osteoarthritis, weakness, and atrophy of the surrounding musculature can contribute to joint disability and pain,” he said. For these patients, referral to physical therapy for periarticular strengthening can provide pain relief, he added.
Pinning Down the Pain Point
The many different structures within the shoulder that can cause pain make diagnosis a challenge, Nicole Angelo, DO, MS, a physiatrist at the Hospital for Special Surgery, New York City, said in an interview.
Potential sources of pain include the joint of the shoulder itself, the structures within it (labrum, capsule, and ligaments), and the surrounding rotator cuff muscles and tendons, she said. Patients also may experience overlapping pain referred from the neck (cervical spine) related to nerve irritation (cervical radiculopathy) or arthritis, she noted.
“A patient’s history, including mechanism and acuity of injury, as well as exam, specifically weakness in certain movements,” can help determine whether advanced imaging and surgical intervention may be required,” Angelo told this news organization.
Frozen shoulder is the most missed diagnosis of shoulder pain in primary care, Brian Feeley, MD, chief of sports medicine and shoulder surgery at the University of California, San Francisco (UCSF), said in an interview.
Frozen shoulder, also known as adhesive capsulitis, can mimic many other conditions including rotator cuff problems, shoulder arthritis, and biceps problems, Feeley said. “When people have a loss of active and passive range of motion and no evidence of arthritis on x-rays, their diagnosis is most likely frozen shoulder,” he said.
Another challenge for primary care providers is identifying the severity of rotator cuff problems, Feeley said. “I like to think of rotator cuff problems along a spectrum — impingement is inflammation above the rotator cuff and suggests an imbalance between rotator cuff strength and deltoid strength,” said Feeley. “Partial thickness tears are often normal age-related problems but can be a source of pain,” he added.
However, full-thickness tears encompass a range of problems, from very small asymptomatic holes in the rotator cuff to massive tears that require shoulder replacement, Feeley explained. “Tendinopathy, or changes in the collagen organization in the tendon of the rotator cuff, sounds problematic, but most often is either incidental or part of aging,” he added.
When Shoulder Pain Isn’t Caused by the Shoulder
Primary care patients presenting with shoulder pain may in fact have a neck or spine problem instead, Feeley told this news organization. “Pain that is in the shoulder blade area or down the arm and into the fingers is usually coming from the neck/cervical spine,” he said.
In some cases, shoulder pain stems from the joints below the shoulder, including the elbow, because of arthritis, tennis elbow (lateral epicondylopathy), or golfer’s elbow (medial epicondylopathy), said Angelo. “Conditions of the elbow and neck can also affect shoulder mechanics or cause someone to use the joint more or less frequently,” she said. The interconnections between the neck and joints of the upper extremity, including referral patterns, complicate the diagnosis of shoulder pain; therefore, careful history-taking and examination of joints both above and below the shoulder are essential, she added.
Conservative Care
Shoulder problems often can be managed conservatively with therapeutic exercise focused on maintaining range of motion of the shoulder and strengthening the musculature around the shoulder, Angelo said. “Often, working with a physical therapist to address the mechanics of how the shoulder is moving and how the muscles are firing can help decrease pain and help patients meet their functional goals,” said Angelo. “Injections into the joint, the bursa adjacent to the rotator cuff, and, at times, into the tendons themselves can also be beneficial in relieving pain and improving function,” she said.
In some cases, a short, consistent course of anti-inflammatory medications can be part of a conservative strategy for the management of shoulder pain, Angelo noted.
“Utilizing these medications on an as-needed basis can also help patients improve their ability to sleep, perform their daily activities, and participate in physical therapy,” she said. A course of physical therapy that promotes maintaining shoulder range of motion, strengthening of the rotator cuff musculature, and working on the mechanics between the scapula and humerus is a good first step for most shoulder conditions, Angelo told this news organization.
“If there is concern due to recent trauma, significant weakness, or new/persistent numbness, referral to a specialist should be considered,” she said. If conservative measures including analgesics and exercise have failed to improve shoulder pain, advanced imaging and further interventional treatment may be necessary, Angelo added.
Most shoulder problems can and should be managed nonoperatively, Feeley said. Surgery should be reserved for patients whose shoulder pain has not improved with nonoperative care in most situations, he said. “It is often surprising for patients to hear, but most things in the shoulder actually get better without surgery, and changes on MRI are often normal for age,” Feeley noted. For example, more than 80% of individuals older than 50 will show signs of a labral tear or arthritis in the acromioclavicular joint, he said. “These are incidental findings that don’t need treatment,” he added.
More research is needed to develop more medications to manage pain for all musculoskeletal conditions, including shoulder pain, said Feeley. “But for now, for patients with shoulder pain, I tend to recommend a combination of Tylenol and an NSAID to improve inflammation and reduce pain, and a guided [physical] therapy program at home or in person. The combination of both usually will be successful,” he said.
Postsurgical Shoulder Pain
“For patients who have shoulder surgery, the techniques to manage pain around surgery have improved tremendously over the last decade, particularly with multimodal pain management and nerve blocks,” Feeley told this news organization. These advances have tremendously reduced the need for narcotics for pain management beyond the first 72 hours after surgery, he said. “I strongly recommend patients and primary care doctors to stop all narcotics as soon as possible after shoulder surgery, since they are not nearly as effective for management of pain after the first few days, and they should never be used as a sleep aid,” he emphasized.
Managing pain during recovery from shoulder surgery also involves about 6 weeks in a sling to protect the repair, followed by 6 weeks of active motion but no strengthening, then 3 months of strengthening exercises, he said.
Shoulder pain resources for patients: https://www.hss.edu/condition-list_shoulder-pain-causes.asp
Feeley’s 10-minute video on shoulder examination and pain assessment at the UCSF 14th Annual Primary Care Sports Medicine Conference, 2019: Video on the Essential Shoulder Exam
Kolfenbach disclosed receiving royalties from Elsevier for being the editor of Rheumatology Secrets and Wolters Kluwer for authoring several articles on UpToDate. Feeley and Angelo had no relevant financial conflicts to disclose.
A version of this article appeared on Medscape.com.
The causes of shoulder pain may be as common as a traumatic injury or as rare as a systemic inflammatory condition, according to the American Academy of Orthopaedic Surgeons. The combination of joints, tendons, and muscles that make up the shoulder can present diagnostic and clinical challenges, but several experts shared their tips for management.
Evaluation and Diagnosis
Rotator cuff tendinopathy/tendinitis and subacromial bursitis are typically the most common causes of shoulder pain presenting to a primary care provider, said Jason Kolfenbach, MD, a rheumatologist at UC Health, Denver, Colorado, in an interview. “Other causes of shoulder pain may include acromioclavicular osteoarthritis, biceps tendinitis (often a secondary process in the setting of rotator cuff disease), and true glenohumeral joint osteoarthritis,” he said.
Experts estimate that as much as 80% of shoulder pain involves the muscles, tendons, and ligaments surrounding the joint, rather than true arthritis, said Kolfenbach, who was a co-author of a Medscape slideshow on evaluating shoulder pain. In the slideshow, the authors noted that proper evaluation is needed for successful pain management. Some patients may do well with nonsteroidal anti-inflammatory drugs (NSAIDs), rest, ice, and physical therapy, but more serious conditions may require steroids, disease-modifying antirheumatic drugs, or surgery.
If a patient’s joint pain with active range of motion is relieved when an examiner supports the affected limb (passive range of motion), the cause is more likely related to muscles, tendons, or ligaments, Kolfenbach said.
Primary care providers may not be familiar with examination maneuvers to diagnose shoulder pain, although they are often tasked with evaluating and managing these patients, said Kolfenbach.
Education focused on practical aspects of these maneuvers may help improve primary care confidence in utilizing them and lead to more appropriate ordering of imaging testing and better pain management plans for patients, he said.
However, “If there is concern for a true intra-articular process, plain radiographs are recommended to determine if there is loss of cartilage space and/or other anatomic drivers of pain,” he noted. “Even in conditions of documented intra-articular arthritis, such as osteoarthritis, weakness, and atrophy of the surrounding musculature can contribute to joint disability and pain,” he said. For these patients, referral to physical therapy for periarticular strengthening can provide pain relief, he added.
Pinning Down the Pain Point
The many different structures within the shoulder that can cause pain make diagnosis a challenge, Nicole Angelo, DO, MS, a physiatrist at the Hospital for Special Surgery, New York City, said in an interview.
Potential sources of pain include the joint of the shoulder itself, the structures within it (labrum, capsule, and ligaments), and the surrounding rotator cuff muscles and tendons, she said. Patients also may experience overlapping pain referred from the neck (cervical spine) related to nerve irritation (cervical radiculopathy) or arthritis, she noted.
“A patient’s history, including mechanism and acuity of injury, as well as exam, specifically weakness in certain movements,” can help determine whether advanced imaging and surgical intervention may be required,” Angelo told this news organization.
Frozen shoulder is the most missed diagnosis of shoulder pain in primary care, Brian Feeley, MD, chief of sports medicine and shoulder surgery at the University of California, San Francisco (UCSF), said in an interview.
Frozen shoulder, also known as adhesive capsulitis, can mimic many other conditions including rotator cuff problems, shoulder arthritis, and biceps problems, Feeley said. “When people have a loss of active and passive range of motion and no evidence of arthritis on x-rays, their diagnosis is most likely frozen shoulder,” he said.
Another challenge for primary care providers is identifying the severity of rotator cuff problems, Feeley said. “I like to think of rotator cuff problems along a spectrum — impingement is inflammation above the rotator cuff and suggests an imbalance between rotator cuff strength and deltoid strength,” said Feeley. “Partial thickness tears are often normal age-related problems but can be a source of pain,” he added.
However, full-thickness tears encompass a range of problems, from very small asymptomatic holes in the rotator cuff to massive tears that require shoulder replacement, Feeley explained. “Tendinopathy, or changes in the collagen organization in the tendon of the rotator cuff, sounds problematic, but most often is either incidental or part of aging,” he added.
When Shoulder Pain Isn’t Caused by the Shoulder
Primary care patients presenting with shoulder pain may in fact have a neck or spine problem instead, Feeley told this news organization. “Pain that is in the shoulder blade area or down the arm and into the fingers is usually coming from the neck/cervical spine,” he said.
In some cases, shoulder pain stems from the joints below the shoulder, including the elbow, because of arthritis, tennis elbow (lateral epicondylopathy), or golfer’s elbow (medial epicondylopathy), said Angelo. “Conditions of the elbow and neck can also affect shoulder mechanics or cause someone to use the joint more or less frequently,” she said. The interconnections between the neck and joints of the upper extremity, including referral patterns, complicate the diagnosis of shoulder pain; therefore, careful history-taking and examination of joints both above and below the shoulder are essential, she added.
Conservative Care
Shoulder problems often can be managed conservatively with therapeutic exercise focused on maintaining range of motion of the shoulder and strengthening the musculature around the shoulder, Angelo said. “Often, working with a physical therapist to address the mechanics of how the shoulder is moving and how the muscles are firing can help decrease pain and help patients meet their functional goals,” said Angelo. “Injections into the joint, the bursa adjacent to the rotator cuff, and, at times, into the tendons themselves can also be beneficial in relieving pain and improving function,” she said.
In some cases, a short, consistent course of anti-inflammatory medications can be part of a conservative strategy for the management of shoulder pain, Angelo noted.
“Utilizing these medications on an as-needed basis can also help patients improve their ability to sleep, perform their daily activities, and participate in physical therapy,” she said. A course of physical therapy that promotes maintaining shoulder range of motion, strengthening of the rotator cuff musculature, and working on the mechanics between the scapula and humerus is a good first step for most shoulder conditions, Angelo told this news organization.
“If there is concern due to recent trauma, significant weakness, or new/persistent numbness, referral to a specialist should be considered,” she said. If conservative measures including analgesics and exercise have failed to improve shoulder pain, advanced imaging and further interventional treatment may be necessary, Angelo added.
Most shoulder problems can and should be managed nonoperatively, Feeley said. Surgery should be reserved for patients whose shoulder pain has not improved with nonoperative care in most situations, he said. “It is often surprising for patients to hear, but most things in the shoulder actually get better without surgery, and changes on MRI are often normal for age,” Feeley noted. For example, more than 80% of individuals older than 50 will show signs of a labral tear or arthritis in the acromioclavicular joint, he said. “These are incidental findings that don’t need treatment,” he added.
More research is needed to develop more medications to manage pain for all musculoskeletal conditions, including shoulder pain, said Feeley. “But for now, for patients with shoulder pain, I tend to recommend a combination of Tylenol and an NSAID to improve inflammation and reduce pain, and a guided [physical] therapy program at home or in person. The combination of both usually will be successful,” he said.
Postsurgical Shoulder Pain
“For patients who have shoulder surgery, the techniques to manage pain around surgery have improved tremendously over the last decade, particularly with multimodal pain management and nerve blocks,” Feeley told this news organization. These advances have tremendously reduced the need for narcotics for pain management beyond the first 72 hours after surgery, he said. “I strongly recommend patients and primary care doctors to stop all narcotics as soon as possible after shoulder surgery, since they are not nearly as effective for management of pain after the first few days, and they should never be used as a sleep aid,” he emphasized.
Managing pain during recovery from shoulder surgery also involves about 6 weeks in a sling to protect the repair, followed by 6 weeks of active motion but no strengthening, then 3 months of strengthening exercises, he said.
Shoulder pain resources for patients: https://www.hss.edu/condition-list_shoulder-pain-causes.asp
Feeley’s 10-minute video on shoulder examination and pain assessment at the UCSF 14th Annual Primary Care Sports Medicine Conference, 2019: Video on the Essential Shoulder Exam
Kolfenbach disclosed receiving royalties from Elsevier for being the editor of Rheumatology Secrets and Wolters Kluwer for authoring several articles on UpToDate. Feeley and Angelo had no relevant financial conflicts to disclose.
A version of this article appeared on Medscape.com.
Vitamin K Supplementation Reduces Nocturnal Leg Cramps in Older Adults
TOPLINE:
Vitamin K supplementation significantly reduced the frequency, intensity, and duration of nocturnal leg cramps in older adults. No adverse events related to vitamin K were identified.
METHODOLOGY:
- Researchers conducted a multicenter, double-blind, placebo-controlled randomized clinical trial in China from September 2022 to December 2023.
- A total of 199 participants aged ≥ 65 years with at least two documented episodes of nocturnal leg cramps during a 2-week screening period were included.
- Participants were randomized in a 1:1 ratio to receive either 180 μg of vitamin K (menaquinone 7) or a placebo daily for 8 weeks.
- The primary outcome was the mean number of nocturnal leg cramps per week, while secondary outcomes were the duration and severity of muscle cramps.
- The ethics committees of Third People’s Hospital of Chengdu and Affiliated Hospital of North Sichuan Medical College approved the study, and all participants provided written informed consent.
TAKEAWAY:
- Vitamin K group experienced a significant reduction in the mean weekly frequency of cramps (mean difference, 2.60 [SD, 0.81] to 0.96 [SD, 1.41]) compared with the placebo group, which maintained a mean weekly frequency of 3.63 (SD, 2.20) (P < .001).
- The severity of nocturnal leg cramps decreased more in the vitamin K group (mean difference, −2.55 [SD, 2.12] points) than in the placebo group (mean difference, −1.24 [SD, 1.16] points).
- The duration of nocturnal leg cramps also decreased more in the vitamin K group (mean difference, −0.90 [SD, 0.88] minutes) than in the placebo group (mean difference, −0.32 [SD, 0.78] minutes).
- No adverse events related to vitamin K use were identified, indicating a good safety profile for the supplementation.
IN PRACTICE:
“Given the generally benign characteristics of NLCs, treatment modality must be both effective and safe, thus minimizing the risk of iatrogenic harm,” the study authors wrote.
SOURCE:
This study was led by Jing Tan, MD, the Third People’s Hospital of Chengdu in Chengdu, China. It was published online on October 28 in JAMA Internal Medicine.
LIMITATIONS:
This study did not investigate the quality of life or sleep, which could have provided additional insights into the impact of vitamin K on nocturnal leg cramps. The relatively mild nature of nocturnal leg cramps experienced by the participants may limit the generalizability of the findings to populations with more severe symptoms.
DISCLOSURES:
This study was supported by grants from China Health Promotion Foundation and the Third People’s Hospital of Chengdu Scientific Research Project. Tan disclosed receiving personal fees from BeiGene, AbbVie, Pfizer, Xian Janssen Pharmaceutical, and Takeda Pharmaceutical outside the submitted work.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
Vitamin K supplementation significantly reduced the frequency, intensity, and duration of nocturnal leg cramps in older adults. No adverse events related to vitamin K were identified.
METHODOLOGY:
- Researchers conducted a multicenter, double-blind, placebo-controlled randomized clinical trial in China from September 2022 to December 2023.
- A total of 199 participants aged ≥ 65 years with at least two documented episodes of nocturnal leg cramps during a 2-week screening period were included.
- Participants were randomized in a 1:1 ratio to receive either 180 μg of vitamin K (menaquinone 7) or a placebo daily for 8 weeks.
- The primary outcome was the mean number of nocturnal leg cramps per week, while secondary outcomes were the duration and severity of muscle cramps.
- The ethics committees of Third People’s Hospital of Chengdu and Affiliated Hospital of North Sichuan Medical College approved the study, and all participants provided written informed consent.
TAKEAWAY:
- Vitamin K group experienced a significant reduction in the mean weekly frequency of cramps (mean difference, 2.60 [SD, 0.81] to 0.96 [SD, 1.41]) compared with the placebo group, which maintained a mean weekly frequency of 3.63 (SD, 2.20) (P < .001).
- The severity of nocturnal leg cramps decreased more in the vitamin K group (mean difference, −2.55 [SD, 2.12] points) than in the placebo group (mean difference, −1.24 [SD, 1.16] points).
- The duration of nocturnal leg cramps also decreased more in the vitamin K group (mean difference, −0.90 [SD, 0.88] minutes) than in the placebo group (mean difference, −0.32 [SD, 0.78] minutes).
- No adverse events related to vitamin K use were identified, indicating a good safety profile for the supplementation.
IN PRACTICE:
“Given the generally benign characteristics of NLCs, treatment modality must be both effective and safe, thus minimizing the risk of iatrogenic harm,” the study authors wrote.
SOURCE:
This study was led by Jing Tan, MD, the Third People’s Hospital of Chengdu in Chengdu, China. It was published online on October 28 in JAMA Internal Medicine.
LIMITATIONS:
This study did not investigate the quality of life or sleep, which could have provided additional insights into the impact of vitamin K on nocturnal leg cramps. The relatively mild nature of nocturnal leg cramps experienced by the participants may limit the generalizability of the findings to populations with more severe symptoms.
DISCLOSURES:
This study was supported by grants from China Health Promotion Foundation and the Third People’s Hospital of Chengdu Scientific Research Project. Tan disclosed receiving personal fees from BeiGene, AbbVie, Pfizer, Xian Janssen Pharmaceutical, and Takeda Pharmaceutical outside the submitted work.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
Vitamin K supplementation significantly reduced the frequency, intensity, and duration of nocturnal leg cramps in older adults. No adverse events related to vitamin K were identified.
METHODOLOGY:
- Researchers conducted a multicenter, double-blind, placebo-controlled randomized clinical trial in China from September 2022 to December 2023.
- A total of 199 participants aged ≥ 65 years with at least two documented episodes of nocturnal leg cramps during a 2-week screening period were included.
- Participants were randomized in a 1:1 ratio to receive either 180 μg of vitamin K (menaquinone 7) or a placebo daily for 8 weeks.
- The primary outcome was the mean number of nocturnal leg cramps per week, while secondary outcomes were the duration and severity of muscle cramps.
- The ethics committees of Third People’s Hospital of Chengdu and Affiliated Hospital of North Sichuan Medical College approved the study, and all participants provided written informed consent.
TAKEAWAY:
- Vitamin K group experienced a significant reduction in the mean weekly frequency of cramps (mean difference, 2.60 [SD, 0.81] to 0.96 [SD, 1.41]) compared with the placebo group, which maintained a mean weekly frequency of 3.63 (SD, 2.20) (P < .001).
- The severity of nocturnal leg cramps decreased more in the vitamin K group (mean difference, −2.55 [SD, 2.12] points) than in the placebo group (mean difference, −1.24 [SD, 1.16] points).
- The duration of nocturnal leg cramps also decreased more in the vitamin K group (mean difference, −0.90 [SD, 0.88] minutes) than in the placebo group (mean difference, −0.32 [SD, 0.78] minutes).
- No adverse events related to vitamin K use were identified, indicating a good safety profile for the supplementation.
IN PRACTICE:
“Given the generally benign characteristics of NLCs, treatment modality must be both effective and safe, thus minimizing the risk of iatrogenic harm,” the study authors wrote.
SOURCE:
This study was led by Jing Tan, MD, the Third People’s Hospital of Chengdu in Chengdu, China. It was published online on October 28 in JAMA Internal Medicine.
LIMITATIONS:
This study did not investigate the quality of life or sleep, which could have provided additional insights into the impact of vitamin K on nocturnal leg cramps. The relatively mild nature of nocturnal leg cramps experienced by the participants may limit the generalizability of the findings to populations with more severe symptoms.
DISCLOSURES:
This study was supported by grants from China Health Promotion Foundation and the Third People’s Hospital of Chengdu Scientific Research Project. Tan disclosed receiving personal fees from BeiGene, AbbVie, Pfizer, Xian Janssen Pharmaceutical, and Takeda Pharmaceutical outside the submitted work.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
Virtual Yoga Classes Improve Chronic Low Back Pain
TOPLINE:
Virtual yoga classes significantly reduced chronic low back pain intensity and improved back-related function in health system employees. Improvements were sustained at 24 weeks, with reduced pain medication use and better sleep quality.
METHODOLOGY:
- A single-blinded, 24-week, 2-arm, randomized clinical trial was conducted from May 3, 2022, through May 23, 2023, comparing live-streamed yoga classes with a wait-list control among adults with chronic low back pain.
- A total of 140 participants aged 18-64 years with chronic low back pain were recruited from the Cleveland Clinic Employee Health Plan.
- Inclusion criteria included a mean low back pain intensity score of at least 4 on an 11-point numerical rating scale and daily back pain interference about half or more of the days.
- The intervention consisted of 12 consecutive weekly, 60-minute, virtual, live-streamed hatha yoga group classes.
Coprimary outcomes were mean pain intensity in the previous week on the 11-point numerical rating scale and back-related function as assessed using the 23-point modified Roland Morris Disability Questionnaire at 12 weeks.
TAKEAWAY:
- Participants in the virtual yoga group showed greater reductions in mean pain intensity at 12 weeks (mean change, –1.5 points; P < .001) and 24 weeks (mean change, –2.3 points; P < .001) compared to the wait-list control group.
- Back-related function improved significantly in the virtual yoga group at 12 weeks (mean change, –2.8 points; P < .001) and 24 weeks (mean change, –4.6 points; P < .001), compared with the control group.
- Virtual yoga participants reported 21.2 percentage points less use of any analgesic medication during the past week at 24 weeks, compared with the control group.
- Sleep quality improved more in the virtual yoga group at 12 weeks (mean change, 0.4 points; P = .008) and 24 weeks (mean change, 0.4 points; P = .005), compared with the control group.
IN PRACTICE:
“Given the demonstrated noninferiority of yoga to physical therapy, structured virtual yoga programs and physical therapy are reasonable choices for patients with [chronic low back pain] depending on accessibility, cost, and patient preference. These findings support the call by the National Academy of Medicine for increased evidenced-based pain treatments that can be disseminated via technology-based platforms,” wrote the authors of the study.
SOURCE:
The study was led by Hallie Tankha, PhD, Cleveland Clinic in Ohio. It was published online on November 1, 2024, in JAMA Network Open.
LIMITATIONS:
The study had a low adherence rate, with only 36.6% of participants attending at least 50% of the yoga classes. There was also a higher rate of missing data in the yoga group compared to the control group. The study did not include a longer-term follow-up assessment beyond 24 weeks.
DISCLOSURES:
This study was supported by grants from Cleveland Clinic Healthcare Delivery and Implementation Science Center. One coauthor disclosed receiving personal fees from the Blue Cross Blue Shield Association. Eric Roseen, DC, PhD, reported receiving grants from the National Institutes of Health National Center for Complementary and Integrative Health. One coauthor disclosed receiving personal fees from UpToDate and grants from NCCIH related to yoga and tai chi for treatment of pain. Additional disclosures are noted in the original article.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
TOPLINE:
Virtual yoga classes significantly reduced chronic low back pain intensity and improved back-related function in health system employees. Improvements were sustained at 24 weeks, with reduced pain medication use and better sleep quality.
METHODOLOGY:
- A single-blinded, 24-week, 2-arm, randomized clinical trial was conducted from May 3, 2022, through May 23, 2023, comparing live-streamed yoga classes with a wait-list control among adults with chronic low back pain.
- A total of 140 participants aged 18-64 years with chronic low back pain were recruited from the Cleveland Clinic Employee Health Plan.
- Inclusion criteria included a mean low back pain intensity score of at least 4 on an 11-point numerical rating scale and daily back pain interference about half or more of the days.
- The intervention consisted of 12 consecutive weekly, 60-minute, virtual, live-streamed hatha yoga group classes.
Coprimary outcomes were mean pain intensity in the previous week on the 11-point numerical rating scale and back-related function as assessed using the 23-point modified Roland Morris Disability Questionnaire at 12 weeks.
TAKEAWAY:
- Participants in the virtual yoga group showed greater reductions in mean pain intensity at 12 weeks (mean change, –1.5 points; P < .001) and 24 weeks (mean change, –2.3 points; P < .001) compared to the wait-list control group.
- Back-related function improved significantly in the virtual yoga group at 12 weeks (mean change, –2.8 points; P < .001) and 24 weeks (mean change, –4.6 points; P < .001), compared with the control group.
- Virtual yoga participants reported 21.2 percentage points less use of any analgesic medication during the past week at 24 weeks, compared with the control group.
- Sleep quality improved more in the virtual yoga group at 12 weeks (mean change, 0.4 points; P = .008) and 24 weeks (mean change, 0.4 points; P = .005), compared with the control group.
IN PRACTICE:
“Given the demonstrated noninferiority of yoga to physical therapy, structured virtual yoga programs and physical therapy are reasonable choices for patients with [chronic low back pain] depending on accessibility, cost, and patient preference. These findings support the call by the National Academy of Medicine for increased evidenced-based pain treatments that can be disseminated via technology-based platforms,” wrote the authors of the study.
SOURCE:
The study was led by Hallie Tankha, PhD, Cleveland Clinic in Ohio. It was published online on November 1, 2024, in JAMA Network Open.
LIMITATIONS:
The study had a low adherence rate, with only 36.6% of participants attending at least 50% of the yoga classes. There was also a higher rate of missing data in the yoga group compared to the control group. The study did not include a longer-term follow-up assessment beyond 24 weeks.
DISCLOSURES:
This study was supported by grants from Cleveland Clinic Healthcare Delivery and Implementation Science Center. One coauthor disclosed receiving personal fees from the Blue Cross Blue Shield Association. Eric Roseen, DC, PhD, reported receiving grants from the National Institutes of Health National Center for Complementary and Integrative Health. One coauthor disclosed receiving personal fees from UpToDate and grants from NCCIH related to yoga and tai chi for treatment of pain. Additional disclosures are noted in the original article.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
TOPLINE:
Virtual yoga classes significantly reduced chronic low back pain intensity and improved back-related function in health system employees. Improvements were sustained at 24 weeks, with reduced pain medication use and better sleep quality.
METHODOLOGY:
- A single-blinded, 24-week, 2-arm, randomized clinical trial was conducted from May 3, 2022, through May 23, 2023, comparing live-streamed yoga classes with a wait-list control among adults with chronic low back pain.
- A total of 140 participants aged 18-64 years with chronic low back pain were recruited from the Cleveland Clinic Employee Health Plan.
- Inclusion criteria included a mean low back pain intensity score of at least 4 on an 11-point numerical rating scale and daily back pain interference about half or more of the days.
- The intervention consisted of 12 consecutive weekly, 60-minute, virtual, live-streamed hatha yoga group classes.
Coprimary outcomes were mean pain intensity in the previous week on the 11-point numerical rating scale and back-related function as assessed using the 23-point modified Roland Morris Disability Questionnaire at 12 weeks.
TAKEAWAY:
- Participants in the virtual yoga group showed greater reductions in mean pain intensity at 12 weeks (mean change, –1.5 points; P < .001) and 24 weeks (mean change, –2.3 points; P < .001) compared to the wait-list control group.
- Back-related function improved significantly in the virtual yoga group at 12 weeks (mean change, –2.8 points; P < .001) and 24 weeks (mean change, –4.6 points; P < .001), compared with the control group.
- Virtual yoga participants reported 21.2 percentage points less use of any analgesic medication during the past week at 24 weeks, compared with the control group.
- Sleep quality improved more in the virtual yoga group at 12 weeks (mean change, 0.4 points; P = .008) and 24 weeks (mean change, 0.4 points; P = .005), compared with the control group.
IN PRACTICE:
“Given the demonstrated noninferiority of yoga to physical therapy, structured virtual yoga programs and physical therapy are reasonable choices for patients with [chronic low back pain] depending on accessibility, cost, and patient preference. These findings support the call by the National Academy of Medicine for increased evidenced-based pain treatments that can be disseminated via technology-based platforms,” wrote the authors of the study.
SOURCE:
The study was led by Hallie Tankha, PhD, Cleveland Clinic in Ohio. It was published online on November 1, 2024, in JAMA Network Open.
LIMITATIONS:
The study had a low adherence rate, with only 36.6% of participants attending at least 50% of the yoga classes. There was also a higher rate of missing data in the yoga group compared to the control group. The study did not include a longer-term follow-up assessment beyond 24 weeks.
DISCLOSURES:
This study was supported by grants from Cleveland Clinic Healthcare Delivery and Implementation Science Center. One coauthor disclosed receiving personal fees from the Blue Cross Blue Shield Association. Eric Roseen, DC, PhD, reported receiving grants from the National Institutes of Health National Center for Complementary and Integrative Health. One coauthor disclosed receiving personal fees from UpToDate and grants from NCCIH related to yoga and tai chi for treatment of pain. Additional disclosures are noted in the original article.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
JIA Treatment Has Increasingly Involved New DMARDs Since 2001
TOPLINE:
The use of newer biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) for treating juvenile idiopathic arthritis (JIA) rose sharply from 2001 to 2022, while the use of conventional synthetic DMARDs (csDMARDs) plummeted, with adalimumab becoming the most commonly used b/tsDMARD.
METHODOLOGY:
- Researchers performed a serial cross-sectional study using Merative MarketScan Commercial Claims and Encounters data from 2000 to 2022 to describe recent trends in DMARD use for children with JIA in the United States.
- They identified 20,258 new episodes of DMARD use among 13,696 children with JIA (median age, 14 years; 67.5% girls) who newly initiated at least one DMARD.
- Participants were required to have ≥ 365 days of continuous healthcare and pharmacy eligibility prior to the index date, defined as the date of DMARD initiation.
TAKEAWAY:
- The use of csDMARDs declined from 89.5% to 43.2% between 2001 and 2022 (P < .001 for trend), whereas the use of bDMARDs increased from 10.5% to 50.0% over the same period (P < .001).
- Methotrexate was the most commonly used DMARD throughout the study period ; however, as with other csDMARDs, its use declined from 42.1% in 2001 to 21.5% in 2022 (P < .001 ).
- Use of the tumor necrosis factor inhibitor adalimumab doubled from 7% in 2007 to 14% in 2008 and increased further up to 20.5% by 2022; adalimumab also became the most predominantly used b/tsDMARD after csDMARD monotherapy, accounting for 77.8% of prescriptions following csDMARDs in 2022.
- Even though the use of individual TNF inhibitors increased, their overall popularity fell in recent years as the use of newer b/tsDMARDs, such as ustekinumab and secukinumab, increased.
IN PRACTICE:
“These real-world treatment patterns give us insight into how selection of therapies for JIA has evolved with increasing availability of effective agents and help prepare for future studies on comparative DMARD safety and effectiveness,” the authors wrote.
SOURCE:
The study was led by Priyanka Yalamanchili, PharmD, MS, Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Rutgers University, New Brunswick, New Jersey, and was published online October 22, 2024, in Arthritis & Rheumatology.
LIMITATIONS:
The dependence on commercial claims data may have limited the generalizability of the findings to other populations, such as those with public insurance or without insurance. The study did not have access to demographic data of the participants to investigate the presence of disparities in the use of DMARDs. Moreover, the lack of clinical details about the patients with JIA, including disease severity and specialty of prescribers, may have affected the interpretation of the results.
DISCLOSURES:
The study was supported by funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and several other institutes of the National Institutes of Health, as well as the Rheumatology Research Foundation and the Juvenile Diabetes Research Foundation. No conflicts of interest were reported by the authors.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
The use of newer biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) for treating juvenile idiopathic arthritis (JIA) rose sharply from 2001 to 2022, while the use of conventional synthetic DMARDs (csDMARDs) plummeted, with adalimumab becoming the most commonly used b/tsDMARD.
METHODOLOGY:
- Researchers performed a serial cross-sectional study using Merative MarketScan Commercial Claims and Encounters data from 2000 to 2022 to describe recent trends in DMARD use for children with JIA in the United States.
- They identified 20,258 new episodes of DMARD use among 13,696 children with JIA (median age, 14 years; 67.5% girls) who newly initiated at least one DMARD.
- Participants were required to have ≥ 365 days of continuous healthcare and pharmacy eligibility prior to the index date, defined as the date of DMARD initiation.
TAKEAWAY:
- The use of csDMARDs declined from 89.5% to 43.2% between 2001 and 2022 (P < .001 for trend), whereas the use of bDMARDs increased from 10.5% to 50.0% over the same period (P < .001).
- Methotrexate was the most commonly used DMARD throughout the study period ; however, as with other csDMARDs, its use declined from 42.1% in 2001 to 21.5% in 2022 (P < .001 ).
- Use of the tumor necrosis factor inhibitor adalimumab doubled from 7% in 2007 to 14% in 2008 and increased further up to 20.5% by 2022; adalimumab also became the most predominantly used b/tsDMARD after csDMARD monotherapy, accounting for 77.8% of prescriptions following csDMARDs in 2022.
- Even though the use of individual TNF inhibitors increased, their overall popularity fell in recent years as the use of newer b/tsDMARDs, such as ustekinumab and secukinumab, increased.
IN PRACTICE:
“These real-world treatment patterns give us insight into how selection of therapies for JIA has evolved with increasing availability of effective agents and help prepare for future studies on comparative DMARD safety and effectiveness,” the authors wrote.
SOURCE:
The study was led by Priyanka Yalamanchili, PharmD, MS, Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Rutgers University, New Brunswick, New Jersey, and was published online October 22, 2024, in Arthritis & Rheumatology.
LIMITATIONS:
The dependence on commercial claims data may have limited the generalizability of the findings to other populations, such as those with public insurance or without insurance. The study did not have access to demographic data of the participants to investigate the presence of disparities in the use of DMARDs. Moreover, the lack of clinical details about the patients with JIA, including disease severity and specialty of prescribers, may have affected the interpretation of the results.
DISCLOSURES:
The study was supported by funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and several other institutes of the National Institutes of Health, as well as the Rheumatology Research Foundation and the Juvenile Diabetes Research Foundation. No conflicts of interest were reported by the authors.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
The use of newer biologic or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) for treating juvenile idiopathic arthritis (JIA) rose sharply from 2001 to 2022, while the use of conventional synthetic DMARDs (csDMARDs) plummeted, with adalimumab becoming the most commonly used b/tsDMARD.
METHODOLOGY:
- Researchers performed a serial cross-sectional study using Merative MarketScan Commercial Claims and Encounters data from 2000 to 2022 to describe recent trends in DMARD use for children with JIA in the United States.
- They identified 20,258 new episodes of DMARD use among 13,696 children with JIA (median age, 14 years; 67.5% girls) who newly initiated at least one DMARD.
- Participants were required to have ≥ 365 days of continuous healthcare and pharmacy eligibility prior to the index date, defined as the date of DMARD initiation.
TAKEAWAY:
- The use of csDMARDs declined from 89.5% to 43.2% between 2001 and 2022 (P < .001 for trend), whereas the use of bDMARDs increased from 10.5% to 50.0% over the same period (P < .001).
- Methotrexate was the most commonly used DMARD throughout the study period ; however, as with other csDMARDs, its use declined from 42.1% in 2001 to 21.5% in 2022 (P < .001 ).
- Use of the tumor necrosis factor inhibitor adalimumab doubled from 7% in 2007 to 14% in 2008 and increased further up to 20.5% by 2022; adalimumab also became the most predominantly used b/tsDMARD after csDMARD monotherapy, accounting for 77.8% of prescriptions following csDMARDs in 2022.
- Even though the use of individual TNF inhibitors increased, their overall popularity fell in recent years as the use of newer b/tsDMARDs, such as ustekinumab and secukinumab, increased.
IN PRACTICE:
“These real-world treatment patterns give us insight into how selection of therapies for JIA has evolved with increasing availability of effective agents and help prepare for future studies on comparative DMARD safety and effectiveness,” the authors wrote.
SOURCE:
The study was led by Priyanka Yalamanchili, PharmD, MS, Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Rutgers University, New Brunswick, New Jersey, and was published online October 22, 2024, in Arthritis & Rheumatology.
LIMITATIONS:
The dependence on commercial claims data may have limited the generalizability of the findings to other populations, such as those with public insurance or without insurance. The study did not have access to demographic data of the participants to investigate the presence of disparities in the use of DMARDs. Moreover, the lack of clinical details about the patients with JIA, including disease severity and specialty of prescribers, may have affected the interpretation of the results.
DISCLOSURES:
The study was supported by funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and several other institutes of the National Institutes of Health, as well as the Rheumatology Research Foundation and the Juvenile Diabetes Research Foundation. No conflicts of interest were reported by the authors.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
Managing Age-Related Muscle Loss in Primary Care
Scene 1: Exercise Medicine Clinic, Rio de Janeiro, Brazil I just finished one evaluation on physical fitness and health and looked at my schedule. My next patient would be a 65-year-old man. How fit will he be? Will he have evident age-related muscle loss? I gave myself a short break and my mind went to the late 1970s.
Once upon a time, the practice of medicine was based primarily on the skill of your physical examination, previous experiences, and your ability to reason logically and make solid deductions. In 1979, the stethoscope was part of my dress code. After one elective semester as a research fellow at the Ambrose Cardiorespiratory Unit at McMaster University Medical Centre, in Hamilton, Canada, where I was honored to witness the dawn of evidence-based medicine, I graduated from Federal University of Rio de Janeiro. I still remember being introduced to some promising novelties in cardiology, such as M-mode echocardiograms and myocardial scintigraphy. Radiology was primarily centered on x-rays, and lab testing was basic and poorly automatized.
Over the following decades, medical practice changed dramatically with the incorporation of new technologies. Recent advances in diagnostic tools, genetics, artificial intelligence, and sophisticated statistical analyses, along with well-collected scientific data, have molded how clinicians should think and work.
At the same time, clinical profiles also changed. Internists and primary care physicians are regularly managing patients who are, on average, older and have or are on the way to having potentially life-threatening chronic diseases, accompanied by poor lifestyle habits, and, highly important, often some degree of disability, frailty, and loss of independence. Many of them exhibit age-related muscle loss.
Scene 2: Exercise Medicine Clinic, Rio de Janeiro, Brazil
Conscious of the benefits of interrupting my sitting time with activity, I left my office and walked to meet my patient in the waiting room. I called his name and introduced myself. I watched how he listened and reacted to my speech, and how easy or hard it was for him to rise from the chair — readiness, velocity, and number of supports required: none, one, or two hands. I offered my own hand to him, and when we shook, I gauged the strength of his grip.
I invited him into my office and took note of his somatotype and body composition, and whether he had any central obesity. Of course, and I should by no means miss this chance, I carefully observed how he walked in — his gait, speed, balance, posture — how he pulled up the chair, and how he managed to lower himself into his seat. Before I even sat in my own chair, I asked him if he remembered what his body weight was 5 years ago and what it was today. Before we got started in earnest, I had already managed to collect several pieces of relevant information.
Exercise Physiology: Changing Landscape
Muscle activity depends on muscle mass and function, and peaks somewhere between ages 25 and 35 before declining. The drop is slow in the early stages but accelerates rapidly after age 60 or 65.
Two of the most relevant variables in muscle function are strength and power. As a product of force and velocity, muscle power could be a more crucial factor than strength for many daily activities that demand movement against gravity or inertia, such as placing carry-on baggage in the overhead bin of an airplane or rising from the floor or chair.
The association between muscle mass and muscle strength or power is moderate, and physiologic data have indicated that the decline of muscle power with aging is faster and larger than that of muscle strength.
The term “sarcopenia” has become definitively incorporated into the medical glossary. From the Greek (“sark” and “penia”), sarcopenia was defined as reduced muscle mass, but more recently it has encompassed muscle strength in its definition. However, a recent consensus paper from the Global Leadership Initiative in Sarcopenia, using a Delphi approach, rejected the inclusion of muscle power in the concept of sarcopenia. On the other hand, a long time ago, some authors coined and advocated the use the term “dynapenia” to more precisely reflect the reduced levels of muscle strength and power that often accompany aging.
The best available intervention to counteract age-related deterioration of muscle activity is resistance exercise. The types of resistance exercises vary widely — by number of sets and repetitions, intervals between sets, speed of execution of movement, and percentage of maximal weight/load.
We recently proposed that, after an evaluation to identify the main muscle variable requiring attention, the resistance exercise program should be individually tailored and prescribed according to the objective to counteract sarcopenia or dynapenia.
What is more important for autonomy and better daily living conditions in old and very old individuals: muscle mass, muscle strength, or muscle power? More likely the response is muscle power — in practical terms, dynapenia rather than sarcopenia. This short video presents practical tips for obtaining optimal results in fighting dynapenia. The first choice should be power training or high velocity–based training, emphasizing two to three sets of six to eight repetitions performed as fast as possible (on the concentric or shortening phase of muscle contraction) with relatively high loads.
Internists and primary care physicians are most likely satisfied with the information they obtain by simple observation, and already can superficially grade the magnitude of a patient’s age-related muscle loss and its consequences to daily living.
However, those who want more objective information on nonaerobic physical fitness can add one to three simple tests to their consultation: the sitting-rising test (SRT); the 10-second one-legged test (10sOLS test); and the Flexitest. Poor performance on each of these — and particularly all three — is strongly associated with an increased risk for premature death in middle-aged and older individuals. These tests require no extra equipment and can be performed rapidly, and interpreting the results takes only a few moments using published reference values.
Age-related muscle loss profoundly affects our ability to sit and rise from the floor, so if time is limited, the SRT is the best assessment, as it measures all nonaerobic components of physical fitness. For a quick interpretation, consider that SRT scores vary from 0 to 10, do not substantially differ by sex, and that a composite score equal to or greater than 8 will reflect a minimum age-adjusted percentile of 61, most likely indicating relevant age-related muscle loss is not yet occurring.
Dr. Araújo is Professor and Dean of Research and Education, Exercise Medicine Clinic (CLINIMEX), Rio de Janeiro, Brazil. He reported conflicts of interest with INBRAMED.
A version of this article first appeared on Medscape.com.
Scene 1: Exercise Medicine Clinic, Rio de Janeiro, Brazil I just finished one evaluation on physical fitness and health and looked at my schedule. My next patient would be a 65-year-old man. How fit will he be? Will he have evident age-related muscle loss? I gave myself a short break and my mind went to the late 1970s.
Once upon a time, the practice of medicine was based primarily on the skill of your physical examination, previous experiences, and your ability to reason logically and make solid deductions. In 1979, the stethoscope was part of my dress code. After one elective semester as a research fellow at the Ambrose Cardiorespiratory Unit at McMaster University Medical Centre, in Hamilton, Canada, where I was honored to witness the dawn of evidence-based medicine, I graduated from Federal University of Rio de Janeiro. I still remember being introduced to some promising novelties in cardiology, such as M-mode echocardiograms and myocardial scintigraphy. Radiology was primarily centered on x-rays, and lab testing was basic and poorly automatized.
Over the following decades, medical practice changed dramatically with the incorporation of new technologies. Recent advances in diagnostic tools, genetics, artificial intelligence, and sophisticated statistical analyses, along with well-collected scientific data, have molded how clinicians should think and work.
At the same time, clinical profiles also changed. Internists and primary care physicians are regularly managing patients who are, on average, older and have or are on the way to having potentially life-threatening chronic diseases, accompanied by poor lifestyle habits, and, highly important, often some degree of disability, frailty, and loss of independence. Many of them exhibit age-related muscle loss.
Scene 2: Exercise Medicine Clinic, Rio de Janeiro, Brazil
Conscious of the benefits of interrupting my sitting time with activity, I left my office and walked to meet my patient in the waiting room. I called his name and introduced myself. I watched how he listened and reacted to my speech, and how easy or hard it was for him to rise from the chair — readiness, velocity, and number of supports required: none, one, or two hands. I offered my own hand to him, and when we shook, I gauged the strength of his grip.
I invited him into my office and took note of his somatotype and body composition, and whether he had any central obesity. Of course, and I should by no means miss this chance, I carefully observed how he walked in — his gait, speed, balance, posture — how he pulled up the chair, and how he managed to lower himself into his seat. Before I even sat in my own chair, I asked him if he remembered what his body weight was 5 years ago and what it was today. Before we got started in earnest, I had already managed to collect several pieces of relevant information.
Exercise Physiology: Changing Landscape
Muscle activity depends on muscle mass and function, and peaks somewhere between ages 25 and 35 before declining. The drop is slow in the early stages but accelerates rapidly after age 60 or 65.
Two of the most relevant variables in muscle function are strength and power. As a product of force and velocity, muscle power could be a more crucial factor than strength for many daily activities that demand movement against gravity or inertia, such as placing carry-on baggage in the overhead bin of an airplane or rising from the floor or chair.
The association between muscle mass and muscle strength or power is moderate, and physiologic data have indicated that the decline of muscle power with aging is faster and larger than that of muscle strength.
The term “sarcopenia” has become definitively incorporated into the medical glossary. From the Greek (“sark” and “penia”), sarcopenia was defined as reduced muscle mass, but more recently it has encompassed muscle strength in its definition. However, a recent consensus paper from the Global Leadership Initiative in Sarcopenia, using a Delphi approach, rejected the inclusion of muscle power in the concept of sarcopenia. On the other hand, a long time ago, some authors coined and advocated the use the term “dynapenia” to more precisely reflect the reduced levels of muscle strength and power that often accompany aging.
The best available intervention to counteract age-related deterioration of muscle activity is resistance exercise. The types of resistance exercises vary widely — by number of sets and repetitions, intervals between sets, speed of execution of movement, and percentage of maximal weight/load.
We recently proposed that, after an evaluation to identify the main muscle variable requiring attention, the resistance exercise program should be individually tailored and prescribed according to the objective to counteract sarcopenia or dynapenia.
What is more important for autonomy and better daily living conditions in old and very old individuals: muscle mass, muscle strength, or muscle power? More likely the response is muscle power — in practical terms, dynapenia rather than sarcopenia. This short video presents practical tips for obtaining optimal results in fighting dynapenia. The first choice should be power training or high velocity–based training, emphasizing two to three sets of six to eight repetitions performed as fast as possible (on the concentric or shortening phase of muscle contraction) with relatively high loads.
Internists and primary care physicians are most likely satisfied with the information they obtain by simple observation, and already can superficially grade the magnitude of a patient’s age-related muscle loss and its consequences to daily living.
However, those who want more objective information on nonaerobic physical fitness can add one to three simple tests to their consultation: the sitting-rising test (SRT); the 10-second one-legged test (10sOLS test); and the Flexitest. Poor performance on each of these — and particularly all three — is strongly associated with an increased risk for premature death in middle-aged and older individuals. These tests require no extra equipment and can be performed rapidly, and interpreting the results takes only a few moments using published reference values.
Age-related muscle loss profoundly affects our ability to sit and rise from the floor, so if time is limited, the SRT is the best assessment, as it measures all nonaerobic components of physical fitness. For a quick interpretation, consider that SRT scores vary from 0 to 10, do not substantially differ by sex, and that a composite score equal to or greater than 8 will reflect a minimum age-adjusted percentile of 61, most likely indicating relevant age-related muscle loss is not yet occurring.
Dr. Araújo is Professor and Dean of Research and Education, Exercise Medicine Clinic (CLINIMEX), Rio de Janeiro, Brazil. He reported conflicts of interest with INBRAMED.
A version of this article first appeared on Medscape.com.
Scene 1: Exercise Medicine Clinic, Rio de Janeiro, Brazil I just finished one evaluation on physical fitness and health and looked at my schedule. My next patient would be a 65-year-old man. How fit will he be? Will he have evident age-related muscle loss? I gave myself a short break and my mind went to the late 1970s.
Once upon a time, the practice of medicine was based primarily on the skill of your physical examination, previous experiences, and your ability to reason logically and make solid deductions. In 1979, the stethoscope was part of my dress code. After one elective semester as a research fellow at the Ambrose Cardiorespiratory Unit at McMaster University Medical Centre, in Hamilton, Canada, where I was honored to witness the dawn of evidence-based medicine, I graduated from Federal University of Rio de Janeiro. I still remember being introduced to some promising novelties in cardiology, such as M-mode echocardiograms and myocardial scintigraphy. Radiology was primarily centered on x-rays, and lab testing was basic and poorly automatized.
Over the following decades, medical practice changed dramatically with the incorporation of new technologies. Recent advances in diagnostic tools, genetics, artificial intelligence, and sophisticated statistical analyses, along with well-collected scientific data, have molded how clinicians should think and work.
At the same time, clinical profiles also changed. Internists and primary care physicians are regularly managing patients who are, on average, older and have or are on the way to having potentially life-threatening chronic diseases, accompanied by poor lifestyle habits, and, highly important, often some degree of disability, frailty, and loss of independence. Many of them exhibit age-related muscle loss.
Scene 2: Exercise Medicine Clinic, Rio de Janeiro, Brazil
Conscious of the benefits of interrupting my sitting time with activity, I left my office and walked to meet my patient in the waiting room. I called his name and introduced myself. I watched how he listened and reacted to my speech, and how easy or hard it was for him to rise from the chair — readiness, velocity, and number of supports required: none, one, or two hands. I offered my own hand to him, and when we shook, I gauged the strength of his grip.
I invited him into my office and took note of his somatotype and body composition, and whether he had any central obesity. Of course, and I should by no means miss this chance, I carefully observed how he walked in — his gait, speed, balance, posture — how he pulled up the chair, and how he managed to lower himself into his seat. Before I even sat in my own chair, I asked him if he remembered what his body weight was 5 years ago and what it was today. Before we got started in earnest, I had already managed to collect several pieces of relevant information.
Exercise Physiology: Changing Landscape
Muscle activity depends on muscle mass and function, and peaks somewhere between ages 25 and 35 before declining. The drop is slow in the early stages but accelerates rapidly after age 60 or 65.
Two of the most relevant variables in muscle function are strength and power. As a product of force and velocity, muscle power could be a more crucial factor than strength for many daily activities that demand movement against gravity or inertia, such as placing carry-on baggage in the overhead bin of an airplane or rising from the floor or chair.
The association between muscle mass and muscle strength or power is moderate, and physiologic data have indicated that the decline of muscle power with aging is faster and larger than that of muscle strength.
The term “sarcopenia” has become definitively incorporated into the medical glossary. From the Greek (“sark” and “penia”), sarcopenia was defined as reduced muscle mass, but more recently it has encompassed muscle strength in its definition. However, a recent consensus paper from the Global Leadership Initiative in Sarcopenia, using a Delphi approach, rejected the inclusion of muscle power in the concept of sarcopenia. On the other hand, a long time ago, some authors coined and advocated the use the term “dynapenia” to more precisely reflect the reduced levels of muscle strength and power that often accompany aging.
The best available intervention to counteract age-related deterioration of muscle activity is resistance exercise. The types of resistance exercises vary widely — by number of sets and repetitions, intervals between sets, speed of execution of movement, and percentage of maximal weight/load.
We recently proposed that, after an evaluation to identify the main muscle variable requiring attention, the resistance exercise program should be individually tailored and prescribed according to the objective to counteract sarcopenia or dynapenia.
What is more important for autonomy and better daily living conditions in old and very old individuals: muscle mass, muscle strength, or muscle power? More likely the response is muscle power — in practical terms, dynapenia rather than sarcopenia. This short video presents practical tips for obtaining optimal results in fighting dynapenia. The first choice should be power training or high velocity–based training, emphasizing two to three sets of six to eight repetitions performed as fast as possible (on the concentric or shortening phase of muscle contraction) with relatively high loads.
Internists and primary care physicians are most likely satisfied with the information they obtain by simple observation, and already can superficially grade the magnitude of a patient’s age-related muscle loss and its consequences to daily living.
However, those who want more objective information on nonaerobic physical fitness can add one to three simple tests to their consultation: the sitting-rising test (SRT); the 10-second one-legged test (10sOLS test); and the Flexitest. Poor performance on each of these — and particularly all three — is strongly associated with an increased risk for premature death in middle-aged and older individuals. These tests require no extra equipment and can be performed rapidly, and interpreting the results takes only a few moments using published reference values.
Age-related muscle loss profoundly affects our ability to sit and rise from the floor, so if time is limited, the SRT is the best assessment, as it measures all nonaerobic components of physical fitness. For a quick interpretation, consider that SRT scores vary from 0 to 10, do not substantially differ by sex, and that a composite score equal to or greater than 8 will reflect a minimum age-adjusted percentile of 61, most likely indicating relevant age-related muscle loss is not yet occurring.
Dr. Araújo is Professor and Dean of Research and Education, Exercise Medicine Clinic (CLINIMEX), Rio de Janeiro, Brazil. He reported conflicts of interest with INBRAMED.
A version of this article first appeared on Medscape.com.
Clinical Updates on Osteoarthritis of the Hip
As primary care doctors, we diagnosis and treat many patients with osteoarthritis. In fact, according to World Health Organization statistics, approximately 528 million people around the world suffer from some form of this type of arthritis. With the aging of the population and the obesity epidemic, the rate of osteoarthritis has increased 113% since 1990 and is predicted to continue to rise.
While the knee is the most commonly affected joint, osteoarthritis also frequently affects the hands and hips. The American Academy of Orthopaedic Surgeons issued guidelines concerning the management of osteoarthritis of the hip. The clinical guidelines are aimed at orthopedists, but it is important for primary care doctors be aware of them as well since we are the physicians who usually diagnose the disease, manage it in its early stages, and follow the patients with and after the orthopedist has undertaken any procedures.
While the complete set of guidelines is 80 pages long, strong recommendations have been made that everyone should be aware of. The role of non-steroidal anti-inflammatory drugs has been reconfirmed as a modality to improve pain and function. A recommendation against using intra-articular hyaluronic acid in the hip was made as the evidence shows it did not improve pain or function better than placebo. Conversely, intra-articular corticosteroids were shown to improve pain and function in the short-term and many primary care doctors provide this treatment in their practice.
These guidelines do a great job covering the totality of management of osteoarthritis of the hip, from conservation management to surgical and post-surgical treatments. Patients often come to us with their questions so not only is it important to know the evidence for what we do in our practices, we need to know what our orthopedic colleagues are doing. We will be the ones asked to do the pre-operative evaluations on these patients, so we need to understand the procedure and its risks. We will also manage these patients post-operatively and need to be aware of what the evidence shows.
Opioid use is also covered in the guidelines: they recommend against the use of opioids to control pain in these patients. In the age of the opioid epidemic, it is a good reminder to be cautious with these meds. It is also a good time to stress smoking cessation with patients.
The guidelines discuss adverse outcomes in patients with diabetes and/or obesity. As primary care physicians, we need to be aware of those risks and be sure our patients are medically optimized before signing that pre-operative form.
A new feature of these guidelines is a discussion on social detriments to health. This is important for many diseases that we treat and we often don’t realize the impact they can have on a patient’s health and recovery. Even if we know a patient would benefit from physical therapy, it doesn’t help them if the patient has no way to get to the appointment. Some patients have copays for every physical therapy session and just can’t afford it. Knowing what the patient needs medically is not enough. We need to understand how they can access that care. Some patients have no one to help them after hip surgery and may avoid doing it for that reason. As primary care doctors, we should be helping our patients access the care they need.
We need to be able to say that a procedure needs to be delayed in the face of poorly controlled disease, such as diabetes. As the rates of osteoarthritis continue to rise, we need to understand that it is not an inevitable age-based occurrence in a patient’s life but rather an inflammatory disease that causes great pain and dysfunction. Utilizing these guidelines and working with our orthopedic colleagues can help patients decrease pain, improve functioning, and enjoy life again.
Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She was paid by Pfizer as a consultant on Paxlovid, paid by GlaxoSmithKline as a consultant for the Shingrix vaccine, and is the editor in chief of Physician’s Weekly.
As primary care doctors, we diagnosis and treat many patients with osteoarthritis. In fact, according to World Health Organization statistics, approximately 528 million people around the world suffer from some form of this type of arthritis. With the aging of the population and the obesity epidemic, the rate of osteoarthritis has increased 113% since 1990 and is predicted to continue to rise.
While the knee is the most commonly affected joint, osteoarthritis also frequently affects the hands and hips. The American Academy of Orthopaedic Surgeons issued guidelines concerning the management of osteoarthritis of the hip. The clinical guidelines are aimed at orthopedists, but it is important for primary care doctors be aware of them as well since we are the physicians who usually diagnose the disease, manage it in its early stages, and follow the patients with and after the orthopedist has undertaken any procedures.
While the complete set of guidelines is 80 pages long, strong recommendations have been made that everyone should be aware of. The role of non-steroidal anti-inflammatory drugs has been reconfirmed as a modality to improve pain and function. A recommendation against using intra-articular hyaluronic acid in the hip was made as the evidence shows it did not improve pain or function better than placebo. Conversely, intra-articular corticosteroids were shown to improve pain and function in the short-term and many primary care doctors provide this treatment in their practice.
These guidelines do a great job covering the totality of management of osteoarthritis of the hip, from conservation management to surgical and post-surgical treatments. Patients often come to us with their questions so not only is it important to know the evidence for what we do in our practices, we need to know what our orthopedic colleagues are doing. We will be the ones asked to do the pre-operative evaluations on these patients, so we need to understand the procedure and its risks. We will also manage these patients post-operatively and need to be aware of what the evidence shows.
Opioid use is also covered in the guidelines: they recommend against the use of opioids to control pain in these patients. In the age of the opioid epidemic, it is a good reminder to be cautious with these meds. It is also a good time to stress smoking cessation with patients.
The guidelines discuss adverse outcomes in patients with diabetes and/or obesity. As primary care physicians, we need to be aware of those risks and be sure our patients are medically optimized before signing that pre-operative form.
A new feature of these guidelines is a discussion on social detriments to health. This is important for many diseases that we treat and we often don’t realize the impact they can have on a patient’s health and recovery. Even if we know a patient would benefit from physical therapy, it doesn’t help them if the patient has no way to get to the appointment. Some patients have copays for every physical therapy session and just can’t afford it. Knowing what the patient needs medically is not enough. We need to understand how they can access that care. Some patients have no one to help them after hip surgery and may avoid doing it for that reason. As primary care doctors, we should be helping our patients access the care they need.
We need to be able to say that a procedure needs to be delayed in the face of poorly controlled disease, such as diabetes. As the rates of osteoarthritis continue to rise, we need to understand that it is not an inevitable age-based occurrence in a patient’s life but rather an inflammatory disease that causes great pain and dysfunction. Utilizing these guidelines and working with our orthopedic colleagues can help patients decrease pain, improve functioning, and enjoy life again.
Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She was paid by Pfizer as a consultant on Paxlovid, paid by GlaxoSmithKline as a consultant for the Shingrix vaccine, and is the editor in chief of Physician’s Weekly.
As primary care doctors, we diagnosis and treat many patients with osteoarthritis. In fact, according to World Health Organization statistics, approximately 528 million people around the world suffer from some form of this type of arthritis. With the aging of the population and the obesity epidemic, the rate of osteoarthritis has increased 113% since 1990 and is predicted to continue to rise.
While the knee is the most commonly affected joint, osteoarthritis also frequently affects the hands and hips. The American Academy of Orthopaedic Surgeons issued guidelines concerning the management of osteoarthritis of the hip. The clinical guidelines are aimed at orthopedists, but it is important for primary care doctors be aware of them as well since we are the physicians who usually diagnose the disease, manage it in its early stages, and follow the patients with and after the orthopedist has undertaken any procedures.
While the complete set of guidelines is 80 pages long, strong recommendations have been made that everyone should be aware of. The role of non-steroidal anti-inflammatory drugs has been reconfirmed as a modality to improve pain and function. A recommendation against using intra-articular hyaluronic acid in the hip was made as the evidence shows it did not improve pain or function better than placebo. Conversely, intra-articular corticosteroids were shown to improve pain and function in the short-term and many primary care doctors provide this treatment in their practice.
These guidelines do a great job covering the totality of management of osteoarthritis of the hip, from conservation management to surgical and post-surgical treatments. Patients often come to us with their questions so not only is it important to know the evidence for what we do in our practices, we need to know what our orthopedic colleagues are doing. We will be the ones asked to do the pre-operative evaluations on these patients, so we need to understand the procedure and its risks. We will also manage these patients post-operatively and need to be aware of what the evidence shows.
Opioid use is also covered in the guidelines: they recommend against the use of opioids to control pain in these patients. In the age of the opioid epidemic, it is a good reminder to be cautious with these meds. It is also a good time to stress smoking cessation with patients.
The guidelines discuss adverse outcomes in patients with diabetes and/or obesity. As primary care physicians, we need to be aware of those risks and be sure our patients are medically optimized before signing that pre-operative form.
A new feature of these guidelines is a discussion on social detriments to health. This is important for many diseases that we treat and we often don’t realize the impact they can have on a patient’s health and recovery. Even if we know a patient would benefit from physical therapy, it doesn’t help them if the patient has no way to get to the appointment. Some patients have copays for every physical therapy session and just can’t afford it. Knowing what the patient needs medically is not enough. We need to understand how they can access that care. Some patients have no one to help them after hip surgery and may avoid doing it for that reason. As primary care doctors, we should be helping our patients access the care they need.
We need to be able to say that a procedure needs to be delayed in the face of poorly controlled disease, such as diabetes. As the rates of osteoarthritis continue to rise, we need to understand that it is not an inevitable age-based occurrence in a patient’s life but rather an inflammatory disease that causes great pain and dysfunction. Utilizing these guidelines and working with our orthopedic colleagues can help patients decrease pain, improve functioning, and enjoy life again.
Dr. Girgis practices family medicine in South River, New Jersey, and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, New Jersey. She was paid by Pfizer as a consultant on Paxlovid, paid by GlaxoSmithKline as a consultant for the Shingrix vaccine, and is the editor in chief of Physician’s Weekly.
Risk Assessment Tool Can Help Predict Fractures in Cancer
TOPLINE:
METHODOLOGY:
- Cancer-specific guidelines recommend using FRAX to assess fracture risk, but its applicability in patients with cancer remains unclear.
- This retrospective cohort study included 9877 patients with cancer (mean age, 67.1 years) and 45,875 matched control individuals without cancer (mean age, 66.2 years). All participants had dual-energy x-ray absorptiometry (DXA) scans.
- Researchers collected data on bone mineral density and fractures. The 10-year probabilities of major osteoporotic fractures and hip fractures were calculated using FRAX, and the observed 10-year probabilities of these fractures were compared with FRAX-derived probabilities.
- Compared with individuals without cancer, patients with cancer had a shorter mean follow-up duration (8.5 vs 7.6 years), a slightly higher mean body mass index, and a higher percentage of parental hip fractures (7.0% vs 8.2%); additionally, patients with cancer were more likely to have secondary causes of osteoporosis (10% vs 38.4%) and less likely to receive osteoporosis medication (9.9% vs 4.2%).
TAKEAWAY:
- Compared with individuals without cancer, patients with cancer had a significantly higher incidence rate of major fractures (12.9 vs 14.5 per 1000 person-years) and hip fractures (3.5 vs 4.2 per 1000 person-years).
- FRAX with bone mineral density exhibited excellent calibration for predicting major osteoporotic fractures (slope, 1.03) and hip fractures (0.97) in patients with cancer, regardless of the site of cancer diagnosis. FRAX without bone mineral density, however, underestimated the risk for both major (0.87) and hip fractures (0.72).
- In patients with cancer, FRAX with bone mineral density findings were associated with incident major osteoporotic fractures (hazard ratio [HR] per SD, 1.84) and hip fractures (HR per SD, 3.61).
- When models were adjusted for FRAX with bone mineral density, patients with cancer had an increased risk for both major osteoporotic fractures (HR, 1.17) and hip fractures (HR, 1.30). No difference was found in the risk for fracture between patients with and individuals without cancer when the models were adjusted for FRAX without bone mineral density, even when considering osteoporosis medication use.
IN PRACTICE:
“This retrospective cohort study demonstrates that individuals with cancer are at higher risk of fracture than individuals without cancer and that FRAX, particularly with BMD [bone mineral density], may accurately predict fracture risk in this population. These results, along with the known mortality risk of osteoporotic fractures among cancer survivors, further emphasize the clinical importance of closing the current osteoporosis care gap among cancer survivors,” the authors wrote.
SOURCE:
This study, led by Carrie Ye, MD, MPH, University of Alberta, Edmonton, Alberta, Canada, was published online in JAMA Oncology.
LIMITATIONS:
This study cohort included a selected group of cancer survivors who were referred for DXA scans and may not represent the general cancer population. The cohort consisted predominantly of women, limiting the generalizability to men with cancer. Given the heterogeneity of the population, the findings may not be applicable to all cancer subgroups. Information on cancer stage or the presence of bone metastases at the time of fracture risk assessment was lacking, which could have affected the findings.
DISCLOSURES:
This study was funded by the CancerCare Manitoba Foundation. Three authors reported having ties with various sources, including two who received grants from various organizations.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Cancer-specific guidelines recommend using FRAX to assess fracture risk, but its applicability in patients with cancer remains unclear.
- This retrospective cohort study included 9877 patients with cancer (mean age, 67.1 years) and 45,875 matched control individuals without cancer (mean age, 66.2 years). All participants had dual-energy x-ray absorptiometry (DXA) scans.
- Researchers collected data on bone mineral density and fractures. The 10-year probabilities of major osteoporotic fractures and hip fractures were calculated using FRAX, and the observed 10-year probabilities of these fractures were compared with FRAX-derived probabilities.
- Compared with individuals without cancer, patients with cancer had a shorter mean follow-up duration (8.5 vs 7.6 years), a slightly higher mean body mass index, and a higher percentage of parental hip fractures (7.0% vs 8.2%); additionally, patients with cancer were more likely to have secondary causes of osteoporosis (10% vs 38.4%) and less likely to receive osteoporosis medication (9.9% vs 4.2%).
TAKEAWAY:
- Compared with individuals without cancer, patients with cancer had a significantly higher incidence rate of major fractures (12.9 vs 14.5 per 1000 person-years) and hip fractures (3.5 vs 4.2 per 1000 person-years).
- FRAX with bone mineral density exhibited excellent calibration for predicting major osteoporotic fractures (slope, 1.03) and hip fractures (0.97) in patients with cancer, regardless of the site of cancer diagnosis. FRAX without bone mineral density, however, underestimated the risk for both major (0.87) and hip fractures (0.72).
- In patients with cancer, FRAX with bone mineral density findings were associated with incident major osteoporotic fractures (hazard ratio [HR] per SD, 1.84) and hip fractures (HR per SD, 3.61).
- When models were adjusted for FRAX with bone mineral density, patients with cancer had an increased risk for both major osteoporotic fractures (HR, 1.17) and hip fractures (HR, 1.30). No difference was found in the risk for fracture between patients with and individuals without cancer when the models were adjusted for FRAX without bone mineral density, even when considering osteoporosis medication use.
IN PRACTICE:
“This retrospective cohort study demonstrates that individuals with cancer are at higher risk of fracture than individuals without cancer and that FRAX, particularly with BMD [bone mineral density], may accurately predict fracture risk in this population. These results, along with the known mortality risk of osteoporotic fractures among cancer survivors, further emphasize the clinical importance of closing the current osteoporosis care gap among cancer survivors,” the authors wrote.
SOURCE:
This study, led by Carrie Ye, MD, MPH, University of Alberta, Edmonton, Alberta, Canada, was published online in JAMA Oncology.
LIMITATIONS:
This study cohort included a selected group of cancer survivors who were referred for DXA scans and may not represent the general cancer population. The cohort consisted predominantly of women, limiting the generalizability to men with cancer. Given the heterogeneity of the population, the findings may not be applicable to all cancer subgroups. Information on cancer stage or the presence of bone metastases at the time of fracture risk assessment was lacking, which could have affected the findings.
DISCLOSURES:
This study was funded by the CancerCare Manitoba Foundation. Three authors reported having ties with various sources, including two who received grants from various organizations.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Cancer-specific guidelines recommend using FRAX to assess fracture risk, but its applicability in patients with cancer remains unclear.
- This retrospective cohort study included 9877 patients with cancer (mean age, 67.1 years) and 45,875 matched control individuals without cancer (mean age, 66.2 years). All participants had dual-energy x-ray absorptiometry (DXA) scans.
- Researchers collected data on bone mineral density and fractures. The 10-year probabilities of major osteoporotic fractures and hip fractures were calculated using FRAX, and the observed 10-year probabilities of these fractures were compared with FRAX-derived probabilities.
- Compared with individuals without cancer, patients with cancer had a shorter mean follow-up duration (8.5 vs 7.6 years), a slightly higher mean body mass index, and a higher percentage of parental hip fractures (7.0% vs 8.2%); additionally, patients with cancer were more likely to have secondary causes of osteoporosis (10% vs 38.4%) and less likely to receive osteoporosis medication (9.9% vs 4.2%).
TAKEAWAY:
- Compared with individuals without cancer, patients with cancer had a significantly higher incidence rate of major fractures (12.9 vs 14.5 per 1000 person-years) and hip fractures (3.5 vs 4.2 per 1000 person-years).
- FRAX with bone mineral density exhibited excellent calibration for predicting major osteoporotic fractures (slope, 1.03) and hip fractures (0.97) in patients with cancer, regardless of the site of cancer diagnosis. FRAX without bone mineral density, however, underestimated the risk for both major (0.87) and hip fractures (0.72).
- In patients with cancer, FRAX with bone mineral density findings were associated with incident major osteoporotic fractures (hazard ratio [HR] per SD, 1.84) and hip fractures (HR per SD, 3.61).
- When models were adjusted for FRAX with bone mineral density, patients with cancer had an increased risk for both major osteoporotic fractures (HR, 1.17) and hip fractures (HR, 1.30). No difference was found in the risk for fracture between patients with and individuals without cancer when the models were adjusted for FRAX without bone mineral density, even when considering osteoporosis medication use.
IN PRACTICE:
“This retrospective cohort study demonstrates that individuals with cancer are at higher risk of fracture than individuals without cancer and that FRAX, particularly with BMD [bone mineral density], may accurately predict fracture risk in this population. These results, along with the known mortality risk of osteoporotic fractures among cancer survivors, further emphasize the clinical importance of closing the current osteoporosis care gap among cancer survivors,” the authors wrote.
SOURCE:
This study, led by Carrie Ye, MD, MPH, University of Alberta, Edmonton, Alberta, Canada, was published online in JAMA Oncology.
LIMITATIONS:
This study cohort included a selected group of cancer survivors who were referred for DXA scans and may not represent the general cancer population. The cohort consisted predominantly of women, limiting the generalizability to men with cancer. Given the heterogeneity of the population, the findings may not be applicable to all cancer subgroups. Information on cancer stage or the presence of bone metastases at the time of fracture risk assessment was lacking, which could have affected the findings.
DISCLOSURES:
This study was funded by the CancerCare Manitoba Foundation. Three authors reported having ties with various sources, including two who received grants from various organizations.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
Physician Empathy Mitigates Patients’ Chronic Pain
Physicians who treat patients are potentially exposed to two opposing psychological processes: A positive feeling related to the experience of helping someone in need and, on the other hand, the adverse experience of seeing someone’s suffering and being frustrated about their inability to help. The ability to share the feelings of others is often referred to as empathy, while the ability to care for and show interest in others is the key aspect of compassion. Empathy makes it possible to share the positive and negative feelings of others in the same way: We can therefore feel happy when we indirectly share others’ joy and sad when we indirectly share others’ suffering.
Empathy in healthcare professionals is associated with patient satisfaction, diagnostic accuracy, adherence to treatment recommendations, clinical outcomes, clinical expertise, and physician retention. However, evidence indicates a tendency for empathy to decline during physicians’ training and specialization.
Estimating Empathy
Empathy studies are primarily based on observational data that include physician self-assessment or patient-perceived empathy. External evaluation of empathy by the recipient or observer is not the dominant approach, and a systematic review of the topic showed that, in 331 of the 470 studies examined (70.4%), individuals self-reported their level of empathy. The self-assessment system, particularly for doctors, is more likely to measure the doctor’s attitudes about empathy than empathy itself. The lack of correlation between physician and patient empathy assessments made it clear that patients cannot be disregarded when assessing physician empathy.
Consultation and Relational Empathy (CARE) is the primary assessment tool available to patients to measure physician empathy. It is a reliable and consistent system, particularly in primary care scenarios.
The CARE measure captures even small nuances of patient interactions with the physician and has been confirmed as a valuable tool in assessing the relational components of empathy.
Doctor-Patient Relationship
Communication with the physician is generally considered an important element of chronic pain care because it affects patient engagement and decision-making. A collaborative approach involving the patient and clinician in clinical decisions was associated with adherence to pain treatment and improved outcomes among patients with chronic lower back pain. The study conducted in a primary care setting of 1352 participants showed findings regarding physician empathy that did not necessarily involve a therapeutic alliance with the patient based on collaborative communication or expectation of a therapeutic effect of pharmacotherapy. Physician empathy remained the strongest factor associated with patient satisfaction, even after considering various potential confounders, including communication with the physician. In addition, ongoing empathy, especially when reported by patients with a long-term relationship with the physician, supported the hypothesis of a possible lasting effect on patient satisfaction.
Treating Chronic Pain
Empathy is an aspect of the doctor-patient relationship that may be particularly important in patients with chronic pain. A cohort study of 1470 patients with chronic low back pain analyzed whether and how it correlated with chronic pain outcomes. Patients reported their physician’s empathy at the time of enrollment using the CARE measure, which included 10 items on physician’s empathy characteristics during meetings. Physicians whose scores were 30 or higher (ie, rated as good, very good, or excellent in most items) were classified as very empathetic physicians (VEPs), while those whose scores were 29 or lower (ie, rated as poor or passable in most items) were classified as slightly empathetic physicians (SEPs).
Pain intensity was measured with a numerical rating scale (0-10) for the typical pain level within 7 days before each encounter. The long-term stability of CARE scores was assessed in patients who maintained the same physician for more than 24 months. The study showed the following results:
- The CARE score was inversely associated with pain intensity (P < .001).
- Pain intensity was lower in patients in the VEP group than those in the SEP group (6.3 vs 6.7; P < .001).
- The likelihood of having a more empathetic physician generally increased with the decrease in the cut point of the CARE score for greater or less empathy of the physician.
- The extent of the physician’s empathy effects exceeded that reported for nonpharmacological treatments, current opioid use, and lumbar spine surgery.
- The effects of the interaction of empathy with time tended to favor the VEP group with regard to pain but were not statistically significant.
Empathy is an essential aspect of the patient-physician relationship (particularly in delivering care), and these findings demonstrate its relevance in pain therapy. Empathy has high therapeutic value, compared with many pain treatments that are often recommended in clinical practice.
This story was translated from Univadis Italy, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
Physicians who treat patients are potentially exposed to two opposing psychological processes: A positive feeling related to the experience of helping someone in need and, on the other hand, the adverse experience of seeing someone’s suffering and being frustrated about their inability to help. The ability to share the feelings of others is often referred to as empathy, while the ability to care for and show interest in others is the key aspect of compassion. Empathy makes it possible to share the positive and negative feelings of others in the same way: We can therefore feel happy when we indirectly share others’ joy and sad when we indirectly share others’ suffering.
Empathy in healthcare professionals is associated with patient satisfaction, diagnostic accuracy, adherence to treatment recommendations, clinical outcomes, clinical expertise, and physician retention. However, evidence indicates a tendency for empathy to decline during physicians’ training and specialization.
Estimating Empathy
Empathy studies are primarily based on observational data that include physician self-assessment or patient-perceived empathy. External evaluation of empathy by the recipient or observer is not the dominant approach, and a systematic review of the topic showed that, in 331 of the 470 studies examined (70.4%), individuals self-reported their level of empathy. The self-assessment system, particularly for doctors, is more likely to measure the doctor’s attitudes about empathy than empathy itself. The lack of correlation between physician and patient empathy assessments made it clear that patients cannot be disregarded when assessing physician empathy.
Consultation and Relational Empathy (CARE) is the primary assessment tool available to patients to measure physician empathy. It is a reliable and consistent system, particularly in primary care scenarios.
The CARE measure captures even small nuances of patient interactions with the physician and has been confirmed as a valuable tool in assessing the relational components of empathy.
Doctor-Patient Relationship
Communication with the physician is generally considered an important element of chronic pain care because it affects patient engagement and decision-making. A collaborative approach involving the patient and clinician in clinical decisions was associated with adherence to pain treatment and improved outcomes among patients with chronic lower back pain. The study conducted in a primary care setting of 1352 participants showed findings regarding physician empathy that did not necessarily involve a therapeutic alliance with the patient based on collaborative communication or expectation of a therapeutic effect of pharmacotherapy. Physician empathy remained the strongest factor associated with patient satisfaction, even after considering various potential confounders, including communication with the physician. In addition, ongoing empathy, especially when reported by patients with a long-term relationship with the physician, supported the hypothesis of a possible lasting effect on patient satisfaction.
Treating Chronic Pain
Empathy is an aspect of the doctor-patient relationship that may be particularly important in patients with chronic pain. A cohort study of 1470 patients with chronic low back pain analyzed whether and how it correlated with chronic pain outcomes. Patients reported their physician’s empathy at the time of enrollment using the CARE measure, which included 10 items on physician’s empathy characteristics during meetings. Physicians whose scores were 30 or higher (ie, rated as good, very good, or excellent in most items) were classified as very empathetic physicians (VEPs), while those whose scores were 29 or lower (ie, rated as poor or passable in most items) were classified as slightly empathetic physicians (SEPs).
Pain intensity was measured with a numerical rating scale (0-10) for the typical pain level within 7 days before each encounter. The long-term stability of CARE scores was assessed in patients who maintained the same physician for more than 24 months. The study showed the following results:
- The CARE score was inversely associated with pain intensity (P < .001).
- Pain intensity was lower in patients in the VEP group than those in the SEP group (6.3 vs 6.7; P < .001).
- The likelihood of having a more empathetic physician generally increased with the decrease in the cut point of the CARE score for greater or less empathy of the physician.
- The extent of the physician’s empathy effects exceeded that reported for nonpharmacological treatments, current opioid use, and lumbar spine surgery.
- The effects of the interaction of empathy with time tended to favor the VEP group with regard to pain but were not statistically significant.
Empathy is an essential aspect of the patient-physician relationship (particularly in delivering care), and these findings demonstrate its relevance in pain therapy. Empathy has high therapeutic value, compared with many pain treatments that are often recommended in clinical practice.
This story was translated from Univadis Italy, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.
Physicians who treat patients are potentially exposed to two opposing psychological processes: A positive feeling related to the experience of helping someone in need and, on the other hand, the adverse experience of seeing someone’s suffering and being frustrated about their inability to help. The ability to share the feelings of others is often referred to as empathy, while the ability to care for and show interest in others is the key aspect of compassion. Empathy makes it possible to share the positive and negative feelings of others in the same way: We can therefore feel happy when we indirectly share others’ joy and sad when we indirectly share others’ suffering.
Empathy in healthcare professionals is associated with patient satisfaction, diagnostic accuracy, adherence to treatment recommendations, clinical outcomes, clinical expertise, and physician retention. However, evidence indicates a tendency for empathy to decline during physicians’ training and specialization.
Estimating Empathy
Empathy studies are primarily based on observational data that include physician self-assessment or patient-perceived empathy. External evaluation of empathy by the recipient or observer is not the dominant approach, and a systematic review of the topic showed that, in 331 of the 470 studies examined (70.4%), individuals self-reported their level of empathy. The self-assessment system, particularly for doctors, is more likely to measure the doctor’s attitudes about empathy than empathy itself. The lack of correlation between physician and patient empathy assessments made it clear that patients cannot be disregarded when assessing physician empathy.
Consultation and Relational Empathy (CARE) is the primary assessment tool available to patients to measure physician empathy. It is a reliable and consistent system, particularly in primary care scenarios.
The CARE measure captures even small nuances of patient interactions with the physician and has been confirmed as a valuable tool in assessing the relational components of empathy.
Doctor-Patient Relationship
Communication with the physician is generally considered an important element of chronic pain care because it affects patient engagement and decision-making. A collaborative approach involving the patient and clinician in clinical decisions was associated with adherence to pain treatment and improved outcomes among patients with chronic lower back pain. The study conducted in a primary care setting of 1352 participants showed findings regarding physician empathy that did not necessarily involve a therapeutic alliance with the patient based on collaborative communication or expectation of a therapeutic effect of pharmacotherapy. Physician empathy remained the strongest factor associated with patient satisfaction, even after considering various potential confounders, including communication with the physician. In addition, ongoing empathy, especially when reported by patients with a long-term relationship with the physician, supported the hypothesis of a possible lasting effect on patient satisfaction.
Treating Chronic Pain
Empathy is an aspect of the doctor-patient relationship that may be particularly important in patients with chronic pain. A cohort study of 1470 patients with chronic low back pain analyzed whether and how it correlated with chronic pain outcomes. Patients reported their physician’s empathy at the time of enrollment using the CARE measure, which included 10 items on physician’s empathy characteristics during meetings. Physicians whose scores were 30 or higher (ie, rated as good, very good, or excellent in most items) were classified as very empathetic physicians (VEPs), while those whose scores were 29 or lower (ie, rated as poor or passable in most items) were classified as slightly empathetic physicians (SEPs).
Pain intensity was measured with a numerical rating scale (0-10) for the typical pain level within 7 days before each encounter. The long-term stability of CARE scores was assessed in patients who maintained the same physician for more than 24 months. The study showed the following results:
- The CARE score was inversely associated with pain intensity (P < .001).
- Pain intensity was lower in patients in the VEP group than those in the SEP group (6.3 vs 6.7; P < .001).
- The likelihood of having a more empathetic physician generally increased with the decrease in the cut point of the CARE score for greater or less empathy of the physician.
- The extent of the physician’s empathy effects exceeded that reported for nonpharmacological treatments, current opioid use, and lumbar spine surgery.
- The effects of the interaction of empathy with time tended to favor the VEP group with regard to pain but were not statistically significant.
Empathy is an essential aspect of the patient-physician relationship (particularly in delivering care), and these findings demonstrate its relevance in pain therapy. Empathy has high therapeutic value, compared with many pain treatments that are often recommended in clinical practice.
This story was translated from Univadis Italy, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.