Dr. Nicholas Cappello

Most Americans and Canadians, the report states, are getting enough vitamin D and calcium, although older men and women may fall short.

Vitamin D, Calcium & You

— Tetra Images/Getty Images

The new recommended dietary allowances (RDA).

Vitamin D

Adults up to age 70 need 600 IU (international units) daily, up from 400 IU in 1997.

Men and women 71 and older need 800 IU, up from 600 IU.

Calcium

Men need 1,000 mg daily until age 71, down from 1,200 mg in 1997.

Women, beginning at age 51, and both men and women over age 71, need 1,200 mg of calcium a day, the same as in 1997.

I came across a good tip from NPR..Low back pain is second only to cold
symptoms when it comes to complaints that send people to the doctor. Sooner or
later, back pain seems to get most of us.A Comparison of Massage Therapy and
Usual Medical Care for Chronic Low Back PainNow,
a study in the July 5 issue
of the Annals of Internal Medicine shows that massage is an effective treatment for lower back pain. In some cases, researchers report, the benefits of massage lasted for six months or longer.Researchers headed by epidemiologist
Daniel Cherkin, a senior investigator at Group Health Research Institute in Seattle, enrolled 401
people with chronic low back pain and no identifiable reason for the pain.
In relaxation massage, often referred
to as Swedish massage, a variety of maneuvers are used to promote a feeling of
relaxation throughout the body and muscles. Structural massage, commonly
referred to as deep tissue massage, targets specific pain related tissues,
ligaments and joints.”We found that both types of
massage were equally effective in helping people improve their function and
diminish their symptoms,” Cherkin says. He says massage relieved the pain
for six months or more.

No one knows exactly how massage works
to relieve pain, says Dr. Richard Deyo of Oregon Health
Sciences University,
who also took part in the study.”It may be that it helps with
relaxation of muscles that are tense,” Deyo says. “But it may also be
there are simply more generalized effects of relaxation — in the caring and
attention and someone laying hands on — that may all be important.”

For joint replacement surgery, busy hospitals are better. A study published on June 7 in Arthritis and Rheumatism, a peer-reviewed journal of the American College of Rheumatology, found that patients who undergo elective total hip or knee arthroplasty at hospitals with lower surgical volumes had a higher risk of venous thromboembolism and one-year mortality following the procedure.

The authors theorize that the causes of complications at low-volume hospitals could be connected to hospital procedures and peri- and post-operative care processes. One example cited by the authors is the different types and levels of medication prescribed by physicians to prevent blood clots following elective joint replacement surgery. The authors also suggest that the outcome of surgery may well be affected by how much time elapses between initiation of clot prevention therapy and its cessation. Dr. Singh Jasvinder, M.D., M.P.H. of the University of Alabama, lead author of the study, concluded, “Further studies are needed to investigate whether the underlying reasons for poor surgical outcomes at low-volume hospitals are modifiable and which interventions may reduce complications for patients at these facilities.”

Researchers used the Pennsylvania Health Care Cost Containment Council database to identify the number of patients who underwent total hip replacement (n=10,187) and total knee replacement (n=19,418) surgery in 2002 in the state. The mean age of patients in both groups was 69 years, and men comprised 43% of the total hip replacement cohort and 35% of the total knee replacement group. Hospital volume was categorized by less than 25 surgeries, per year, for low-volume hospitals and 200 or more surgeries per year for high volume hospitals.

rthopedic surgeons in the United Kingdom are treating some of their younger patients who suffer from osteoarthritis with a new procedure that involves cementing metal to the damaged parts of the knee. This approach allows the younger patient to receive a partial knee replacement surgery but with fewer or none of the usual negative side effects associated with a more traditional joint replacement.

Osteoarthritis affects 8.5 million people in the United Kingdom and each year the National Health Service carries out more than 70,000 knee-replacement procedures. (Osteoarthritis of the knee develops when the cartilage that coats the bone wears away, either because of wear and tear, injury or genetic predisposition—leading to the bones grinding against one another and deteriorating.)

The particular surgical technique targets only the areas of the knee that have been damaged by the effects of osteoarthritis and, according to the surgeons who’ve written about this surgical technique, provides patients with greater post-operative mobility as compared to more traditional and invasive joint replacement surgery.

The new procedure requires the surgeon to clearly identify and map out which areas of the knee cartilage have become worn down due to osteoarthritis. Then, under general anesthetic or an epidural, the surgeon makes a small (3.5 inch wide) incision on the inside of the knee.

After filing down the rough sections of the knee the surgeon cements a thin shell of cobalt chrome to cover the affected part of the knee. To keep the metal surface from grinding against the bone or other sections of metal, a small plastic bearing is attached to the top of the tibia to replicate the role of the cartilage in the natural knee. Over time, bone tissue grows around the implanted surfaces to make them an integral part of the joint.

“We have patients who do very strenuous activities that they would not be able to do with a full knee replacement,” says David Barrett, professor of orthopedic engineering at Southampton University, who has been performing the operation since October. He says that with this procedure more of the original joint is conserved, none of the ligaments around or inside the knee are disturbed and the plastic insert can be renewed. Additionally, further compartments or areas of the knee can be resurfaced if the arthritis begins to affect other parts of the joint. Barrett has found that patients can get up and walk the same day and usually can go home after a few days.

Some 70%-80% of men (and nearly as many women) have endured a bout of moderate to severe back pain. And the problem goes well beyond pain and inconvenience; the annual cost of medical care and lost productivity is more than $50 billion. It would be encouraging to report that this investment of time and money results in recovery, but in most cases back pain will resolve as quickly without medical attention as it will with a doctor’s care, according to Harvard Men’s Health Watch.

If you have garden-variety back pain, you can probably take care of it yourself. The trick is to know what to do and to recognize those symptoms that really do call for prompt medical tests and treatments..

In the vast majority of cases, back pain is caused by a mechanical problem that can’t be pinpointed exactly. But occasional cases result from some other, more serious causes. The possibilities include infections, vascular disease, and tumors, among other things. That’s why it’s important to know the “red flag” warning signs that suggest serious problems. Among these are recent major injury, radiation of pain down a leg, pain that is constant, pain in the upper back or chest, unexplained fever or weight loss, and pain that increases at night.

About 90% of people with ordinary mechanical low back pain get over it without special therapy. But it takes time to recover. About 30% of patients are substantially improved in just a week, but another 60% take up to eight weeks to get better.

Knee patients need patience: injuries to these joints take weeks to heal. Fraunhofer researchers have now developed a system that documents the healing process in detail. This motivates patients and at the same time helps doctors to fine-tune the course of treatment.

There’s nothing like the sheer delight of sun and snow on a skiing trip. But a momentary lapse of concentration can have nasty consequences. Taking a tumble on the slopes often causes injuries most commonly to the knee. Weeks can go by before knees regain their full function, and patients are obliged to re-learn how to walk. The time it takes for the knee to heal is directly related to how well it reacts to the chosen treatment. But how is an orthopedic doctor to evaluate the healing process? And how are patients to know what progress they are making? Currently, doctors can only perform limited function tests, whilst patients are obliged to rely on their own subjective feelings. Now researchers from the Fraunhofer Institute for Manufacturing Engineering and Automation IPA in Stuttgart have developed a system for gathering exact data on knee mobility. It shows patients as well as medical staff how the joint is doing. “It not only lets sufferers see how their healing process is coming along; it also means doctors can tell straight away whether they need to adapt the treatment,” says Dipl.-Ing. Bernhard Kleiner of Fraunhofer IPA. “This can give patients a psychological boost.” They might not feel they are getting any better, but the system highlights every little improvement in knee mobility. “And that’s very motivating,” says Kleiner.

This is how the novel approach for monitoring the treatment works: Special sensors are placed in a kind of bracket that is integrated into the bandage. These register the knee’s range of movement over a period of time to determine exactly how patients are moving their knee. A new piece of software evaluates these data and presents them in an easy-to-understand format. It sounds pretty simple but it was a tough challenge for the engineers, because such angular measurement systems have only ever been used in industry up to now. The central question was how to place the sensors onto the human body without inconveniencing the patient. The answer, researchers found, lay in using lightweight materials and miniaturizing the sensors, which fall into two categories: angular measurement systems that are based on magnetic principles; and acceleration and rate-of-rotation sensors.

Depending on the injury and treatment, the system not only records the joint’s range of movement but can also determine to what degree it rotates and what forces are acting upon it. The sensors observe movements and store data non-stop. This allows doctors to observe how the knee’s range of movement changes over time, so they can recognize trends and, where necessary, adjust the treatment. What is more, the various fittings for the sensor systems have been designed by the researchers not to restrict freedom of movement in any way, meaning patients do not even notice that their joint is being monitored.

“We would like to apply the measurement of human kinematics to other parts of the body in future,” says Kleiner, and the Fraunhofer researchers have already set their sights on the shoulder and the hips. However, these joints are even more demanding because the system will have to measure their movement about all three axes. To achieve this, engineers are coupling 3-D sensor systems with appropriate software. Visitors to the MEDTEC Europe trade show (March 22-24, 2011, Hall 6, Booth 6211) will have a chance to see the experts demonstrating how mobile joint monitoring works.

The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors approved and released a clinical practice guideline for treating rotator cuff tears. The rotator cuff is a group of muscles and their associated tendons which holds the humerus (upper arm bone) stable in the shoulder joint, allowing the arm to rotate and elevate. Rotator cuff tears are a common cause of pain and disability among adults, occurring often as a consequence of aging, because of tendon degeneration. Tears can also occur following injury from sports or acute trauma.

Clinical practice guidelines, based on the highest quality evidence-based research available, are an educational and learning tool for Academy members, can assist orthopaedic surgeons and patients in potential treatment recommendations, and also serve to improve the design of future clinical studies. In this case, an arduous review of the literature up through 2008 identified 74 studies to be included in the guideline. Robert Pedowitz, MD, chair, and Ken Yamaguchi, MD, co-chair, of the Academy work group developing this guideline, state that although a large number of lower evidence studies exist, they were surprised at the absence of more high quality prospective studies to support many commonly used interventions.

“Although there is a tremendous amount of research on the rotator cuff, much of it does not reach the quality levels necessary to be considered definitive,” says Yamaguchi. “Thus, we cannot say that there were recommendations that could be unequivocally supported.”

That said, Yamaguchi points out that the AAOS work group has recommended 14 interventions for treating rotator cuff tears. There is a consensus opinion among the work group for the following recommendation:

- In the absence of reliable evidence, it is the opinion of the work group that surgery not be performed for asymptomatic full thickness rotator cuff tears. By “asymptomatic,” the work group refers to a patient without symptoms. The primary indication for rotator cuff repair is significant pain or dysfunction affecting the quality of life.

Rotator cuff repair is an option to treat both symptomatic acute and chronic tears. There was no Level 1 evidence, however, to demonstrate a difference in outcome from one type of surgical approach to another.

Dr. Yamaguchi mentioned that many of the common practices for repairing acute tears or chronic tears that have failed conservative management are considered viable options today. The work group found no evidence to refute most of these common treatment practices. It is entirely probable, they believe, that future, good evidence will substantiate current opinion.

“In our opinion, the guideline process taken by the Academy is a valuable exercise that has focused our awareness on what precisely are the modern standards for good evidence,” says Yamaguchi. “This process clearly demonstrates the need for higher quality research and should hasten the progression toward more sophisticated studies in the future.”

Disclaimer: This Clinical Practice Guideline is not intended to be a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. Clinical patients may not necessarily be the same as those found in a clinical trial. Patient care and treatment should always be based on a clinician’s independent medical judgment, given the individual patient’s clinical circumstances.

Note: A physician volunteer work group developed this clinical practice guideline, based upon a systematic review of the current scientific and clinical information and accepted approaches to treatment and/or diagnosis. The entire process included a review panel consisting of internal and external committees, pubic commentaries, and final approval by the AAOS Board of Directors.

A group of Canadian researchers led by Prof. Jean-Pierre Pelletier, Head of the Osteoarthritis Research Unit at the University of Montreal Hospital Research Centre, published a clinical trial in which they confirm, for the first time using quantitative Magnetic Resonance Imaging (qMRI), the disease modifying effects of chondroitin sulphate, a symptomatic slow acting drug for osteoarthritis (SYSADOA).

This clinical trial, published in Annals of the Rheumatic Diseases (impact factor 8.111), explored the effect of chondroitin sulphate (CS) treatment on cartilage volume loss, subchondral bone marrow lesions (BML) and synovitis in patients with knee osteoarthritis (OA). “This study focused on quantifying over time by MRI the main structural changes observed in the cartilage, bone and synovial membrane”, Prof. Pelletier said.

The investigator states that after only six months of treatment with CS, patients show a significant decrease in loss of articular cartilage as compared to the placebo group, and for the first time, a significant reduction in the progression of BMLs by 12 months.

According to Prof. Pelletier, these data highlight not only the importance of the interrelationship between cartilage and subchondral bone in OA, but also its potential role in the disease process and response to treatment with SYSADOAs.

Prof. Pelletier concluded that, “CS is a safe drug with an overall positive effect on OA, significantly reducing the volume of cartilage loss in knee OA, and providing for the first time new information on its positive effect in vivo on other structural changes observed in this disease”.

Professor Pelletier commented that the clinical trial results prove that CS is able to slow the progression of OA, however this does not mean it is able to cure. “The cure involves the regression of all lesions related to OA,” he says, “and that’s not the case. Chondroitin sulphate slows the progression of the disease. This is an important finding as a decrease in the rate of progression of cartilage loss in knee OA patients, as seen by MRI, could potentially reduce the need for total knee replacement a phenomenon that has been observed in other MRI clinical studies”.

Confirming previous studies

The clinical trial by Prof. Pelletier definitively supports the findings of previous studies describing the positive effects of CS on the pathogenic mechanisms of action of OA (Kwan S et al 2007; Monfort J et al 2005; Bassleer et al 1998; Ronca de 1998, etc), and supports the ability of CS to modify the natural history of the disease, as previously demonstrated by Kahan (2009), Michel (2005), and Uebelhart (1998 and 2004), and the two meta-analyses by Hochberg (2008 and 2010).

Similarly, Prof. Pelletier said that these findings refute the conclusions reached by S. Wandel et al. in a meta-analysis published in the British Medical Journal (BMJ) in 2010 to the effect that SYSADOAs do not offer benefits in the treatment of patients with OA.

In this regard, Prof. Pelletier says, “the methodology used by Wandel et al. is questionable based on the opinion of several experts in the field of OA, as reflected by the several letters to the editor posted on the BMJ website, some of which have also been published in the official Journal. The results of the Wandel et al. meta-analysis are in contrast to many other meta-analyses performed by expert scientists dealing with the same issue, which have shown that CS is an effective symptomatic treatment for OA and that it can slow disease progression”.

“In line with my previous comments, following the publication of this meta-analysis, one of the editors from BMJ issued an official statement in the BMJ website questioning some of the assumptions made in the article and also mentioning a possible conflict of interest of the BMJ senior statistics editor, thus seriously questioning the validity and reliability of this meta-analysis”, Prof. Pelletier specified.

Future goals

The expert says the results of this pilot MRI study are very positive and encouraging. Given the evidenced efficacy and safety of the product, it definitely represents a most valuable option for OA patients. Though he notes, “it is important that patients are provided with highly purified pharmaceutical grade CS, the one used in this study, as this is the only one that can guarantee such efficacy and specifically, safety results”.

Jean-Pierre Pelletier, MD, Professor of Medicine, Head Arthritis Division, Director of Osteoarthritis Research Unit, University of Montreal Hospital Research Centre (CRCHUM)

Sixty years ago, people who suffered from scoliosis, a side-to-side curving of the spine that pulls it into an S or C shape, were given a bleak prognosis. Doctors told them they would have shortened lives, and wouldn’t be able to have children or hold active jobs. Surgery was frequently recommended for almost everyone.

Now that doctors know more, they give their patients a much brighter picture.

“There’s a very low chance of scoliosis causing a medical problem,” says Mark Spoonamore, MD, an orthopedic surgeon in the Keck School of Medicine of USC. “Actually, most curves have a low chance of getting worse and don’t require treatment.”

A study that tracked patients with scoliosis for 50 years found that even in people with a large curvature that goes untreated, researchers were unlikely to find any health effects other than an increase in back pain, Spoonamore says.

Only in cases that occur before or during adolescence, when a growth spurt causes faster bone growth, is treatment usually considered to keep a curve from getting worse. Plastic torso braces, which bend the spine into a straighter position, are commonly used to halt curves with a 20 degree bend or more.

While small curves occur with equal frequency among boys and girls, adolescent girls are about 10 times more likely to have a curve that would get worse without a brace. However, boys are much more likely to require surgery for curves of 45 degrees or more.

“One of the hardest things for a young adolescent girl is to wear the brace,” says Spoonamore. Doctors have made it easier with new options that allow patients to wear them all day outside of school or only at night, instead of all day.

Less than 10 percent of scoliosis patients have surgery to correct severe curvatures that can cause problems walking. Stronger, lighter titanium metal rods and screws have been developed that reduce the chance of complications, such as a rod breaking inside a patient after a hard impact, Spoonamore says.

“Most of the time, they never have to do any further surgery to change the rod,” he said. They can even participate in non-contact sports.

While birth defects, paralysis or other health problems can lead to scoliosis, doctors don’t know what causes most cases, although they do know that the condition runs in families. Spoonamore recommends keeping tabs on a child’s spine by having his or her pediatrician do a simple test for scoliosis during regular check-ups.

Study participants were coached in specific exercises aimed at building bone in key fracture points of the wrist, hip and spine. Mission Pharmacal Company supplied Citracal� calcium citrate for the study. Women were encouraged to take two Citracal� tablets twice a day, morning and evening, to ensure at least 800 mg of calcium. The balance of the remaining recommended dietary allowance (RDA) of 1,000 mg per day was to be supplied by their food intake. The women who regularly took the recommended level of 800 mg of calcium supplement daily and continued to consume calcium in their meals showed greater improvement than those who consumed less than the RDA, and women who kept up the with the exercises showed greater improvement than less frequent exercisers. In addition, the study reinforced evidence that long-term, consistent calcium intake and exercise are valuable, as they provided significant improvement in BMD. The UA investigators developed the BEST regimen, which they found effective in building bone in typically vulnerable areas. The regimen includes six core exercises: