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Recent controlled studies suggest a physiologic basis for FMS, which should be diagnosed by its own characteristic features and not by exclusion of other conditions alone. Diffuse musculoskeletal aching, accompanied by multiple TPs in the absence of an underlying arthritic or systemic condition, are the key features for diagnosis. Based on our controlled study, guidelines for diagnosis are provided in Table 5. Successful management of an FMS patient is often challenging, but frequently gratifying if approached with a positive and caring attitude. The most important aspects of management are a firm diagnosis, reassurance regarding the benign nature of the condition, help in changing patient behavior in order to accept pain and increase functional activities and exercise tolerance, and the use of tricyclic agents. Overall, management of fibromyalgia is an art that requires the combined ingredients of patience, understanding, and firmness in helping patients to assume responsibility for their pain management through behavior modifications.
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PMID:Diagnosis, etiology, and management of fibromyalgia syndrome: an update. 328 8

A retrospective study to determine the efficacy of medial gastrocnemius tendon transfer for symptomatic PCL instability is presented. Results from a group of 31 patients undergoing this procedure were compared with a group of 8 patients managed conservatively while awaiting surgery. The mean injury to follow-up interval was 82 months in the operated group and 104 months in the nonoperated group. The mean surgery to follow-up interval was 53 months. Sixty-nine percent of surgical patients were subjectively improved; however, 29 (91%) continued to have pain and 19 (59%) continued to experience giving way. Thirteen patients from the operated group who had associated procedures performed were significantly better subjectively than those with no associated procedures (P less than 0.05). Physical examination demonstrated no difference in clinical laxity between the operated and nonoperated groups. Medial gastrocnemius transfer did not result in any significant reduction in anterior-posterior translation (KT-1000 assessment) when reconstructed knees were compared with control posterior cruciate deficient knees. Surgery, combined with subsequent immobilization, may have also been responsible for the significant reduction in lower limb function observed in the reconstructed patients. We do not recommend this procedure as a primary PCL reconstruction.
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PMID:Posterior cruciate ligament reconstruction by transfer of the medial gastrocnemius tendon. 334 76

The elbow joint is a key joint for positioning of the hand. Four operations have to be considered for the rheumatoid elbow: removal of rheumatoid nodules and bursectomy, resection of the radial head, synovectomy, and arthroplasty. Synovectomy and arthroplasty are carefully analyzed, both from the point of view of recent international literature as well as personal experience. Synovectomy of the elbow is highly effective even when performed relatively late (stage 3 according to Larsen-Dahle-Eek) insofar as pain relief and swelling are concerned. In long-term disease, deterioration as assessed by radiology can usually not be prevented, but clinical improvement may be the reason for the relatively rare indication for arthroplasty. According to recent literature, the results of elbow arthroplasty vary greatly. Fully constrained hinges should no longer be used, and no decision has been made so far on whether semiconstrained or nonconstrained surface replacement is preferred. We use the semiconstrained GSB Mark II prosthesis, which has provided results in nearly 50 cases that rank among the best reported from the point of view of pain relief, improvement of ROM, and low complication rate. Use of our so-called transtricipital approach to the elbow has proved particularly valuable, especially with regard to lack of extension and muscle strength.
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PMID:[Elbow joint]. 376 20

A prospective study was conducted with 383 pregnant women concerning the occurrence in respect of time, the duration, and the mutual interactions of pregnancy risks. 35 per cent of the women with hemorrhages during early pregnancy later had premature labour pain (p less than 0.01). The relative risk of premature labour is greater by the factor 2.2 in pregnant women with hemorrhages during early pregnancy than in women without haemorrhages. There was no difference between the investigated groups in respect of onset and duration of these two risk factors. 54 per cent of the pregnant women in whom circular sature of the cervix according to Shirodkar had been performed, also had premature labour pain (p less than 0.001). After the performance of the Shirodkar suture, premature labour followed in 40% of the pregnant women during the further course of pregnancy, corresponding to a relative risk of 2.3 compared with the group without Shirodkar. Premature labour with subsequent Shirodkar cerclage occurred earlier (21st week) and lasted for a longer time (13 weeks) than with the reverse sequence or if premature labour occurred alone. If cervical insufficiency occurred first, followed by premature labour, the time of birth was definitely much earlier (36 weeks) than with the controls. There was no evident connection between the risks "infections of urinary tract" and "premature labour". On the other hand, 32 per cent of the pregnant women with urinary tract infections suffered an EPH gestosis, corresponding to a relative risk of 2 (p less than 0.001). The results show that clear and specific pointers towards the possible occurrence of other risks can be derived from the presence of certain pregnancy risks based on specific findings.
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PMID:[Observations on the temporal sequence of reported pregnancy risks]. 656 46

One-hundred-ninety-six patients with Stage III and IV Hodgkin's disease were prospectively randomized to receive either treatment with the methanol extraction residue of Bacillus Calmette-Guerin (MER/BCG) or no immunotherapy. Prior to the MER/BCG randomization, patients received six courses of induction and two years of maintenance chemotherapy so that a group with a presumptively low tumor burden could be established. Only patients achieving a complete remission were evaluated. During the first two years of immunotherapy, the MER/BCG group had a relapse frequency twice that of controls. The overall crude relapse frequency and disease-free survival were similar between the two treatment groups. The MER/BCG dose schedule used in this study was associated with a high frequency of unacceptable toxicity. Ulcerations of greater than 1 cm occurred in one-third of the patients with associated pain, fever, and occasional lymphadenopathy. A high degree of patient noncompliance (36%) was observed. Age (P = 0.002), prior radiotherapy (P = 0.032), and chemotherapy (P = 0.044) were prognostic factors found to significantly influence remission duration. These factors were balanced between patients treated with immunotherapy and those who were not. MER/BCG therapy did not significantly delay or prevent relapse.
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PMID:Effect of methanol extraction residue of Bacillus Calmette-Guerin in advanced Hodgkin's disease. 680 82

FMS is a complex condition mainly characterized by the presence of chronic pain. The nature of this complaint thus demands assessment in a hierarchal fashion of the various components of the pain system ranging from the nociceptor through to complex central pain-processing mechanisms. The condition is common and represents the most important defined chronic pain syndrome. Elucidation of the mechanisms and better management of FMS will result in improved knowledge of a whole range of related chronic pain syndromes. The database in FMS is necessarily large but does need to be focused according to the need of the person constructing the database and the need of the individual with FMS. As our understanding of FMS evolves, better ways of assessing the various dimensions of the problem will be devised. Perhaps the challenge we face is to bring all the parts together. In doing so, we may find there is a single essential component that links all the clinical features together, which correlates well with severity, disability and outcome, which is amenable to treatment programs, and which is measurable. The search for the soul of the "elephant" of FMS continues.
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PMID:A database for fibromyalgia. 763 Oct 42

The conclusion is that no one single mechanism can explain FMS and is thus in that sense a compromise. FMS in some patients may start in the muscle, in other patients in the brain. The combination of peripheral and central factors is the key to the pathogenesis of FMS as long as FMS is defined as a pain syndrome.
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PMID:Chronic muscular pain: aetiology and pathogenesis. 785 Aug 76

Since the first comprehensive description of the symptoms of FMS by Yunus et al (1981), numerous investigations have confirmed that FMS is a clinical entity. However, the aetiology of the syndrome is still not fully elucidated. It seems, however, logical to place the origin of the disorder in the muscle. Muscle pain, especially at the muscle-tendon junctions, fatigue and stiffness are the first symptoms. A malfunction of energy metabolism has been detected in part of the muscle fibres. However, it has to be considered that the muscle is not an isolated entity. Its activity is controlled by segmentally arranged motor units of the ventral horn of the spinal cord in response to proprioceptive afferent signals arising in the muscle spindles or in other sensory elements including nociceptors. Together with supraspinal descending inputs, the spinal motor neurone pool is the common final pathway for segmental and suprasegmental inputs, making the motor system extremely powerful for adaptive adjustments but also vulnerable if deficits occur in either of these input levels. A second, recently discovered abnormality seen in FMS is a lowered serotonin level in peripheral and most likely also central structures. The underlying mechanism seems to be defective absorption of the precursor amino acid tryptophan from the gut. Serotonin is involved centrally in the regulation of the sleep pattern, and at the spinal level it acts as a 'gain setter' of motoneurone excitability and suppresses signal transmission of noxious stimuli in dorsal horn neurones. Either of these two disturbances, muscle energy depletion or serotonin deficiency, could by itself evoke many of the symptoms of FMS, and their combined appearance will perpetuate the disease. Depressed levels of somatomedin C, caused by a deficit of stage 4 sleep-dependent release of GH, might represent an additional factor in preventing proper development or repair of myoskeletal structures. Malabsorption of certain amino acids, possibly due to a genetic disorder of gut transport mechanisms, may constitute an additional deleterious factor. The abnormalities found in the HPA and HPT axis may be seen as an attempt of the organism to restore homeostasis. The stimulus eliciting this counter-regulatory reaction may be pain or other afferent signals which normally do not reach the central nervous system. It is doubtful whether the unspecific activation of the HPA axis in a non-inflammatory disease is beneficial.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Neuromediator and hormonal perturbations in fibromyalgia syndrome: results of chronic stress? 785 Aug 79

In recent years the syndrome of hemolysis, elevated liver enzymes and low platelets (H-ELLP) has attracted increasing interest in obstetrics as a serious complication of pregnancy, either alone or in combination with the classical symptoms of EPH-gestosis or eclampsia. In 1993, we observed 3 cases of severe HELLP syndrome in a total of 1126 deliveries. We present the clinical characteristics and the laboratory findings in these cases. A common symptom was general malaise and upper abdominal discomfort or pain. All patients were delivered by cesarean section of healthy infants. We conclude that it is no longer sufficient to emphasize edema, proteinuria and hypertension, but that the signs and symptoms of the HELLP syndrome present a new and increasingly important challenge in obstetric practice.
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PMID:[HELLP syndrome in routine obstetrical care. Three case reports]. 794 27

In conclusion, PCL injuries occur more commonly than previously noted. The PCL-deficient knee is a serious pathology; it is one of functional disability, not functional instability as seen with an ACL disruption. This functional disability is secondary to pain and inflammation from articular cartilage degeneration. The degeneration process occurs over a period of time normally greater than 5 years; eventually knee function is seriously limited. The rehabilitation of the PCL reconstructive or nonoperative patient is greatly dependent on dynamic quadriceps stability. The biomechanics of the PCL and PLC during various exercises are not well understood; however, research is being performed to advance the clinical management following these injuries. The clinician must realize that tremendous tibiofemoral shear forces are created during various knee exercises, in both the closed and open chain. In particular, various knee exercises, in both the closed and open chain. In particular, there are tremendous stresses applied to the PCL during OKC-resisted knee flexion. The clinician must also realize the role of the hamstrings during most closed chain exercises; therefore the author recommends an early program emphasizing isolated open chain quadriceps strengthening progressing to closed chain drills once adequate quadriceps strength has been established. The numerous clinical challenges for the rehabilitation team to hurdle when treating a PCL-injured knee patient have been discussed in this article. The PCL rehabilitation program can no longer be thought of an an ACL rehabilitation program "turned around." The anatomy, biomechanics, and natural history of the PCL-deficient knee differs dramatically from the ACL-deficient knee, and the treatment approach should reflect these considerations.
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PMID:Rehabilitation of isolated and combined posterior cruciate ligament injuries. 795 89


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