Rheumatic Musculoskeletal Research Articles

Prevalence of rheumatic musculoskeletal pain and disability in rural Nepal‐ a cross‐sectional community‐based study adopting WHO‐ILAR COPCORD stage I: Phases I and II protocol

AbstractBackgroundThe burden of musculoskeletal (MSK) pain and disabilities is high in health facilities but remains unknown in the community due to a lack of community‐level studies. The community‐oriented program for control of rheumatic diseases (COPCORD) is focused on determining MSK pain and disabilities through epidemiological surveys. This study adopted the COPCORD stage I protocol to determine the prevalence of rheumatic MSK pain and disability and its associated factors in the Pyuthan district of Nepal.MethodologyA cross‐sectional community‐based study using the quantitative method was conducted in Pyuthan municipality as per COPCORD stage I protocol. COPCORD stage I (phase I and phase II) questionnaires were used to collect data through the interview technique. Populations aged 18 years and above were included in the study. A multistage sampling technique was used, and the total sample size was 2145. The collected data from phase I and phase II were entered in Epidata version 3.1. Descriptive and analytical analysis was done in SPSS. The Chi‐square test was used to find the association between dependent and independent variables.FindingsThe overall prevalence (past and current MSK pain/swelling) was 26.81% (95% CI 24.9–28.7). Current MSK pain/swelling was found in 19.53% of the participants, and past MSK pain/swelling was found in 25.87%. Among self‐reported chronic diseases, joint pain was reported by the majority of the participants (17.86%). Age, sex, education, nature of work, current smoking, tobacco use, and alcohol use were found to be associated with past and current MSK pain/swelling.ConclusionsMore than one‐fourth of the participants had MSK pain/swelling. The prevalence of MSK pain/swelling was higher in elderly participants, females, illiterates, heavy workers, smokers, tobacco users, and alcohol users. Similar studies should be conducted in other regions of the country, and this study should also be expanded to COPCORD Stages II and III to identify the risk factors and to improve the management of MSK pain and disorders.

Promoting the professional reintegration of people with Rheumatic Musculoskeletal Diseases, based upon disability management principles.

In Belgium, people with Rheumatic and Musculoskeletal Diseases (RMDs) represent a major group of patients on sick leave. In order to reduce costs for social security and in respect to the meaning of work for patients, the Belgian National Institute for Health and Disability Insurance (NIHDI) has reached out to ReumaNet to jointly start up the research project “ReumaWerkt” to promote the professional reintegration of people with RMDs.
 Objectives:
 
 Identify and assess the information about professional reintegration available to people with RMDs
 Evaluate resources people with RMDs have to stay at or return to work
 Assess the added value of a certified return to work coordinator (CRTW) and Patient Expert to support people with RMDs towards job retention and professional reintegration
 
 Method: The research “ReumaWerkt” was led by a Patient Expert who is also trained as a Certified Return To Work Coordinator. The research consisted of:
 - Surveys to people with RMDs and other stakeholders
 - Coaching people with RMDs to jointly define tailored answers on professional reintegration, following the DM-methodology.
 The steering group of “ReumaWerkt” included representatives of NIHDI.
 Results: 127 patients and 79 other stakeholders responded to the survey. In total 238 patients received coaching and support.
 
 There is a discrepancy between where people with RMDs expect to find information about professional reintegration and where information is given. Available information is not customized, sometimes inconsistent, mostly too general. Legislation is too complex
 People with RMDs experience physical obstacles at work. Financial incentives are foreseen but are (a) not well known and (b) too limited
 Focusing mainly on job retention and stimulating professional reintegration, taking into account each patient’s personal bio-psycho-social context, is definitely an added value: 80% of the respondents rated 7/10 and more as satisfaction rate. 82% of the respondents would recommend this support to other patients
 
 => information flows need to be improved and more specific
 Conclusions:
 
 Information flows about professional reintegration for people with RMDs need to be improved and be more specific
 People with RMDs have specific needs to allow them to return to or stay at work such as flexible working hours, functional adaptations in their working environment and financial support
 Patient Expertise and applying DM principles are indispensable: people with RMDs need personalized tailored information on professional reintegration opportunities as soon as possible
 
 Next steps:
 - Results were shared with patient organizations, umbrella organizations (Flemish Patient Platform (VPP) and Platform of French speaking patient organization (LUSS)), politicians and other stakeholders
 - The Patient Expert continues coaching people with RMDs to jointly define tailored answers on professional reintegration, following the DM-methodology
 - ReumaNet continues raising awareness on importance of professional reintegration for people with RMDs: campaigns with employers and employees
 Learning for international audience:
 - It is an added value to use Patient Expertise to offer tailor made support
 

Exploring the complexities of pain phenotypes: OMERACT 2023 chronic pain working group workshop

ObjectiveTo educate and discuss pain mechanisms (nociceptive, neuropathic, nociplastic) illuminating its possible impact when measuring different outcomes, which may modify, confound and potentially bias the outcome measures applied across various aspects of Rheumatic Musculoskeletal Diseases (RMDs) clinical trials. MethodsIn the plenary presentations, PM lectured on different pain mechanisms and impact on disease activity assessment. Data from two data sets of RMDs patients, which assessed the prevalence and impact of nociplastic pain were presented and reviewed. Audience breakout group sessions and polling were conducted. ResultsMixed pain etiologies may differentially influence disease activity assessment and therapeutic decision-making. Polling demonstrated a consensus on the need to assess different types of pain as a phenotype, as it constitutes an important contextual factor (a variable that is not an outcome of the trial, but needs to be recognized [and measured] to understand the study results), and to standardize across RMDs. ConclusionThere is need for a standardized pain measure that can differentiate underlying pain mechanisms.

Bone loss occurs in Inflammatory Rheumatic Musculoskeletal Diseases (iRMD) patients treated with low dose glucocorticoids, but is prevented by anti-osteoporosis medications.

The negative effects of glucocorticoids (GCs) on the bone depend on dose and treatment duration. However, it is unclear whether a safe dose exists, especially for patients with inflammatory rheumatic musculoskeletal diseases (iRMDs). We conducted a longitudinal cohort study on women with iRMD. Bone mineral density and fractures were assessed prospectively and compared to a matched cohort. Kaplan-Meier curves with log-rank test were made for iRMD (stratified for glucocorticoid use and dosage) and matched cohort respectively. Multivariable Cox regression survival models were also employed to analyze the effect of GCs on fracture. 884 women with iRMD and 1,766 controls (age, T-score, and 10-year fracture risk matched) were included in the study and followed for up to 6 years. BMD levels decreased significantly in all GCs users not receiving anti-osteoporosis treatment (-4.26% p 0.0011, -4.23% p 0.0422, -2.66% p 0.0006 for ≥5 mg/day, 2.5 mg to 5 mg and 0 to 2.5 mg/day of prednisolone, respectively). Anti-osteoporotic treatment (largely bisphosphonates) prevented bone loss only in patients receiving less than 5 mg/day of prednisone. Fracture incidence was greater in patients with iRMD compared to controls but only GC doses above 5 mg/day were associated with significantly higher risk of fracture. GC doses as low as 2.5 mg/day were associated with BMD loss in iRMD but this effect was preventable. BMD loss in patients taking ≥5 mg/day was not totally prevented by anti-osteoporotic medications currently used in clinical practice, resulting in higher risk of fracture. This article is protected by copyright. All rights reserved.

Post-Acute COVID-19 Joint Pain and New Onset of Rheumatic Musculoskeletal Diseases: A Systematic Review.

As the number of reports of post-acute COVID-19 musculoskeletal manifestations is rapidly rising, it is important to summarize the current available literature in order to shed light on this new and not fully understood phenomenon. Therefore, we conducted a systematic review to provide an updated picture of post-acute COVID-19 musculoskeletal manifestations of potential rheumatological interest, with a particular focus on joint pain, new onset of rheumatic musculoskeletal diseases and presence of autoantibodies related to inflammatory arthritis such as rheumatoid factor and anti-citrullinated protein antibodies. We included 54 original papers in our systematic review. The prevalence of arthralgia was found to range from 2% to 65% within a time frame varying from 4 weeks to 12 months after acute SARS-CoV-2 infection. Inflammatory arthritis was also reported with various clinical phenotypes such as symmetrical polyarthritis with RA-like pattern similar to other prototypical viral arthritis, polymyalgia-like symptoms, or acute monoarthritis and oligoarthritis of large joints resembling reactive arthritis. Moreover, high figures of post-COVID-19 patients fulfilling the classification criteria for fibromyalgia were found, ranging from 31% to 40%. Finally, the available literature about prevalence of rheumatoid factor and anti-citrullinated protein antibodies was largely inconsistent. In conclusion, manifestations of rheumatological interest such as joint pain, new-onset inflammatory arthritis and fibromyalgia are frequently reported after COVID-19, highlighting the potential role of SARS-CoV-2 as a trigger for the development of autoimmune conditions and rheumatic musculoskeletal diseases.

Should Physicians Avoid Routine Iron Supplementation in Rheumatic Musculoskeletal Diseases (RMDs)?

Abstract not available
 CBMJ 2023 January: Vol. 12 No. 01 P: 01-02

High Prevalence of Foot Insufficiency Fractures in Patients With Inflammatory Rheumatic Musculoskeletal Diseases.

To assess the prevalence of foot insufficiency fractures (IF) in patients with rheumatic musculoskeletal disease (RMD) with foot pain. In a retrospective design, 1752 magnetic resonance imaging (MRI) scans of consecutive patients presenting with foot pain in 2 time periods between 2016 and 2018 were evaluated. The group with IF was matched with controls with foot pain without IF. Bone mineral density (BMD) was assessed by dual-energy x-ray absorptiometry. Multivariate analyses were performed. A total of 1145 MRI scans of patients (median age 59 yrs, 82.9% female) with an inflammatory (65.4%) and of 607 with no inflammatory (34.6%) RMD (median age 58 yrs, 80.8% female) were available. Most patients had rheumatoid arthritis (RA; 42.2%), and others had psoriatic arthritis (22.4%), axial spondyloarthritis (11.1%), or connective tissue disease (CTD; 7.6%). Foot IF were found in 129 MRI scans of patients (7.5%). There was no difference between time periods. The prevalence of IF was highest in CTD (23%) and RA (11.4%). More patients with an inflammatory than a noninflammatory RMD had IF (9.1% vs 4.1%, respectively; P < 0.001). Using conventional radiography, IF were only detected in 25%. Low BMD and a history of fractures were more frequent in patients with IF than without (42.6% vs 16.2% and 34.9% vs 8.6%, respectively; P < 0.001). A high prevalence of foot fractures was found in MRI scans of patients with RMD, many without osteoporosis. MRI was more sensitive than radiographs to detect IF.

Optimizing Medication Use in Older Adults With Rheumatic Musculoskeletal Diseases: Deprescribing as an Approach When Less May Be More.

The world population is aging, and the rheumatology workforce must be prepared to care for medically complex older adults. We can learn from our colleagues and experts in geriatrics about how to best manage multimorbidity, polypharmacy, geriatric syndromes, and shifting priorities of older adults in the context of delivering care for rheumatic and musculoskeletal diseases (RMDs). Polypharmacy, a common occurrence in an aging population with multimorbidity, affects half of older adults with RMDs and is associated with increased risk of morbidity and mortality. In addition, potentially inappropriate medications that should be avoided under most circumstances is common in the RMD population. In recent years, deprescribing, known as the process of tapering, stopping, discontinuing, or withdrawing drugs, has been introduced as an approach to improve appropriate medication use among older adults and the outcomes that are important to them. As the rheumatology patient population ages globally, it is imperative to understand the burden of polypharmacy and the potential of deprescribing to improve medication use in older adults with RMDs. We encourage the rheumatology community to implement geriatric principles, when possible, as we move toward becoming an age-friendly health care specialty.

Safety of Biologic-DMARDs in Rheumatic Musculoskeletal Disorders: A Population-Based Study over the First Two Waves of COVID-19 Outbreak

This study aims to explore disease patterns of coronavirus disease (COVID-19) in patients with rheumatic musculoskeletal disorders (RMD) treated with immunosuppressive drugs in comparison with the general population. The observational study considered a cohort of RMD patients treated with biologic drugs or small molecules from September 2019 to November 2020 in the province of Udine, Italy. Data include the assessment of both pandemic waves until the start of the vaccination, between February 2020 and April 2020 (first), and between September 2020 and November 2020 (second). COVID-19 prevalence in 1051 patients was 3.5% without significant differences compared to the general population, and the course of infection was generally benign with 2.6% mortality. A small percentage of COVID-19 positive subjects were treated with low doses of steroids (8%). The most used treatments were represented by anti-TNF agents (65%) and anti-IL17/23 agents (16%). More than two-thirds of patients reported fever, while gastro-intestinal symptoms were recorded in 27% of patients and this clinical involvement was associated with longer swab positivity. The prevalence of COVID-19 in RMD patients has been confirmed as low in both waves. The benign course of COVID-19 in our patients may be linked to the very low number of chronic corticosteroids used and the possible protective effect of anti-TNF agents, which were the main class of biologics herein employed. Gastro-intestinal symptoms might be a predictor of viral persistence in immunosuppressed patients. This finding could be useful to identify earlier COVID-19 carriers with uncommon symptoms, eventually eligible for antiviral drugs.

Immunosuppressant Treatment in Rheumatic Musculoskeletal Diseases Does Not Inhibit Elicitation of Humoral Response to SARS-CoV-2 Infection and Preserves Effector Immune Cell Populations.

COVID-19 has proven to be particularly serious and life-threatening for patients presenting with pre-existing pathologies. Patients affected by rheumatic musculoskeletal disease (RMD) are likely to have impaired immune responses against SARS-CoV-2 infection due to their compromised immune system and the prolonged use of disease-modifying anti-rheumatic drugs (DMARDs), which include conventional synthetic (cs) DMARDs or biologic and targeted synthetic (b/ts) DMARDs. To provide an integrated analysis of the immune response following SARS-CoV-2 infection in RMD patients treated with different classes of DMARDs we carried out an immunological analysis of the antibody responses toward SARS-CoV-2 nucleocapsid and RBD proteins and an extensive immunophenotypic analysis of the major immune cell populations. We showed that RMD individuals under most DMARD treatments mount a sustained antibody response to the virus, with neutralizing activity. In addition, they displayed a sizable percentage of effector T and B lymphocytes. Among b-DMARDs, we found that anti-TNFα treatments are more favorable drugs to elicit humoral and cellular immune responses as compared to CTLA4-Ig and anti-IL6R inhibitors. This study provides a whole picture of the humoral and cellular immune responses in RMD patients by reassuring the use of DMARD treatments during COVID-19. The study points to TNF-α inhibitors as those DMARDs permitting elicitation of functional antibodies to SARS-CoV-2 and adaptive effector populations available to counteract possible re-infections.

Effectiveness of Combined Kinetic Chain Exercises In the Treatment of Knee Osteoarthritis in Peri-Menopausal and Post-Menopausal Women in Guwahati, Assam, India

: Osteoarthritis (OA) is an extremely prevalent Rheumatic Musculoskeletal disorder and the prevalence of knee OA in peri-menopausal and post-menopausal women is reported to be high in many parts of India. Though a growing body of evidence suggests the effectiveness of Combined Kinetic Chain Exercises (CCEs) in the management of knee OA but a precise protocol is yet to be established. The study was aimed to evaluate and compare the effectiveness of two different protocols of CCEs versus conventional CCEs in the management of knee osteoarthritis.151 peri-menopausal/ post menopausal women (40-65 years) with knee osteoarthritis were randomly allocated to either group A (Control group: conventional combined kinetic chain exercises), group B (retrowalking and conventional combined kinetic chain exercises) or group C (perturbation training and conventional combined kinetic chain exercises). Intervention was given for 3 days/week for 6 weeks. Outcome measures used were Numeric Pain Rating Scale (NPRS), Timed Up and Go test (TUG) and Lower Extremity Functional Scale (LEFS). SPSS 21.0 version was used for all statistical analysis. Paired t-test was used for within group analysis and unpaired t-test was used for between group comparisons. Level of significance was considered as p&lt;0.05.Statistically significant improvements were seen within all the three groups at the end of 6 weeks of treatment. Subjects in both the experimental groups (group B and group C) exhibited statistically significant improvements than group A (control group) in all outcome measures. Group B showed better improvements in all outcome measures when compared to group C; but the differences were not statistically significant. It can be concluded that Retrowalking combined with conventional CCEs and Perturbation exercises combined with conventional CCEs are equally effective in the treatment of knee OA; but significantly better than conventional CCEs alone.

Rheumatic Musculoskeletal Diseases and COVID-19 A Review of the First 6 Months of the Pandemic.

In December 2019, a cluster of severe pneumonia was observed in China, with the subsequent discovery of a new beta-coronavirus (SARS-CoV-2) as the causative agent. The elicited disease COVID-19 is characterized by fever, dry cough, myalgia, or fatigue and has a favorable outcome in the majority of cases. However, in some patients COVID-19 leads to severe pneumonia and sepsis with subsequent respiratory failure and gastrointestinal, hematological, neurological, and cardiovascular complications. A higher risk of infection is intrinsic to active rheumatic and musculoskeletal diseases (RMD) and the use of biological disease modifying anti-rheumatic drugs (DMARDs). With an increasing number of reports on COVID-19 in RMD patients, we are beginning to appraise their risks. In this review, we summarize the published cases of COVID-19 infections in RMD patients, including patients with inflammatory arthritis and connective tissue diseases as well as anti-phospholipid syndrome and Kawasaki syndrome. Overall, patients with inflammatory arthritis do not seem to be at a higher risk for infection or a severe course of COVID-19. Risk for critical COVID-19 in patients with systemic inflammatory diseases such as SLE or vasculitis might be increased, but this needs further confirmation. Furthermore, we summarize the data on DMARDs used to fight SARS-CoV-2 infection and hyperinflammation.

Implementation of Physical Activity into routine Clinical pracTice in Rheumatic Musculoskeletal Disease: The IMPACT-RMD study protocol and rationale

Background:Physical activity is an important intervention for improving disease-related symptoms and systemic manifestations in rheumatic and musculoskeletal disease (RMDs). However, studies suggest that RMD patients report that the lack of individualized and consistent information about physical activity from managing doctors and healthcare professionals, acts as a barrier for engagement. On the other hand, managing doctors and healthcare professionals report lack of knowledge in this area and thus lack of confidence to educate and advise RMD patients about the beneficial effects of physical activity. The aim of the present study therefore, is to develop two e-Learning courses for RMD doctors and health professionals: a) the first one to provide consistent information about the collective benefits of physical activity in RMDs and b) the second on how to implement physical activity advice in routine clinical practice.Methods:An international collaboration of seven countries, consisting of one academic institution and one patient organization from each country, will co-develop the two e-Learning courses. The final e-Learning courses will primarily target to improve – through physical activity advice – RMD symptoms which are important for patients.Discussion:The main result of this study will be to co-develop two e-Learning courses that can be used by managing RMD doctors and healthcare professionals to be made aware of the overall benefits of physical activity in RMDs as well as how to implement physical activity advise within their practice.

Laboratory Assessment of Patients with Suspected Rheumatic Musculoskeletal Diseases: Challenges and Pitfalls.

Current patient care in rheumatology relies primarily on a combination of traditional clinical assessment and standard laboratory tests. Investigators seek to discover new biomarkers and novel technologies to boost the research in this field. Mechanistic biomarkers such as cytokines, cell types, antibodies, signaling molecules, are rooted in the mechanism underlying the disease and can guide the clinical management of the disease. Conversely, descriptive biomarkers are byproducts of the disease process, depict the state of a disease but are not involved in its pathogenesis. In this article, we reviewed the field of common laboratory biomarkers in rheumatology, highlighting both their descriptive or mechanistic value as well as their role in clinical practice.

Rheumatic-musculoskeletal pain and disorders in a naïve group of individuals 15 months following a Chikungunya viral epidemic in south India: a population based observational study

Prospective community data on arthropathy following Chikungunya (CHIKV), a self-limiting, arboviral infection, causing debilitating arthropathy are lacking. The clinical profile of chronic rheumatic-musculoskeletal (RMSK) pain and disorders, captured inadvertently about 15 months following a CHIKV epidemic is described. Patients with RMSK pain following the CHIKV epidemic in 2007 were identified from a randomly selected population of 5277 (Age > 15 years) in a village in south India, using a validated questionnaire-based house-to-house survey. Typical narration, records and serology were relied upon to classify CHIKV. Respondents who recorded active pain sites on a human mannequin were evaluated by Rheumatology physicians. A total of 1396 CHIKV infected individuals with painful MSKD were identified, of whom 437 patients (mean age: 48.37 ± 13.62 years; 71.6% women) who were naïve to RMSK pain prior to the epidemic were studied in detail. Incidence of RMSK pain and disorders in the naïve group was 8.3% (437/5277). Knee was the commonest self-reported pain site (83.3%). Majority of the patients (57%) had postviral non-specific polyarthralgia. Soft tissue rheumatism was very common (27.7%). Rheumatoid arthritis and seronegative spondyloarthritis were observed in 6 and 11 patients, respectively. Although a causal association could not be established, this study has unravelled a wide spectrum of unrecognised post-CHIKV chronic RMSK disorders. Aetiopathogenesis and risk factors of chronicity need to be studied further.

Persistent rheumatic musculoskeletal pain and disorders at one year post-chikungunya epidemic in south Maharashtra—a rural community based observational study with special focus on naïve persistent rheumatic musculoskeletal cases and selected cytokine expression

The recent Chikungunya (CHIKV) epidemic (2006) unleashed an unrecognized spectrum of rheumatic musculoskeletal (RMSK) pain and disorders. The data on persistent RMSK is lacking. About 10% clinical acute cases are considered to suffer from chronic arthritis. We used an arthritis camp approach in a 9000 populated village Modnimb (district Sholapur) in December 2007 to identify naive cases of RMSK following symptomatic CHIKV outbreak in December 2006. A 10-day intensive publicity through public announcement and media pamphlet distribution program was carried out to attract villagers with persistent aches and pains and a past history of acute CHIKV illness to attend a 3 day free of cost evaluation arthritis camps. Blood samples were collected from consenting patients. Village volunteers and health workers participated in it. 1.4 percent (95% confidence interval 1.13, 1.60) village population was found to suffer from naive persistent RMSK pain and disorders at 1 year following acute CHIKV infection. Patients were generally >45 years age and females were predominant. Knee was the predominant pain site in 79% cases. Though 27% cases suffered from non-specific arthralgias (NSA), the diagnosis in 48% and 15% cases respectively was consistent with OA (often knee and spine) and undifferentiated inflammatory arthritis (0.2% crude prevalence). Overall, the clinical RMSK profile was benign and none reported any significant functional disability or mobility impairment. Seventy-three percent patients tested seropositive for anti-CHIKV IgG antibody; none for IgM antibody. None showed any abnormality on routine laboratory haematology and biochemistry testing; seropositive RF, ANA and anti-CCP was infrequent. Though CRP values were low, IL-6 was elevated and was not associated with any clinical phenotype. As compared to normal healthy population values assayed a year prior to the epidemic in a neighboring village, cases with persistent RMSK showed elevated IFN-γ, TNF-α and IL-13. Also, the clinical phenotype and cytokine expression did not seem to differ between the seropositive and seronegative groups for anti-CIKV IgG antibody. Conclusion In this rural community study, at least 1.4% population continued to suffer from some form of RMSK at 1 year following acute CHIKV epidemic. Though clinically unimpressive, a large number showed elevated pro-inflammatory cytokine expression. A longer follow-up may explain this disconnect.

Is There an Urban-Rural Divide? Population Surveys of Rheumatic Musculoskeletal Disorders in the Pune Region of India Using the COPCORD Bhigwan Model

To estimate urban prevalence of rheumatic musculoskeletal (MSK) disorders and compare to an earlier rural regional study. We screened 8145 adults from a preselected urban locality in Pune, India, for MSK pain in a cross-sectional house-to-house survey (Stage I) over 20 weeks. The World Health Organization-International League of Associations for Rheumatology (WHO-ILAR) Community Oriented Program for Control of Rheumatic Diseases (COPCORD) Bhigwan model was used. Thirty trained community volunteers completed Phases I and II questionnaires, concurrent with rheumatology evaluation (Phase III). Clinical diagnosis was based on standard diagnosis/classification criteria. Point prevalence rates from our survey and the earlier Bhigwan village (Pune district) survey were standardized (adjusted age-sex to India population census 2001) and are reported for osteoarthritis (OA), rheumatoid arthritis (RA), seronegative spondyloarthritis (SSA), and inflammatory arthritis (IA). One thousand one hundred fifty-two urban cases (65% women) were identified (14.1%, 95% confidence interval 13.4, 14.9). The self-reported pain sites (Phase II) were hip (0.4), knees (6.3), ankle (1.9), feet (0.7), shoulders (2), hands (1.3), wrist (1.2), neck (1.9), upper back (1.7), low back (5.5), thigh (1.5), calf (1.4), and sole (0.8); corresponding rural sites being hip (1.1), knees (13.7), ankle (7), feet (1.6), shoulders (7.9), hands (6.3), wrist (6.9), neck (6.8), upper back (8.4), low back (12.6), thigh (4.8), calf (7.1) and sole (2.2). OA disorders, soft tissue rheumatism (STR) and ill-defined aches and pains were predominant in both surveys; < 10% reported IA. The major disorders among urban cases were OA (4), STR (1.2), RA (0.2, ACR criteria 1988), undifferentiated IA (0.3), SSA (0.3), and gout (0.06); corresponding rates in Bhigwan were OA (6.3), STR (3.8), RA (0.5), undifferentiated IA (0.8), SSA (0.3), and gout (0.1). Infections were conspicuously absent. While similar in spectrum, standardized prevalence rates of self-reported pain sites and rheumatic MSK disorders were significantly lower in the urban (current Pune COPCORD surveys) versus rural (Bhigwan) community, and in both communities aches and pains that are poorly understood by modern science were predominant.

Epidemiology of rheumatic musculoskeletal disorders in the developing world

The epidemiology of rheumatic musculoskeletal (MSK) disorders in the developing world is much less well known than it is in the developed world. We expect ethnicity, traditions, socioeconomics and lifestyles to have an impact, but overall data are sparse. This report focuses on the WHO-ILAR COPCORD (community-oriented programme for control of rheumatic diseases). COPCORD was designed to collect community data on pain and disability in the developing economies. Several countries in Asia-Pacific and Central South America have completed COPCORD surveys. Despite some limitations in methodology, COPCORD provides a fair estimate of the spectrum and extent of rheumatic MSK disorders. We digress from a general overview to highlight the scenario for rheumatoid arthritis, and draw a few parallels with known statistics from the developed world. Overall, the emerging spectrum and severity are not very different, but in the developing countries the burden of disease, worsened by dismal rheumatology services, is likely to be staggering.

Rheumatic musculoskeletal symptoms associated with carcinoma of the prostate gland.

The importance of searching for a malignancy in patients in whom rheumatic symptoms develop for the first time after the age of 60 years is emphasized. Case histories are presented to illustrate the disabling rheumatic symptoms that led the patients to seek medical aid. Treatment with estrogens alleviated the rheumatic symptoms in these patients, all of whom had carcinoma of the prostate gland.