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To compare the effectiveness of a physiotherapy programme with a control treatment of advice and education in patients with neurogenic claudication symptoms. Pragmatic randomised controlled clinical trial. Primary care-based musculoskeletal service. Adults aged 50 or over with neurogenic claudication symptoms causing limitation of walking. Condition-specific home exercises combined with advice and education, or advice and education alone. The primary outcome was the difference in improvement of symptom severity scores on the Swiss Spinal Stenosis Scale at eight weeks. Secondary outcomes included measures of physical function, pain and general well-being at eight weeks and 12 months. There was no significant difference between groups in the Swiss Spinal Stenosis symptom severity scale at eight weeks (t = 0.47, p = 0.643): mean change (SD) control group -0.18 (0.47), treatment group -0.10 (0.66), difference (95% CI) 0.08 (-0.19, 0.35); baseline-adjusted difference 0.06 (-0.19, 0.31)]. An unplanned subgroup analysis suggested that for patients with the top 25% of baseline symptom severity scores, the physiotherapy exercise programme resulted in an improvement in the primary outcome, and modest but consistently better secondary outcomes at both time-points compared to the control group. The effectiveness in different subgroups requires further direct evaluation. In the treatment of patients with neurogenic claudication symptoms, a physiotherapist-prescribed home exercise programme is no more effective than advice and education. The study was approved by Leeds Central Ethics Committee and informed consent was given by all participating patients. The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all forms, formats and media (whether known now or created in the future), to i) publish, reproduce, distribute, display and store the Contribution, ii) translate the Contribution into other languages, create adaptations, reprints, include within collections and create summaries, extracts and/or, abstracts of the Contribution, iii) create any other derivative work(s) based on the Contribution, iv) to exploit all subsidiary rights in the Contribution, v) the inclusion of electronic links from the Contribution to third party material where-ever it may be located; and, vi) licence any third party to do any or all of the above. ISRCTN 78288224 - doi10.1186/ISRCTN35836727; UKCRN 4814.

Background Neurogenic claudication (NC) is the clinical syndrome commonly associated with lumbar spinal stenosis (LSS). Non-surgical management is recommended as initial treatment, but little is known about current practice in relation to the assessment and management of these patients in the non-surgical setting. Methods We conducted a questionnaire survey of physiotherapists in a large UK primary care musculoskeletal service which provides a city-wide multidisciplinary assessment and treatment facility for patients with spinal and other musculoskeletal problems. Data on therapists' recognition and management of patients with NC and LSS were collected. Results Fifty out of 54 therapists completed questionnaires, and all but one of these identified a clearly recognised posture-related clinical syndrome of NC. Almost all respondents (48: 96%) reported the routine use of physiotherapy treatments. In particular, advice and education (49: 98%) along with an exercise programme (47: 94%) incorporating flexion-based exercises (41: 82%) and trunk muscle stabilising exercises (35: 70%) were favoured. Conclusion Musculoskeletal physiotherapy clinicians in this survey recognised a clear clinical syndrome of NC, based on the findings of posture-dependent symptoms. Most therapists reported the routine use of flexion-based exercise, reflecting recommendations in the literature which are based on theoretical benefits, but for which trial evidence is lacking. There is a need for research evidence to guide the choice of physiotherapy treatments.

For centuries, nonsteroidal anti-inflammatory drugs (NSAIDs) have been part of our clinical practice. They started out as drugs with anti-inflammatory and analgesic action, and gradually their use has been expanded to new therapeutic targets, some of which are unrelated to their primary mode of action. Today, our armamentarium includes a large range of compounds, attesting to their utility in the treatment of clinical pathologies ranging from pain and inflammation to prevention and treatment of cancer. On the other hand, although NSAIDs share many common properties, their use poses risks, and physicians should be cognizant of their subtle differences and potential complications. In this context, this review article presents insight into NSAIDs’ pathophysiology and mode of action in the clinical setting, their indications, and their potential side effects.

An association has been demonstrated between haemorrhoids and joint hypermobility. Reasons for this are discussed. Many performing artists are hypermobile and the extra-articular features of joint hypermobility should not be forgotten or underestimated as a potential constraint upon performance.

Objective To determine the clinical effectiveness and cost-effectiveness of nurse-led care (NLC) for people with rheumatoid arthritis (RA). Methods In a multicentre pragmatic randomised controlled trial, the assessment of clinical effects followed a non-inferiority design, while patient satisfaction and cost assessments followed a superiority design. Participants were 181 adults with RA randomly assigned to either NLC or rheumatologist-led care (RLC), both arms carrying out their normal practice. The primary outcome was the disease activity score (DAS28) assessed at baseline, weeks 13, 26, 39 and 52; the non-inferiority margin being DAS28 change of 0.6. Mean differences between the groups were estimated controlling for covariates following per-protocol (PP) and intention-to-treat (ITT) strategies. The economic evaluation (NHS and healthcare perspectives) estimated cost relative to change in DAS28 and quality-adjusted life-years (QALY) derived from EQ5D. Results Demographics and baseline characteristics of patients under NLC (n=91) were comparable to those under RLC (n=90). Overall baseline-adjusted difference in DAS28 mean change (95% CI) for RLC minus NLC was −0.31 (−0.63 to 0.02) for PP and -0.15 (−0.45 to 0.14) for ITT analyses. Mean difference in healthcare cost (RLC minus NLC) was £710 (−£352, £1773) and −£128 (−£1263, £1006) for PP and ITT analyses, respectively. NLC was more cost-effective with respect to cost and DAS28, but not in relation to QALY utility scores. In all secondary outcomes, significance was met for non-inferiority of NLC. NLC had higher ‘general satisfaction’ scores than RLC in week 26. Conclusions The results provide robust evidence to support non-inferiority of NLC in the management of RA. Trial registration ISRCTN29803766

Compared to elite athletes, elite performers, especially musicians and dancers, invariably lack expert medical backup even though their needs are just as great as the sportspeople. In some countries, this is now being realised and addressed. It is hoped that a new MSc in Performing Arts Medicine, recently introduced in the UK, will go some way towards correcting this, and its syllabus has provided the catalyst for this themed issue.

Fibromyalgia is a common although ill understood condition, overlapping with several other diffuse conditions that might provide clues to its pathogenesis. Low-dose amitriptyline remains the mainstay of treatment, although other tricyclics appear to be effective, as do some other antidepressants in doses lower than those used for depression. Tramadol may have a specific place amongst analgesics. Hormonal factors may be important and drugs used in combination appear more effective than a single drug, particularly if they block different CNS transmitters. Physiotherapy might help, particularly if more applied and modest improvements have been claimed for a wide variety of other drugs. Amongst cytokines, interleukin-6 and -8 appear to be the most useful targets for drug action.

Objectives Describe patterns of diurnal variation of gait velocity in patients with RA Methods Inpatients with RA walked at self-selected speed along an 8m GAITRite instrumented walkway (CIR Systems Inc, USA) 5 times during a single day; waking (0 hr), +1 hr, +3 hrs, +6, & +12 hrs.

The non‐steroidal anti‐inflammatory drugs (NSAIDs) are widely used for analgesia but may inhibit bone formation. We investigated whether the reported NSAID effect on bone is related to inhibition of bone marrow mesenchymal stem cell (MSC) proliferation and osteogenic and chondrogenic differentiation and evaluated both cyclooxygenase (COX)‐1 and COX‐2 specific drugs. The effects of seven COX‐1 and COX‐2 inhibitors on MSC proliferation and osteogenic and chondrogenic differentiation were tested using Vybrant, sodium 3′‐[1‐(phenylaminocarbonyl)‐ 3,4‐tetrazolium]‐bis (4‐methoxy‐6‐nitro) benzene sulfonic acid hydrate (XTT), functional and quantitative assays of MSC differentiation. The MSC expression of COX‐1 and COX‐2 and prostaglandin E2 (PGE‐2) levels were evaluated serially during lineage differentiation by quantitative PCR and ELISA. None of the NSAIDs at broad range of concentration (range 10−3 to 100 μg/ml) significantly affected MSC proliferation. Surprisingly, MSC osteogenic differentiation inhibition was not evident. However, NSAIDs affected chondrogenic potential with a reduction in sulphated glycosaminoglycans (sGAG) content by 45% and 55% with diclofenac and ketorolac, respectively (P < 0.05 compared to controls). Parecoxib and meloxicam, more COX‐2 specific reagents inhibited sGAG to a lesser degree, 22% and 27% respectively (P < 0.05 compared to controls). Cartilage pellet immunohistochemistry confirmed the above results. Pellet chondrogenesis was associated with increased COX‐1 expression levels but not COX‐2, and COX‐1 specific drugs suppressed MSC PGE‐2 more than COX‐2 specific inhibitors. These findings suggest that NSAIDs may inhibit bone formation via blockage of MSC chondrogenic differentiation which is an important intermediate phase in normal endochondral bone formation.

Introduction Gout affects 2.5% of the UK's adult population and is now the most common type of inflammatory arthritis. The long-term management of gout requires reduction of serum urate levels and this is most often achieved with use of xanthine oxidase inhibitors, such as allopurinol. Febuxostat is the first new xanthine oxidase inhibitor since allopurinol and was licensed for use in 2008. The European Medicines Agency requested a postlicensing cardiovascular safety study of febuxostat versus allopurinol, which has been named the Febuxostat versus Allopurinol Streamlined trial (FAST). Methods and analysis FAST is a cardiovascular safety study using the prospective, randomised, open, blinded endpoint design. FAST is recruiting in the UK and Denmark. Recruited patients are aged over 60 years, prescribed allopurinol for symptomatic hyperuricaemia and have at least one additional cardiovascular risk factor. After an allopurinol lead-in phase where the dose of allopurinol is optimised to achieve European League against Rheumatism (EULAR) urate targets (serum urate <357 µmol/L), patients are randomised to either continue optimal dose allopurinol or to use febuxostat. Patients are followed-up for an average of 3 years. The primary endpoint is first occurrence of the Anti-Platelet Trialists’ Collaboration (APTC) cardiovascular endpoint of non-fatal myocardial infarction, non-fatal stroke or cardiovascular death. Secondary endpoints are all cause mortality and hospitalisations for heart failure, unstable, new or worsening angina, coronary or cerebral revascularisation, transient ischaemic attack, non-fatal cardiac arrest, venous and peripheral arterial vascular thrombotic event and arrhythmia with no evidence of ischaemia. The primary analysis is a non-inferiority analysis with a non-inferiority upper limit for the HR for the primary outcome of 1.3. Ethics and dissemination FAST (ISRCTN72443728) has ethical approval in the UK and Denmark, and results will be published in a peer reviewed journal. Trial Registration number FAST is registered in the EU Clinical Trials Register (EUDRACT No: 2011-001883-23) and International Standard Randomised Controlled Trial Number Register (ISRCTN No: ISRCTN72443728).