Twenty-three rheumatic disease patients with glucocorticoid-induced osteopenia (defined by measurement of forearm bone mass) completed an 18-month double-blind, randomized study to assess the effect of oral calcium and 1,25-dihydroxyvitamin D ( 1,25-OH2D) or calcium and placebo on bone and mineral metabolism. Intestinal 47Ca absorption was increased (P < 0.05) and serum parathyroid hormone levels were suppressed (P < 0.01) by 1,25-OH2D (mean dose 0.4 pgl day); however, no significant gain in forearm bone mass occurred, and bone fractures were frequent in both groups. In the 1,25-OH2D group, histomorphometric analysis of iliac crest biopsy specimens demonstrated a decrease in osteoclasts/mm2 of trabecular bone (P < 0.05) and parameters of osteoblastic activity (P < 0.05), indicating that 1,25-OH2D reduced both bone resorption and formation. We conclude that 1,25-OH2D should not be used for treatment of glucocorticoidinduced osteopenia. Since patients receiving calcium and placebo did not exhibit a loss of forearm bone mass, elemental calcium supplementation of 500 mg daily might be useful to maintain skeletal mass in patients receiving long-term glucocorticord therapy. Submitted for publication March 27, 1984; accepted in revised form July I I , 1984. Oral administration of glucocorticords in humans results in severe osteopenia caused by several mechanisms (1-3). Histologic studies of bone in humans receiving glucocorticoids demonstrate decreased bone formation (4-6) and increased numbers of osteoclasts and osteoclast-resorbing surfaces (5-7). The decrease in formation rate probably represents a direct effect of glucocorticoids on osteoblasts. Specifically, glucocorticoids decrease the recruitment of progenitor cells to osteoblasts and the synthesis of collagen and noncollagen protein by preexisting osteoblasts (8,9).The mechanism by which glucocorticoids increase bone resorption is more controversial. In vitro, glucocorticoids inhibit osteoclast activity (3, lo). However, in vivo, glucocorticoids greatly decrease intestinal calcium absorption (2,11,12) and may stimulate parathyroid hormone (PTH), thus providing an indirect stimulus to osteoclastic activity (6,13

Objective. This study documents the measurement properties of a brief, self-administered questionnaire of disease signs and symptoms in patients with rheumatoid arthritis. Measurement of disease signs and symptoms is a key aspect of outcome evaluation in rheumatology-

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Physician-educators devote many hours to the instruction of medical students in history-taking and physical examination techniques. A lecture format, supplemented by slides to illustrate normal and abnormal physical findings, is the usual method of introducing students to the examination of patients. As an alternative, we developed a videotape program demonstrating history-taking and physical examination of patients with rheumatic diseases. Effectiveness was assessed by cognitive testing and compared to effectiveness of a lecture by the same physician providing the same information.Study design. Two color videotapes were produced by the Washington University Arthritis Center and the St. Louis VA Hospitals. The first tape (12 minutes) "History: The Patient with Arthritis," presented general principles of history-taking with emphasis on rheumatic complaints. Three patients, one with degenerative joint disease, one with rheumatoid arthritis, and one with gout, were interviewed by a physician. The second tape (55 minutes) "Physical Examination: The Patient with Arthritis," described general principles of physical examination followed by specific techniques for examination of gait, posture, spine, peripheral joints, and periarticular structures. (Hoppenfeld S: Physical Examination of the Spine and Extremities. New York, Appelton-Century-Crofts, 1976). These techniques were demonstrated using a normal individual and then using patients with typical rheumatic manifestations. The program concluded with a demonstration illustrating synthesis of information from history and physical to reach the correct diagnosis.Two written tests of cognitive knowledge were developed by a panel of rheumatologists, allied health personnel, and educators who viewed the tapes and attended the lecture. Questions were classified for degree of difficulty and categorized as follows: anatomy, history, physical findings, and synthesis of information. Two tests (A and B) of comparable difficulty were composed and administered to 6 college graduates with no background in physical diagnosis and to 8 rheumatologists. Mean scores (percent correct answers for A and B combined) were 27% k 3 SEM for the first group and 88% +-1 SEM for the experts (P -= 0.001 by Student's t test). Scores on A and B did not differ significantly. Sample questions in two categories:

Editor's Note: The following two editorials review the development of physical therapy and occupational therapy in arthritis care. These papers are the last in our year-long series reviewing the history of the Arthritis Health Professions Association.Physical therapy is one of the fundamental components of comprehensive care for individuals with arthritis, and physical therapists are key members of the arthritis patient care team. Given this important role, it is not surprising that, from its inception, physical therapists have played an active part in the growth and development of the Arthritis Health Professions Association. This editorial reviews briefly the development of physical therapy as a profession, the role of physical therapy in the treatment of arthritis, and the involvement and contributions of physical therapists within the AHPA.