2023 EULAR classification criteria for hand osteoarthritis.

OBJECTIVES: The objective of this study is to develop classification criteria for overall hand osteoarthritis (OA), interphalangeal OA and thumb base OA based on self-reported data and radiographic features. METHODS: The classification criteria sets were developed in three phases. In phase 1, we identified criteria that discriminated hand OA from controls. In phase 2, we used a consensus-based decision analysis approach to derive a clinician-based evaluation of the relative importance of the criteria. In phase 3, we refined the scoring system, determined the cut-offs for disease classification and compared the sensitivity and specificity of the European Alliance of Associations for Rheumatology (EULAR) criteria with the 1990 American College of Rheumatology (ACR) criteria. RESULTS: In persons with hand symptoms and no other disease (including psoriasis) or acute injury that can explain the hand symptoms (mandatory criteria), hand OA can be classified based on age, duration of morning stiffness, number of joints with osteophytes and joint space narrowing, and concordance between symptoms and radiographic findings. Using a sum of scores based on each diagnostic element, overall hand OA can be classified if a person achieves 9 or more points on a 0-15 scale. The cut-off for interphalangeal OA and thumb base OA is 8 points. While the EULAR criteria demonstrated better sensitivity than the ACR criteria in the phase 1 data set, the performance of the two criteria sets was similar in two external cohorts. CONCLUSIONS: International experts developed the EULAR criteria to classify overall hand OA, interphalangeal OA and thumb base OA in clinical studies using a rigorous methodology.

Organisation and content of supervised group exercise for people with axial spondyloarthritis in The Netherlands.

Supervised group exercise (SGE) is recommended for people with axial spondyloarthritis (axSpA). Recent literature suggests that its contents and dosage must probably be revised. As a first step towards renewal, this study examined the current SGE organisation and content for people with axSpA in The Netherlands. A pen-and-paper survey was sent to the boards of the 82 local patient associations affiliated with the Dutch Arthritis Society in 2016. One member of each board was asked to complete questions on the nature and organisation of SGE and one of the supervising therapists to complete questions on the SGE supervision and contents. The questionnaire was returned by representatives of 67/82 (82%) local patient associations, of which 17 (25%) provided axSpA-specific SGE (16/17 SGE programmes with both land-based exercise and hydrotherapy and 1/17 with only hydrotherapy). These involved in total 56 groups with 684 participants and 59 supervisors, of whom 54 were physical therapists and 21 had had postgraduate education on rheumatic and musculoskeletal diseases (RMDs). Besides mobility and strengthening exercises and sports (17/17), most programmes included aerobic exercise (10/17), but rarely with heart rate monitoring (1/17), patient education (8/17), periodic assessments (2/17), or exercise personalisation (1/17). In the Netherlands, a quarter of local patient associations organised axSpA-specific SGE, mostly containing land-based exercises combined with sports and hydrotherapy. Most supervisors lacked postgraduate education on RMDs and most programmes lacked intensity monitoring, patient education, periodic assessments, and personalisation, which are needed for optimising exercise programmes according to current scientific insights.

Dutch multidisciplinary guideline on Achilles tendinopathy.

OBJECTIVE: To provide a comprehensive, evidence-based overview of the risk factors, prevention, diagnosis, imaging, treatment and prognosis for Achilles tendinopathy. To make clinical recommendations for healthcare practitioners and patients. DESIGN: Comprehensive multidisciplinary guideline process funded by the Quality Foundation of the Dutch Federation of Medical Specialists. This process included a development, commentary and authorisation phase. Patients participated in every phase. DATA SOURCES: Multiple databases and existing guidelines were searched up to May 2019. Information from patients, healthcare providers and other stakeholders were obtained using a digital questionnaire, focus group interview and invitational conference. STUDY ELIGIBILITY CRITERIA: Studies on both insertional and/or midportion Achilles tendinopathy were eligible. Specific eligibility criteria were described per module. DATA EXTRACTION AND SYNTHESIS: To appraise the certainty of evidence, reviewers extracted data, assessed risk of bias and used the Grading of Recommendations Assessment, Development and Evaluation method, where applicable. Important considerations were: patient values and preferences, costs, acceptability of other stakeholders and feasibility of implementation. Recommendations were made based on the results of the evidence from the literature and the considerations. PRIMARY OUTCOME MEASURE: The primary and secondary outcome measures were defined per module and defined based on the input of patients obtained in collaboration with the Netherlands Patient Federation and healthcare providers from different professions. RESULTS: Six specific modules were completed: risk factors and primary prevention, diagnosis, imaging, treatment prognosis and secondary prevention for Achilles tendinopathy. SUMMARY/CONCLUSION: Our Dutch multidisciplinary guideline on Achilles tendinopathy provides six modules developed according to the standards of the Dutch Federation of Medical Specialists. Evidence-based recommendations for clinical practice are given for risk factors, prevention, diagnosis, imaging, treatment and prognosis. This guideline can assist healthcare providers and patients in clinical practice.

Adequately dosed aerobic physical activity in people with axial spondyloarthritis: associations with physical therapy.

INTRODUCTION: This study aimed to compare the engagement in moderate- and vigorous-intensity PA in axSpA patients with and without current physical therapy (PT). METHODS: In this cross-sectional study, a survey, including current PT treatment (yes/no) and PA, using the 'Short QUestionnaire to ASsess Health-enhancing PA' (SQUASH), was sent to 458 axSpA patients from three Dutch hospitals. From the SQUASH, the proportions meeting aerobic PA recommendations (≥ 150 min/week moderate-, ≥ 75 min/week vigorous-intensity PA or equivalent combination; yes/no) were calculated. To investigate the association between PT treatment and meeting the PA recommendations, odds ratios (OR) with 95% confidence intervals (95% CI) were estimated using logistic regression models, adjusting for sex, age, health status and hospital. RESULTS: The questionnaire was completed by 200 patients, of whom 68%, 50% and 82% met the moderate-, vigorous- or combined-intensity PA recommendations, respectively. Ninety-nine patients (50%) had PT treatment, and those patients were more likely to meet the moderate- (OR 2.09 [95% CI 1.09-3.99]) or combined-intensity (OR 3.35 [95% CI 1.38-8.13]) PA recommendations, but not the vigorous-intensity PA recommendation (OR 1.53 [95% CI 0.80-2.93]). Aerobic exercise was executed in 19% of individual PT programs. CONCLUSION: AxSpA patients with PT were more likely to meet the moderate- and combined-intensity PA recommendations, whereas there was no difference in meeting the vigorous-intensity PA recommendation. Irrespective of having PT treatment, recommendations for vigorous-intensity PA are met by only half of the patients. Implementation should thus focus on aerobic PA in patients without PT and on vigorous-intensity PA in PT programs.

Validity and responsiveness of the Michigan Hand Questionnaire in patients with systemic sclerosis.

OBJECTIVE: The aim was to assess the validity and responsiveness of the Michigan Hand Questionnaire (MHQ) in patients with SSc. METHODS: Data were gathered in connection with a randomized, controlled trial comparing the effectiveness of a 12-week multidisciplinary team care programme, including a hand function treatment module, with regular care. Hand function was evaluated by the MHQ (37 items, six domains: Function, Daily activities, Pain, Work, Aesthetics and Satisfaction) and other measurements, including the HAQ, Hand Mobility in Scleroderma, Sequential Occupational Dexterity Assessment (SODA), grip strength, pinch grip and modified Rodnan Skin Score. Fifty-three patients (28 intervention group and 25 control group) completed evaluation at baseline and after 12 weeks. Validity was determined by computing Spearman correlation coefficients between the baseline MHQ total score and subscales and other measures of (hand) disability. Responsiveness in the intervention group was evaluated by the standardized response mean and effect size (ES). In addition, the pooled ES for the difference between the two groups was computed. RESULTS: Significant correlations were seen between the MHQ total score and the HAQ (r = -0.62), Hand Mobility in Scleroderma (r = -0.54), SODA (r = 0.47), SODA Pain (r = 0.32) and modified Rodnan Skin Score (r = 0.46). The ES of the MHQ total score within the intervention group was 0.49, which was larger than that of all other outcome measures. Similar results were obtained for the standardized response mean. The pooled ES of the difference between intervention and control groups for the MHQ total score was 0.86. CONCLUSION: The MHQ demonstrated adequate validity and responsiveness in patients with SSc.

Hand function is already reduced before RA development and reflects subclinical tenosynovitis.

BACKGROUND: Clinically suspect arthralgia (CSA) is characterised by arthralgia of small joints and considered a risk stage for development of rheumatoid arthritis (RA). However, it remains unknown if the function of the hands is already affected and what mechanisms underlie impaired hand-function in CSA. METHODS: We studied various measures of hand function in two CSA populations. CSA patients in the TREAT EARLIER-trial (n=236) were evaluated at baseline for: grip strength on a dynamometer (GS), patient-reported difficulties in the grip domain of the Health Assessment Questionnaire (HAQ) questionnaire and incomplete fist closure at physical examination. Findings were validated in an independent CSA cohort (n=600) where hand function was measured as: GS evaluated by squeezing the examiner's fingers, grip domain of the HAQ questionnaire and fist closure. Contrast-enhanced MRI of the hands measured synovitis, tenosynovitis and bone marrow oedema (summed as subclinical inflammation) in both cohorts. RESULTS: GS (on a dynamometer) was reduced in 75% compared with reference values in healthy controls, 60% reported grip difficulties and 13% had incomplete fist closure. Reduced GS was associated with subclinical inflammation (-0.38 kg/point inflammation, 95% CI -0.68 to -0.08). Studying separate MRI features, GS reduction was independently associated with tenosynovitis, decreasing with -2.63 kg (95% CI -2.26 to -0.33)/point tenosynovitis (range observed tenosynovitis scores: 0-20). Similar relations with tenosynovitis were seen for patient-reported grip difficulties (OR 1.12/point, 95% CI 1.07 to 1.42) and incomplete fist closure (OR 1.36/point, 95% CI 1.03 to 1.79). In the validation cohort, 36% had decreased examiner-assessed GS, 51% reported grip difficulties and 14% incomplete fist closure: all were associated with tenosynovitis. Decreased dynamometer-measured GS was most sensitive for detecting tenosynovitis (75%), while incomplete fist closure was most specific (88%-90%). CONCLUSION: Hand function is already often affected before RA development. These limitations are related to subclinical inflammation and tenosynovitis in particular.

Differences in characteristics, health status and fulfillment of exercise recommendations between axial spondyloarthritis patients with and without supervised group exercise.

OBJECTIVE: Since decades, supervised group exercise (SGE) is recommended for people with axial spondyloarthritis (axSpA). This study examines if weekly SGE contributes to fulfillment of exercise recommendations in axSpA patients. METHODS: Cross-sectional data from three studies with axSpA patients in The Netherlands, including two with outpatient populations (n = 196 and n = 153) and one with SGE participants (n = 128), were analysed. Sociodemographic and disease characteristics, SGE participation, health status (ASAS Health Index), spinal mobility and fulfillment of the recommendations for leisure-time aerobic (≥150 min/week moderate-intensity or ≥75 min/week vigorous-intensity) and strength and mobility (≥2 sessions/week) exercise (measured with SQUASH-questionnaire) were assessed. Differences between patients with and without SGE were analysed. RESULTS: In the two outpatient populations (n = 349), 17 patients (5%) used SGE. The SGE participants (n = 145) were significantly older, had longer disease duration, were less frequently employed, used less medication and had worse spinal mobility than patients without SGE (n = 332). There were no significant differences in health status. Patients with SGE fulfilled the moderate-intensity aerobic (89 % vs. 69%) and strength and mobility (44 % vs. 29%) exercise recommendations more often than patients without SGE, but the aerobic exercise recommendation was less often fulfilled with vigorous-intensity exercise (5 % vs. 12%). CONCLUSION: SGE is used by just few, especially older, axSpA patients and contributes to fulfilling recommendations for moderate-intensity, mobility and strength exercise. Both in patients with and without SGE, only a minority fulfilled the recommendations for vigorous-intensity, strength and mobility exercises. Therefore, future promotion of exercise should focus on implementing these types of exercise.

Development of radiographic classification criteria for hand osteoarthritis: a methodological report (Phase 2).

OBJECTIVES: In Phase 1 of developing new hand osteoarthritis (OA) classification criteria, features associated with hand OA were identified in a population with hand complaints. Radiographic findings could better discriminate patients with hand OA and controls than clinical examination findings. The objective of Phase 2 was to achieve consensus on the features and their weights to be included in three radiographic criteria sets of overall hand OA, interphalangeal OA and thumb base OA. METHODS: Multidisciplinary, international expert panels were convened. Patient vignettes were used to identify important features consistent with hand OA. A consensus-based decision analysis approach implemented using 1000minds software was applied to identify the most important features and their relative importance influencing the likelihood of symptoms being due to hand OA. Analyses were repeated for interphalangeal and thumb base OA. The reliability and validity of the proposed criteria sets were tested. RESULTS: The experts agreed that the criteria sets should be applied in a population with pain, aching or stiffness in hand joint(s) not explained by another disease or acute injury. In this setting, five additional criteria were considered important: age, morning stiffness, radiographic osteophytes, radiographic joint space narrowing and concordance between symptoms and radiographic findings. The reliability and validity were very good. CONCLUSION: Radiographic features were considered critical when determining whether a patient had symptoms due to hand OA. The consensus-based decision analysis approach in Phase 2 complemented the data-driven results from Phase 1, which will form the basis of the final classification criteria sets.

How to optimize exercise behavior in axial spondyloarthritis? Results of an intervention mapping study.

OBJECTIVE: Many individuals with axial spondyloarthritis (axSpA) do not engage in adequate exercise, despite its proven health benefits. This study aimed to identify the intervention components needed to optimize exercise behavior in people with axSpA. METHODS: The first three steps of the Intervention Mapping protocol were used: 1) needs assessment; 2) identification of axSpA-specific exercise barriers and facilitators (´determinants'); 3) selection of effective intervention components addressing potentially modifiable determinants. All three steps included scoping reviews and semi-structured interviews with patients (n = 2) and physical therapists (n = 2). RESULTS: The scoping reviews included 28, 23 and 15 papers, respectively. Step 1 showed that only one third of axSpA patients exercise regularly, demonstrating especially a lack of strengthening and cardiorespiratory exercises. Based on eight determinants identified in Step 2, 10 intervention components were selected in Step 3: education, motivational interviewing, goal setting, action planning, monitoring, feedback, tailoring, guided practice, therapists' training and group exercise encouragement. CONCLUSION: Using the Intervention Mapping method, 10 intervention components for optimizing exercise behavior in people with axSpA were identified and an intervention with behavior change guidance and a training for health professionals is proposed. PRACTICE IMPLICATIONS: This study provides a foundation for the development of an axSpA-specific exercise intervention.

Supervised Group Exercise in Axial Spondyloarthritis: Patients' Satisfaction and Perspective on Evidence-Based Enhancements.

OBJECTIVE: Supervised group exercise (SGE) has been proven effective in patients with axial spondyloarthritis (SpA), but its contents and dosage do not always comply with current scientific insight. This aim of this study was to describe axial SpA patients' satisfaction with current SGE and perspective on potential evidence-based SGE enhancements. METHODS: Patients with axial SpA who participated in SGE in 4 regions in The Netherlands (n = 118) completed a cross-sectional survey on their satisfaction with features of their current SGE (8 questions scored on a 3-point Likert scale; 1 overall grade, scored according to an 11-point scale) and their perspective on the introduction of appropriately dosed cardiorespiratory and strengthening exercise, monitoring of exercise intensity, periodic reassessments, patient education, and supervision by physical therapists with specific expertise (4 dichotomous questions and one 5-point Likert scale). RESULTS: Most patients were satisfied with the current total intensity (84 of 112 patients [75%]), duration (93 of 111 patients [84%]), and load (89 of 117 patients [76%]) of the program and the proportion of mobility (102 of 114 patients [90%]), strengthening (90 of 115 patients [78%]), and cardiorespiratory exercise (82 of 114 patients [72%]). The median overall grade of the program was a 7 (interquartile range 7-8). Most patients agreed with the implementation of more frequent (home) exercise (73 of 117 patients [62%]), heart-rate monitoring (97 of 117 patients [83%]), and annual reassessments (97 of 118 patients [82%]), whereas 50% agreed with the introduction of patient education (37 of 74 patients). The majority found supervision by therapists specializing in axial SpA to be of high importance (105 of 118 patients [89%]). CONCLUSION: The majority of SGE participants with axial SpA were satisfied with current SGE but also agreed with enhancements in line with scientific evidence. Current satisfaction levels indicate that a planned implementation strategy, including education and addressing potential barriers and facilitators for the uptake of enhancements, is warranted.

Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis.

BACKGROUND: An up-to-date overview of the effectiveness and safety of dynamic exercise therapy (exercise therapy with a sufficient intensity, duration, and frequency to establish improvement in aerobic capacity and/or muscle strength) is lacking. OBJECTIVES: To assess the effectiveness and safety of short-term (< three months) and long-term (> three months) dynamic exercise therapy programs (aerobic capacity and/or muscle strength training), either land or water-based, for people with RA. To do this we updated a previous Cochrane review (van den Ende 1998) and made categories for the different forms of dynamic exercise programs. SEARCH STRATEGY: A literature search (to December 2008) within various databases was performed in order to identify randomised controlled trials (RCTs). SELECTION CRITERIA: RCTs that included an exercise program fulfilling the following criteria were selected: a) frequency at least twice weekly for > 20 minutes; b) duration > 6 weeks; c) aerobic exercise intensity > 55% of the maximum heart rate and/or muscle strengthening exercises starting at 30% to 50% of one repetition maximum; and d) performed under supervision. Moreover, the RCT included one or more of the following outcome measures: functional ability, aerobic capacity, muscle strength, pain, disease activity or radiological damage. DATA COLLECTION AND ANALYSIS: Two review authors independently selected eligible studies, rated the methodological quality, and extracted data. A qualitative analysis (best-evidence synthesis) was performed and, where appropriate, a quantitative data analysis (pooled effect sizes). MAIN RESULTS: In total, eight studies were included in this updated review (two additional studies). Four of the eight studies fulfilled at least 8/10 methodological criteria. In this updated review four different dynamic exercise programs were found: (1) short-term, land-based aerobic capacity training, which results show moderate evidence for a positive effect on aerobic capacity (pooled effect size 0.99 (95% CI 0.29 to 1.68). (2) short-term, land-based aerobic capacity and muscle strength training, which results show moderate evidence for a positive effect on aerobic capacity and muscle strength (pooled effect size 0.47 (95% CI 0.01 to 0.93). (3) short-term, water-based aerobic capacity training, which results show limited evidence for a positive effect on functional ability and aerobic capacity. (4) long-term, land-based aerobic capacity and muscle strength training, which results show moderate evidence for a positive effect on aerobic capacity and muscle strength. With respect to safety, no deleterious effects were found in any of the included studies. AUTHORS' CONCLUSIONS: Based on the evidence, aerobic capacity training combined with muscle strength training is recommended as routine practice in patients with RA.

Responsiveness of the Michigan Hand Outcomes Questionnaire--Dutch language version in patients with rheumatoid arthritis.

OBJECTIVE: To investigate the responsiveness of the Michigan Hand Outcomes Questionnaire (MHQ) in patients with rheumatoid arthritis (RA) who were treated in a multidisciplinary hand clinic. DESIGN: Observational study comparing the responsiveness of the MHQ with that of various other outcome measures for hand function. SETTING: Multidisciplinary hand clinic within a tertiary referral center for rheumatologic care. PARTICIPANTS: Twenty-eight patients with problems in hand function due to RA were assessed before and 3 months after conservative and/or surgical treatment. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Assessments included, apart from a previously validated Dutch language version of the MHQ, a visual analog scale for pain, grip strength, the Sequential Occupational Dexterity Assessment, the Arthritis Impact Measurement Scales (AIMS) hand and finger function scale, and each patient's rating of subjective change in hand function. Measurements of responsiveness included the standardized response mean (SRM), effect size, and responsiveness ratio. In addition, the Spearman rank correlations (rho) between the change scores of the MHQ and those of other measures of hand function were calculated. RESULTS: The mean MHQ total score improved significantly between baseline (mean +/- standard deviation, 48.3+/-12.2) and follow-up (mean, 54.7+/-16.9) (change score, -7.2; 95% confidence interval, -11.1 to -3.3). The SRM, effect size, and responsiveness ratio of the MHQ total score were -0.72, -0.52, and -1.99, respectively. Significant associations were found between the changes of the MHQ total score and each patient's rating of subjective change in hand function (rho=.64, P=.001) and the change score of the AIMS hand function scale (rho=-.24, P=.260). CONCLUSIONS: The MHQ proved to be a responsive measure of hand function in patients with RA who were treated in connection with a multidisciplinary hand clinic.