Standards of care for acute and chronic musculoskeletal pain: the Bone and Joint Decade (2000-2010).

Musculoskeletal conditions often manifest with the onset of pain and the resulting physical limitations. Musculoskeletal pain is almost inevitable in an individual's lifetime. It is one of the most common reasons for self-medication and entry into the health care system. Musculoskeletal pain affects 1 in 4 adults and is the most common source of serious long-term pain and physical disability. The monumental impact of musculoskeletal conditions is now recognized by the United Nations, the World Health Organization, World Bank, and numerous governments throughout the world through support of the Bone and Joint Decade 2000 to 2010 initiative. Individuals with musculoskeletal pain concerns are regularly ignored, their complaints often misunderstood by health care providers, and accordingly they do not receive timely or effective treatment. The standards of care in this document are designed to provide generic guidelines for appropriate care of people with acute or chronic musculoskeletal pain. This document was developed over a 4-year period using multiple international meetings and a Task Force of the Bone and Joint Decade for developing international standards for the care of acute and chronic musculoskeletal pain. The final document is a product of the World Health Organization Collaborating Centre for Evidence-Based Health Care in Musculoskeletal Disorders.

Comparison of treatment strategies in early rheumatoid arthritis: a randomized trial.

BACKGROUND: In patients with early rheumatoid arthritis, initial combination therapies provide earlier clinical improvement and less progression of joint damage after 1 year compared with initial monotherapies (as demonstrated in the BeSt study). OBJECTIVE: To evaluate whether the initial clinical and radiographic efficacy of combination therapies could be maintained during the second year of follow-up in patients with early rheumatoid arthritis. DESIGN: Randomized, controlled clinical trial with blinded assessors. SETTING: 18 peripheral and 2 university medical centers in the Netherlands. PATIENTS: 508 patients with early active rheumatoid arthritis. INTERVENTION: Sequential monotherapy (group 1), step-up combination therapy (group 2), initial combination therapy with tapered high-dose prednisone (group 3), or initial combination therapy with infliximab (group 4). Trimonthly treatment adjustments were made to achieve low disease activity. MEASUREMENTS: Primary end points were functional ability (Health Assessment Questionnaire) and Sharp-van der Heijde score for radiographic joint damage. RESULTS: Groups 3 and 4 had more rapid clinical improvement during the first year; all groups improved further to a mean functional ability score of 0.6 (overall, P = 0.257) and 42% were in remission (overall, P = 0.690) during the second year. Progression of joint damage remained better suppressed in groups 3 and 4 (median scores of 2.0, 2.0, 1.0, and 1.0 in groups 1, 2, 3, and 4, respectively [P = 0.004]). After 2 years, 33%, 31%, 36%, and 53% of patients in groups 1 through 4, respectively, were receiving single-drug therapy for initial treatment. There were no significant differences in toxicity. LIMITATIONS: Patients and physicians were aware of the allocated group, and the assessors were blinded. CONCLUSIONS: Currently available antirheumatic drugs can be highly effective in patients with early rheumatoid arthritis in a setting of tight disease control. Initial combination therapies seem to provide earlier clinical improvement and less progression of joint damage, but all treatment strategies eventually showed similar clinical improvements. In addition, combination therapy can be withdrawn successfully and less treatment adjustments are needed than with initial monotherapies.

How to assess musculoskeletal conditions. Prognostics.

Both patients and clinicians confronted with rheumatic disease need prognostic information to direct their management strategies. Prognosis refers to the prediction of outcome of disease. Clinicians confronted with prognostic problems in individual patients usually have to rely on evidence from prognostic studies on prognostic factors or clinical prediction models. Prognostic factors are patient characteristics that can be used to predict the outcome of disease. Clinical prediction models are sets of prognostic factors developed by logistic regression modelling. These models estimate the probabilities of the various forms of outcome of a disease and they can be valuable prognostic tools in daily clinical practice. To judge whether an article on prognosis fulfils the necessary methodological standards and contains relevant information, clinicians can use a number of guidelines that are described in this chapter. To find out whether the results of a prognostic study are applicable to individual patients in daily practice, the clinician should obtain clarity on three aspects: (i) generalizability, (ii) the possibility of extrapolating the results to the particular clinical situation, and (iii) feasibility. Decision analysis values the information provided by prognostic testing insofar as it alters treatment strategies. The treatment threshold is the probability of a particular disease outcome for which the net risks of treatment and no treatment are equal. Treatment is indicated if the probability of the disease outcome is higher than the treatment threshold.

Introduction: Value of epidemiological research for clinical practice.

Epidemiology is the scientific analysis of the occurrence of diseases in the general population in relationship to the characteristics of the individual subjects and their environment. Traditional epidemiology is concerned with discovering basic truths on the frequencies of diseases and their aetiology; clinical epidemiology represents a special field that translates clinical practice into quantitative science; public health epidemiology is the basis of knowledge, prevention and treatment of diseases in the population. Epidemiology has an important clinical impact for it can be used to understand the pathogenesis of diseases, improve diagnostic accuracy, help the patient to reduce risk factors and the physician to choose the correct therapeutic approach.

Cost-utility analysis of treatment strategies in patients with recent-onset rheumatoid arthritis.

OBJECTIVE: To evaluate societal costs and quality-adjusted life years (QALYs) of treatment strategies for patients with recent-onset active rheumatoid arthritis (RA). METHODS: Patients (n = 508) were randomly allocated to 1 of 4 treatment strategy groups: sequential monotherapy, step-up combination therapy, initial combination therapy with prednisone, or initial combination therapy with infliximab. For 2 years, patients reported cost and utility measures. RESULTS: Average QALYs (ideally 2.00) for groups 1-4 were 1.29, 1.31, 1.32, and 1.41, respectively, for the British EuroQol (P