Enhancing current guidance for psoriatic arthritis and its comorbidities: recommendations from an expert consensus panel.

OBJECTIVES: Existing guidelines for psoriatic arthritis (PsA) cover many aspects of management. Some gaps remain relating to routine practice application. An expert group aimed to enhance current guidance and develop recommendations for clinical practice that are complementary to existing guidelines. METHODS: A steering committee comprising experienced, research-active clinicians in rheumatology, dermatology and primary care agreed on themes and relevant questions. A targeted literature review of PubMed and Embase following a PICO framework was conducted. At a second meeting, recommendations were drafted and subsequently an extended faculty comprising rheumatologists, dermatologists, primary care clinicians, specialist nurses, allied health professionals, non-clinical academic participants and members of the Brit-PACT patient group, was recruited. Consensus was achieved via an online voting platform when 75% of respondents agreed in the range of 7-9 on a 9-point scale. RESULTS: The guidance comprised 34 statements covering four PsA themes. Diagnosis focused on strategies to identify PsA early and refer appropriately, assessment of diagnostic indicators, use of screening tools and use of imaging. Disease assessment centred on holistic consideration of disease activity, physical functioning and impact from a patient perspective, and on how to implement shared decision-making. For comorbidities, recommendations included specific guidance for high-impact conditions such as depression and obesity. Management statements (which excluded extant guidance on pharmacological therapies) covered multidisciplinary team working, implementation of lifestyle modifications and treat-to-target strategies. Minimising corticosteroid use was recommended where feasible. CONCLUSION: The consensus group have made evidence-based best practice recommendations for the management of PsA to enhance the existing guidelines.

Bone in osteoarthritis: imaging and interventions.

PURPOSE OF REVIEW: To review the recent literature on bone in osteoarthritis (OA), with a focus on imaging and intervention studies. RECENT FINDINGS: Most studies focused on knee OA; hip and hand studies were uncommon. Bone shape studies demonstrated that shape changes precede radiographic OA, predict joint replacement, and have demonstrated high responsiveness. Novel quantitative 3D imaging markers (B-score) have better characterized OA severity, including preradiographic OA status. The addition of computerized tomography-derived 3D metrics has improved the prediction of hip joint replacement when compared to radiographs alone.Recent studies of bisphosphonates for knee OA have reported no benefits on pain or bone marrow lesion (BML) size. A meta-analysis on Vitamin D supplementation in knee OA suggested minimal symptom improvement and no benefits on the structure. Cathepsin K inhibition demonstrated reduction in OA bone change progression, but with no symptom benefit. Studies of injections of bone substitutes into BMLs (subchondroplasty) have generally been small and potential benefits remain unclear. SUMMARY: Subchondral bone features are associated with pain, incidence and progression of OA. Recent studies have validated quantitative bone shape as a biomarker for OA trials. Trials of bone-targeted OA therapies have been disappointing although cathepsin K inhibition may slow structural progression.

Impact and therapy of osteoarthritis: the Arthritis Care OA Nation 2012 survey.

Osteoarthritis (OA) is the fastest growing cause of disability worldwide. The aim of this study was to understand the impact of OA on individuals and to explore current treatment strategies. An online UK-wide survey of people with self-reported OA was conducted, composed of 52 questions exploring the impact of OA, diagnosis and treatment, the role of health professionals and self-management. Four thousand forty-three people were invited with 2,001 respondents (49 % response, 56 % women; mean age 65 years). Fifty-two percent reported that OA had a large impact on their lives. Fifteen percent of respondents had taken early retirement on average 7.8 years earlier than planned. In consultations with general practitioners, only half reported a discussion on pain; fewer reported discussing their fears (21 %) or management goals (15 %). Nearly half (48 %) reported not seeking medical help until pain was frequently unbearable. Oral analgesics (62 %), topical therapies (47 %), physiotherapy (38 %) and steroid injections (28 %) were commonly used. The majority (71 %) reported varying degrees of persistent pain despite taking all prescribed medication. Although 64 % knew that increasing exercise was important, only 36 % acted on this knowledge; 87 % who increased exercise found it beneficial. Over half had future concerns related to mobility (60 %), maintaining independence (52 %) and coping with everyday activities (51 %). OA had significant individual economic impact especially on employment. Current treatment strategies still leave most people in pain with significant fears for the future. There is considerable opportunity to improve the holistic nature of OA consultations especially in provision of information and promotion of self-management strategies.

Acupuncture for chronic knee pain: a randomized clinical trial.

IMPORTANCE: There is debate about benefits of acupuncture for knee pain. OBJECTIVE: To determine the efficacy of laser and needle acupuncture for chronic knee pain. DESIGN, SETTING, AND PARTICIPANTS: Zelen-design clinical trial (randomization occurred before informed consent), in Victoria, Australia (February 2010-December 2012). Community volunteers (282 patients aged ≥50 years with chronic knee pain) were treated by family physician acupuncturists. INTERVENTIONS: No acupuncture (control group, n = 71) and needle (n = 70), laser (n = 71), and sham laser (n = 70) acupuncture. Treatments were delivered for 12 weeks. Participants and acupuncturists were blinded to laser and sham laser acupuncture. Control participants were unaware of the trial. MAIN OUTCOMES AND MEASURES: Primary outcomes were average knee pain (numeric rating scale, 0 [no pain] to 10 [worst pain possible]; minimal clinically important difference [MCID], 1.8 units) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, 0 [no difficulty] to 68 [extreme difficulty]; MCID, 6 units) at 12 weeks. Secondary outcomes included other pain and function measures, quality of life, global change, and 1-year follow-up. Analyses were by intention-to-treat using multiple imputation for missing outcome data. RESULTS: At 12 weeks and 1 year, 26 (9%) and 50 (18%) participants were lost to follow-up, respectively. Analyses showed neither needle nor laser acupuncture significantly improved pain (mean difference; -0.4 units; 95% CI, -1.2 to 0.4, and -0.1; 95% CI, -0.9 to 0.7, respectively) or function (-1.7; 95% CI, -6.1 to 2.6, and 0.5; 95% CI, -3.4 to 4.4, respectively) compared with sham at 12 weeks. Compared with control, needle and laser acupuncture resulted in modest improvements in pain (-1.1; 95% CI, -1.8 to -0.4, and -0.8; 95% CI, -1.5 to -0.1, respectively) at 12 weeks, but not at 1 year. Needle acupuncture resulted in modest improvement in function compared with control at 12 weeks (-3.9; 95% CI, -7.7 to -0.2) but was not significantly different from sham (-1.7; 95% CI, -6.1 to 2.6) and was not maintained at 1 year. There were no differences for most secondary outcomes and no serious adverse events. CONCLUSIONS AND RELEVANCE: In patients older than 50 years with moderate or severe chronic knee pain, neither laser nor needle acupuncture conferred benefit over sham for pain or function. Our findings do not support acupuncture for these patients. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12609001001280.

How do people with knee osteoarthritis use osteoarthritis pain medications and does this change over time? Data from the Osteoarthritis Initiative.

INTRODUCTION: The aim of this analysis was to describe comprehensively the cross-sectional and longitudinal patterns of analgesic and nutraceutical medication use for knee osteoarthritis (OA) in a contemporary US cohort and to investigate associated demographic and clinical factors. METHODS: Baseline, 12, 24 and 36 month data were obtained retrospectively from the National Institutes of Health Osteoarthritis Initiative. Participants had symptomatic radiographic knee OA. Multiple binary logistic regression models identified characteristics independently associated with the use of analgesics or nutraceuticals. RESULTS: We included 987 subjects (55.9% female, mean age 61.5 years, 71.0% white). At baseline, 68.2% reported frequent use of a conventional analgesic or nutraceutical for joint pain (for more than half of the previous month). Non-prescription non-steroidal anti-inflammatory drugs (NSAIDs) were the most frequently reported medications (26.8%), even in those more than 75-years old. Multiple conventional analgesics were used by 11.9%. Frequent analgesic use was more likely in women (odds ratio (OR) 1.8 (95% confidence interval (CI) 1.3 to 2.3)) and people with more pain (moderate 1.7 (1.2 to 2.4); severe 3.1 (2.1 to 4.7)); nutraceutical use was less likely in non-whites (0.4 (0.3 to 0.6)), those more than 74-years old (0.6 (0.3 to 0.9)) and those with comorbidities (0.6 (0.5 to 0.9)) and more likely in people with Kellgren-Lawrence (KL) grade 4 (2.2 (1.5 to 3.3)). Overall there was no change in the proportion of participants frequently using prescription or over the counter (OTC) analgesics at 36 months, although most people had changed medication type; of those using a traditional analgesic at baseline approximately one third were still using the same type at 36 months (ranging from 26.2% of baseline prescription NSAID users to 40.6% of baseline acetaminophen users). All participants reporting baseline analgesic use also reported 36 month analgesic use. Female participants (OR 95% CI 1.2 to 3.2, P = 0.009), those with high body mass index (1.2 to 4.8, P = 0.010) and those with moderate (1.6 to 2.6, P = 0.090) or severe (1.8 to 12.0, P = 0.002) baseline pain were more likely to use pain medication during the 36 month follow-up period; participants more than 75-years old were less likely (0.2 to 1.0, P = 0.053). CONCLUSIONS: Most people with knee OA used pharmacological therapies frequently, and use appeared to be according to American College of Rheumatology recommendations. Change in medication type used was common. Persistent non-prescription NSAID use in older people is an area of concern.

Osteoarthritis: a holistic approach.

Osteoarthritis represents a massive and rapidly increasing burden on our society and the NHS. Current treatments are limited in efficacy and have significant toxicities. A conference was organised in conjunction with the British Society of Rheumatology with the aim of updating frontline clinicians and researchers on the size and causes of this problem, with a focus on modern management.

Should imaging be a component of rheumatoid arthritis remission criteria? A comparison between traditional and modified composite remission scores and imaging assessments.

OBJECTIVES: Patients can fulfil clinical criteria for remission, yet still have evidence of synovitis detectable clinically and by ultrasound, and this is associated with structural damage. Stricter remission criteria may more accurately reflect true remission (no synovitis). This hypothesis was examined by studying patients using more stringent thresholds for clinical remission and determining their levels of ultrasound synovitis. METHODS: Rheumatoid arthritis patients with a disease activity score in 28 joints (DAS28) ≤2.6 for at least 6 months were classified using standard and more stringent DAS28 and simplified disease activity index (SDAI) remission thresholds and the corresponding clinical and ultrasound imaging measures of synovitis recorded. RESULTS: 128 patients (all DAS28 <2.6, median DAS28 1.70) receiving either disease-modifying antirheumatic drugs alone (n=66) or with a tumour necrosis factor blocker (n=62) were recruited. Of the 640 imaged joints, 5% had moderate or severe power Doppler (PD) activity, 8% were clinically swollen and 1% tender. In patients fulfilling DAS28, American College of Rheumatology or SDAI remission criteria, moderate or severe PD activity was present in 21%, 15% and 19%, respectively. More stringent DAS28 and SDAI criteria reduced the mean number of swollen and tender joints (p<0.001) but not the percentage of patients with PD activity: 32 patients had a DAS28 <1.17 but eight (25%) had significant PD activity. CONCLUSION: Using more stringent remission criteria resulted in reduced signs and symptoms of inflammation, but the percentage of joints with PD activity was not reduced, even in those without signs or symptoms. These data suggest that clinical criteria are sufficiently insensitive to detect low but clinically relevant levels of inflammation accurately.

Exercise therapy after corticosteroid injection for moderate to severe shoulder pain: large pragmatic randomised trial.

OBJECTIVE: To compare the effectiveness of subacromial corticosteroid injection combined with timely exercise and manual therapy (injection plus exercise) or exercise and manual therapy alone (exercise only) in patients with subacromial impingement syndrome. DESIGN: Pragmatic randomised clinical trial. SETTING: Primary care based musculoskeletal service. Patients Adults aged 40 or over with subacromial impingement syndrome with moderate or severe shoulder pain. INTERVENTIONS: Injection plus exercise or exercise only. MAIN OUTCOME MEASURES: Primary outcome was the difference in improvement in the total shoulder pain and disability index at 12 weeks. RESULTS: 232 participants were randomised (115 to injection plus exercise, 117 to exercise only). The mean age was 56 (range 40-78), 127 were women, and all had had a median of 16 weeks of shoulder pain (interquartile range 12-28). At week 12 there was no significant difference between the groups in change in total pain and disability index (mean difference between change in groups 3.26 (95% confidence interval -0.81 to 7.34), P=0.116). Improvement was significantly greater in the injection plus exercise group at week 1 (6.56, 4.30 to 8.82) and week 6 (7.37, 4.34 to 10.39) for the total pain and disability index (P<0.001), with no differences at week 24 (-2.26, -6.77 to 2.25, P=0.324). CONCLUSIONS: In the treatment of patients with subacromial impingement syndrome, injection plus exercise and exercise only are similarly effective at 12 weeks. Trial registration ISRCT 25817033; EudraCT No 2005-003628-20.

Optimising pain control in osteoarthritis.

A recent large survey showed that 81% of people with osteoarthritis (OA) are in constant pain or are limited in their ability to perform everyday tasks. Patients present with joint pain and stiffness and are often unable to carry out their usual activities which impacts significantly on their quality of life. Anxiety and depression are common in patients with OA and will affect their mood and response to pain so identifying and treating associated anxiety and depression is very important. The PHQ9 and GAD7 can be used to screen for depression and anxiety. The OA process affects all structures within a joint, including the synovial lining and the subchondral bone. When sensitive MRI techniques are used synovitis is found to be almost ubiquitous in painful knee OA. When ultrasound is used, synovitis is seen in up to 45% of patients with painful hand OA. Many current treatments for OA are thought to target the synovium e.g. NSAIDs and this may be why they are effective. Changes in the subchondral bone are also common on MRI and associated with pain. Paracetamol and topical NSAIDs should be tried before oral NSAIDs. Topical NSAIDs are effective in the short-term and are not associated with systemic toxicity. Oral NSAIDs should be used at the lowest effective dose for the shortest possible time. All oral NSAIDs and COX-2 drugs should be prescribed with a PPI. There is less trial data on opioids than on NSAIDs but there is evidence for their efficacy. Patients who have moderate to severe pain that is not responding to oral analgesics or anti-inflammatories may benefit from intra-articular corticosteroids. Timing of analgesia is important. Advise patients to use analgesia before they exercise, so adherence to exercise routines is maintained. Consider long-acting preparations so pain relief is at a maximum throughout the most symptomatic period of the day or night.

Assessment and management of neurogenic claudication associated with lumbar spinal stenosis in a UK primary care musculoskeletal service: a survey of current practice among physiotherapists.

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.