EULAR recommendations for the health professional's approach to pain management in inflammatory arthritis and osteoarthritis.

Pain is the predominant symptom for people with inflammatory arthritis (IA) and osteoarthritis (OA) mandating the development of evidence-based recommendations for the health professional's approach to pain management. A multidisciplinary task force including professionals and patient representatives conducted a systematic literature review of systematic reviews to evaluate evidence regarding effects on pain of multiple treatment modalities. Overarching principles and recommendations regarding assessment and pain treatment were specified on the basis of reviewed evidence and expert opinion. From 2914 review studies initially identified, 186 met inclusion criteria. The task force emphasised the importance for the health professional to adopt a patient-centred framework within a biopsychosocial perspective, to have sufficient knowledge of IA and OA pathogenesis, and to be able to differentiate localised and generalised pain. Treatment is guided by scientific evidence and the assessment of patient needs, preferences and priorities; pain characteristics; previous and ongoing pain treatments; inflammation and joint damage; and psychological and other pain-related factors. Pain treatment options typically include education complemented by physical activity and exercise, orthotics, psychological and social interventions, sleep hygiene education, weight management, pharmacological and joint-specific treatment options, or interdisciplinary pain management. Effects on pain were most uniformly positive for physical activity and exercise interventions, and for psychological interventions. Effects on pain for educational interventions, orthotics, weight management and multidisciplinary treatment were shown for particular disease groups. Underpinned by available systematic reviews and meta-analyses, these recommendations enable health professionals to provide knowledgeable pain-management support for people with IA and OA.

The prospective association between psychological distress and disease activity in rheumatoid arthritis: a multilevel regression analysis.

BACKGROUND: Cross-sectional associations suggest a mutual impact of disease activity and psychological distress in rheumatoid arthritis (RA), but a prospective association has not been established. OBJECTIVE: To examine concurrent and prospective associations between psychological distress and disease activity. METHODS: Patients with RA (N=545, disease duration ≤1 year, age 18-83 years, 69% female, 64% rheumatoid factor (RF) positive) were monitored for 5 years. The Thompson joint score and erythrocyte sedimentation rate were assessed every 6 months. Depressed mood and anxiety were measured every 12 months. Multilevel regression analysis was used. RF positivity, age and female sex were included as covariates. RESULTS: Concurrent levels of psychological distress and disease activity were positively associated (p≤0.04). Prospectively, depressed mood was associated with disease activity levels 6 months later (p≤0.04). The Thompson joint score was associated with psychological distress levels 6 months later (p≤0.03) and also with an increase in depressed mood over the subsequent 6 months (p=0.02). No other significant prospective associations were found (p≥0.07). CONCLUSIONS: Psychological distress and disease activity are positively associated when measured at the same time as well as when measured 6 months apart. While some support was found for the idea that a higher level of disease activity is a risk factor for an increase in psychological distress, the results do not support the notion that psychological distress is a risk factor for future exacerbation of disease activity.

The prevalence of severe fatigue in rheumatic diseases: an international study.

Fatigue is a common, disabling, and difficult-to-manage problem in rheumatic diseases. Prevalence estimates of fatigue within rheumatic diseases vary considerably. Data on the prevalence of severe fatigue across multiple rheumatic diseases using a similar instrument is missing. Our aim was to provide an overview of the prevalence of severe fatigue across a broad range of rheumatic diseases and to examine its association with clinical and demographic variables. Online questionnaires were filled out by an international sample of 6120 patients (88 % female, mean age 47) encompassing 30 different rheumatic diseases. Fatigue was measured with the RAND(SF)-36 Vitality scale. A score of ≤35 was taken as representing severe fatigue (90 % sensitivity and 81 % specificity for chronic fatigue syndrome). Severe fatigue was present in 41 to 57 % of patients with a single inflammatory rheumatic disease such as rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, Sjögren's syndrome, psoriatic arthritis, and scleroderma. Severe fatigue was least prevalent in patients with osteoarthritis (35 %) and most prevalent in patients with fibromyalgia (82 %). In logistic regression analysis, severe fatigue was associated with having fibromyalgia, having multiple rheumatic diseases without fibromyalgia, younger age, lower education, and language (French: highest prevalence; Dutch: lowest prevalence). In conclusion, one out of every two patients with a rheumatic disease is severely fatigued. As severe fatigue is detrimental to the patient, the near environment, and society at large, unraveling the underlying mechanisms of fatigue and developing optimal treatment should be top priorities in rheumatologic research and practice.

Contribution of the subjective components of the disease activity score to the response to biologic treatment in rheumatoid arthritis.

OBJECTIVE: A significant proportion of patients with rheumatoid arthritis do not respond adequately to biologic treatment. We hypothesized that lack of response to (biologic) disease-modifying antirheumatic drugs (DMARDs) is high in patients in whom the subjective, patient-reported component of the Disease Activity Score 28 (DAS28) is high at baseline. The primary aim of our present study was to investigate the contribution of the more subjective versus the objective components of the DAS28 to response to biologic agents in RA patients, as well as the changes in this contribution over time. The secondary aim was to examine whether the value of this subjective contribution at baseline affects the response to treatment. METHODS: The DAS28-P (the subjective components of the DAS28 relative to the total DAS28) was calculated. Patients were derived from the computer-assisted Management in Early Rheumatoid Arthritis Trial-II and the Biologicals and Outcome Compared and Predicted in Utrecht Region in Rheumatoid Arthritis Study. Ordinal logistic regression analyses were performed. RESULTS: The DAS28-P score at baseline was not associated with the level of response according to European League Against Rheumatism criteria at 3 months. Overall, a significant reduction in the DAS28-P score was observed 3 months after start of treatment, showing a greater reduction of the combined subjective components in good responders. CONCLUSION: The results reject the hypothesis that the lack of response to biologic DMARDs is especially high in patients in whom the patient-reported component of the DAS28 is high at baseline; these subjective components are not linked to treatment response.

Change of psychological distress and physical disability in patients with rheumatoid arthritis over the last two decades.

OBJECTIVE: During the past decades, a more cautious approach with respect to prescribing medication and physical exercise progressed toward evidence-based guidelines regarding the management of rheumatoid arthritis (RA). Currently, physical activity and other means to improve well-being and functioning are encouraged, and the disease is targeted earlier with more intensive and aggressive pharmacologic treatment. The current study examined whether psychological distress and physical disability in patients with RA reduced over the last 2 decades and whether this is explained by a reduction of disease activity. METHODS: From 1990-2011, consecutive patients with RA (n = 1,151, age range 17-86 years, 68% female, 62% rheumatoid factor positive) were monitored at diagnosis and after 3-5 years of treatment (followup). Depressed mood, anxiety, and physical disability were predicted in multiple linear regression analyses by year of assessment, disease activity, and patient demographics. RESULTS: Over the decades, depressed mood (P = 0.01), anxiety (P = 0.001), and physical disability (P = 0.02) reduced at diagnosis and within-treatment improvement of anxiety (P = 0.04) and physical disability (P < 0.001) increased. Percentages of patients with depressed mood, anxiety, and physical disability at followup changed from 25%, 23%, and 53%, respectively, 2 decades ago to 14%, 12%, and 31%, respectively, currently. After taking account of reduction in disease activity, the decrease in physical disability remained significant (P < 0.001). CONCLUSION: Over the last 2 decades, psychological distress and physical disability decreased. This favorable trend might partly be due to reduced disease activity. The results indicate that patients with RA have a better opportunity to live a valued life currently than 20 years ago.