Best Pract Res Clin Rheumatol
· 2016 Aug · PMID 27931963
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Musculoskeletal regional pain syndromes often lead to patient referrals in general and rheumatological practice. Detailed history taking and clinical examination can in most cases reveal the cause for pain and direct the...Musculoskeletal regional pain syndromes often lead to patient referrals in general and rheumatological practice. Detailed history taking and clinical examination can in most cases reveal the cause for pain and direct the subsequent management of the conditions. Yet, when in doubt, imaging methods have to support the clinical assessment. This paper presents the underlying pathologies of the most frequently encountered regional pain syndromes and the role of musculoskeletal ultrasonography and magnetic resonance imaging in their visualization. It presents data, where available, on diagnostic accuracy and comparisons with gold standards. The article stresses the advantages and disadvantages of the analyzed imaging modalities and suggests the future research agenda.
Mathiessen A, Cimmino MA, Hammer HB
… +3 more, Haugen IK, Iagnocco A, Conaghan PG
Best Pract Res Clin Rheumatol
· 2016 Aug · PMID 27931960
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In daily clinical practice, conventional radiography is still the most applied imaging technique to supplement clinical examination of patients with suspected osteoarthritis (OA); it may not always be needed for diagnosi...In daily clinical practice, conventional radiography is still the most applied imaging technique to supplement clinical examination of patients with suspected osteoarthritis (OA); it may not always be needed for diagnosis. Modern imaging modalities can visualize multiple aspects of the joint, and depending on the diagnostic need, radiography may no longer be the modality of choice. Magnetic resonance imaging (MRI) provides a complete assessment of the joint and has a pivotal role in OA research. Computed tomography (CT) and nuclear medicine offer alternatives in research scenarios, while ultrasound can visualize bony and soft-tissue pathologies and is highly feasible in the clinic. In this chapter, we overview the recent literature on established and newer imaging modalities, summarizing their ability to detect and quantify the range of OA pathologies and determining how they may contribute to early OA diagnosis. This accurate imaging-based detection of pathologies will underpin true understanding of much needed structure-modifying therapies.
Østergaard M, Eder L, Christiansen SN
… +1 more, Kaeley GS
Best Pract Res Clin Rheumatol
· 2016 Aug · PMID 27931958
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Psoriatic arthritis (PsA) is an inflammatory joint disease characterised by the presence of arthritis and often enthesitis and/or spondylitis in patients with psoriasis. However, it presents a wide range of disease manif...Psoriatic arthritis (PsA) is an inflammatory joint disease characterised by the presence of arthritis and often enthesitis and/or spondylitis in patients with psoriasis. However, it presents a wide range of disease manifestations in various patterns. Imaging is an important part of management of PsA, and is used for multiple reasons including establishing/confirming a diagnosis of inflammatory joint disease, determining the extent of disease, monitoring activity and damage, assessing therapeutic efficacy, and identifying complications of disease or treatment, in the setting of clinical practice or clinical studies. Magnetic resonance imaging (MRI) allows detailed assessment of all peripheral and axial joints involved in PsA, and can visualise both inflammation and structural changes. Ultrasonography (US) can visualise many of the peripheral heterogeneous tissue compartments affected by PsA. In contrast to MRI, US is not useful for assessing axial involvement in the spine and sacroiliac joints. In this paper, we will provide an overview of the status, strengths and limitations of MRI and US in peripheral PsA in routine clinical practice and clinical trials.
Allen KD, Choong PF, Davis AM
… +11 more, Dowsey MM, Dziedzic KS, Emery C, Hunter DJ, Losina E, Page AE, Roos EM, Skou ST, Thorstensson CA, van der Esch M, Whittaker JL
Best Pract Res Clin Rheumatol
· 2016 Jun · PMID 27886944
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Osteoarthritis (OA) is a leading cause of pain and disability worldwide. Despite the existence of evidence-based treatments and guidelines, substantial gaps remain in the quality of OA management. There is underutilizati...Osteoarthritis (OA) is a leading cause of pain and disability worldwide. Despite the existence of evidence-based treatments and guidelines, substantial gaps remain in the quality of OA management. There is underutilization of behavioral and rehabilitative strategies to prevent and treat OA as well as a lack of processes to tailor treatment selection according to patient characteristics and preferences. There are emerging efforts in multiple countries to implement models of OA care, particularly focused on improving nonsurgical management. Although these programs vary in content and setting, key lessons learned include the importance of support from all stakeholders, consistent program delivery and tools, a coherent team to run the program, and a defined plan for outcome assessment. Efforts are still needed to develop, deliver, and evaluate models of care across the spectrum of OA, from prevention through end-stage disease, in order to improve care for this highly prevalent global condition.
Slater H, Dear BF, Merolli MA
… +2 more, Li LC, Briggs AM
Best Pract Res Clin Rheumatol
· 2016 Jun · PMID 27886943
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Musculoskeletal (MSK) conditions are the second leading cause of morbidity-related burden of disease globally. EHealth is a potentially critical factor that enables the implementation of accessible, sustainable and more...Musculoskeletal (MSK) conditions are the second leading cause of morbidity-related burden of disease globally. EHealth is a potentially critical factor that enables the implementation of accessible, sustainable and more integrated MSK models of care (MoCs). MoCs serve as a vehicle to drive evidence into policy and practice through changes at a health system, clinician and patient level. The use of eHealth to implement MoCs is intuitive, given the capacity to scale technologies to deliver system and economic efficiencies, to contribute to sustainability, to adapt to low-resource settings and to mitigate access and care disparities. We follow a practice-oriented approach to describing the 'what' and 'how' to harness eHealth in the implementation of MSK MoCs. We focus on the practical application of eHealth technologies across care settings to those MSK conditions contributing most substantially to the burden of disease, including osteoarthritis and inflammatory arthritis, skeletal fragility-associated conditions and persistent MSK pain.
Stinson J, Connelly M, Kamper SJ
… +2 more, Herlin T, Toupin April K
Best Pract Res Clin Rheumatol
· 2016 Jun · PMID 27886942
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Chronic musculoskeletal pain among children and adolescents is common and can negatively affect quality of life. It also represents a high burden on the health system. Effective models of care for addressing the preventi...Chronic musculoskeletal pain among children and adolescents is common and can negatively affect quality of life. It also represents a high burden on the health system. Effective models of care for addressing the prevention and management of pediatric musculoskeletal pain are imperative. This chapter will address the following key questions: (1) Why are pediatric-specific models of pain care needed? (2) What is the burden of chronic musculoskeletal pain among children and adolescents? (3) What are the best practice approaches for early identification and prevention of chronic musculoskeletal pain in children and adolescents? (4) What are the recommended strategies for clinical management of chronic pain, including pharmacological, physical, psychological and complementary, and alternative approaches? (5) What are the most effective strategies for implementing models of pain care across different care settings? (6) What are the research priorities to improve models of care for children and adolescents with chronic musculoskeletal pain?
Walsh L, Hill S, Wluka AE
… +7 more, Brooks P, Buchbinder R, Cahill A, Dans LF, Lowe D, Taylor M, Tugwell P
Best Pract Res Clin Rheumatol
· 2016 Jun · PMID 27886940
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Consumer involvement in the design and delivery of their healthcare is an integral strategy to ensure that health services and systems meet consumers' needs. This is also true for the design and delivery of Models of Car...Consumer involvement in the design and delivery of their healthcare is an integral strategy to ensure that health services and systems meet consumers' needs. This is also true for the design and delivery of Models of Care. This chapter presents the identified healthcare needs of people with musculoskeletal conditions and focuses on the current systematic review evidence for consumer involvement interventions in musculoskeletal Models of Care across the micro, meso and macro levels of healthcare. This chapter also presents three case studies of consumer involvement in different aspects of healthcare, offers a series of practice points to help translate the systematic review evidence into practice, and also provides direction to available resources, which support the implementation of consumer involvement within Models of Care.
Dziedzic KS, French S, Davis AM
… +2 more, Geelhoed E, Porcheret M
Best Pract Res Clin Rheumatol
· 2016 Jun · PMID 27886938
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Musculoskeletal conditions represent one of the largest causes of years lived with disability in high-income economies. These conditions are predominantly managed in primary care settings, and yet, there is a paucity of...Musculoskeletal conditions represent one of the largest causes of years lived with disability in high-income economies. These conditions are predominantly managed in primary care settings, and yet, there is a paucity of evidence on which approaches work well in increasing the uptake of best practice and in closing the evidence-to-practice gap. Increasingly, musculoskeletal models of service delivery (as components of models of care) such as integrated care, stratified care and therapist-led care have been tested in primary health care pathways for joint pain in older adults, for low back pain and for arthritis. In this chapter, we discuss why implementation of these models is important for primary care and how models are implemented using three case examples: we review implementation theory, principles and outcomes; we consider the role of health economic evaluation; and we propose key evidence gaps in this field. We propose the following research priorities for this area: investigating the generalisability of models of care across, for example, urban and rural settings, and for different musculoskeletal conditions; increasing support for self-management; understanding the importance of context in choosing a model of care; detailing how implementation has been undertaken; and evaluation of implementation and its impact.
Best Pract Res Clin Rheumatol
· 2016 Feb · PMID 27421213
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Autoimmune connective tissue diseases (CTDs) have a propensity to affect multiple organ systems as well as physical function, quality of life, and survival. Their clinical heterogeneity, multisystem involvement, and low...Autoimmune connective tissue diseases (CTDs) have a propensity to affect multiple organ systems as well as physical function, quality of life, and survival. Their clinical heterogeneity, multisystem involvement, and low worldwide prevalence present challenges for researchers to establish a study design to help better understand the course and outcomes of CTDs. Systemic sclerosis (SSc) is a notable example of a CTD, wherein longitudinal cohort studies (LCS) have enabled us to elucidate disease manifestations, disease course, and risk and prognostic factors for clinically important outcomes, by embedding research in clinical practice. Nevertheless, further efforts are needed to better understand SSc especially with regard to recognizing organ involvement early, developing new therapies, optimizing the use of existing therapies, and defining treatment targets. The heterogeneous multi-organ nature of SSc would lend itself well to a structured model of care, wherein step-up treatment algorithms are used with the goal of attaining a prespecified treatment target. In this chapter, we discuss the rationale for a structured treatment approach in SSc and propose possible treatment algorithms for three of the more common disease manifestations, namely skin involvement, digital ulcers and gastrointestinal tract involvement. We discuss possible strategies for evaluating and implementing these algorithms in the setting of LCS. We conclude by presenting a research agenda for the development of structured models of care in SSc.
Best Pract Res Clin Rheumatol
· 2015 Jun · PMID 26612235
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Musculoskeletal disorders (MSDs) are the leading cause of work disability, sickness absence from work, 'presenteeism' and loss of productivity across all the European Union (EU) member states. It is estimated that the to...Musculoskeletal disorders (MSDs) are the leading cause of work disability, sickness absence from work, 'presenteeism' and loss of productivity across all the European Union (EU) member states. It is estimated that the total cost of lost productivity attributable to MSDs among people of working age in the EU could be as high as 2% of gross domestic product (GDP). This paper examines the available evidence on the economic burden of MSDs on work across Europe and highlights areas of policy, clinical and employment practice which might improve work outcomes for individuals and families and reduce the economic and social costs of MSDs.
OBJECTIVE: The aims of this study were to assess the agreement of physicians and nurses performing tender and swollen joint counts (TJCs/SJCs) in rheumatoid arthritis (RA) and identify factors that might influence their...OBJECTIVE: The aims of this study were to assess the agreement of physicians and nurses performing tender and swollen joint counts (TJCs/SJCs) in rheumatoid arthritis (RA) and identify factors that might influence their examinations including patient age, sex, race, RA disease duration, body mass index, RA disease activity level, comorbid fibromyalgia, comorbid osteoarthritis, and levels of acute-phase reactants. METHODS: Seventy-two RA participants underwent TJCs/SJCs of 28 joints using a standardized protocol by 2 nurses and 2 rheumatologists. Demographic, laboratory, radiographic, and clinical data were obtained to assess the influence of these factors on TJCs/SJCs. Intraclass correlations (ICCs) among examiners were determined for TJCs/SJCs. Nurse-physician differences and agreement of individual joints were evaluated using Cohen κ. Analysis of variance was performed to detect differences in means between examiners for TJCs/SJCs. Intraclass correlation and Fisher Z tests were used to identify factors influencing TJCs/SJCs. RESULTS: Agreement was strong among these nurses and physicians for total TJCs/SJCs (ICC = 0.84/ICC = 0.79, respectively). κ was best for hand joint tenderness and poorest for shoulder swelling. Some significant differences in mean TJCs/SJCs were found between examiners. Fibromyalgia significantly reduced agreement of both TJCs and SJCs. Agreement of TJC was significantly reduced when patients had lower disease activity, greater work impairment, lower mental health quality of life, and elevated erythrocyte sedimentation rate, whereas female sex, assessor's perception of but not radiographic hand osteoarthritis, and elevated C-reactive protein significantly reduced agreement for SJC. CONCLUSIONS: Strong agreement was found among nurses and physicians for total 28-joint counts, with agreement at individual joints being stronger for tenderness than swelling. Fibromyalgia significantly reduced ICCs of TJCs/SJCs.
Dermatomyositis and polymyositis are rare chronic inflammatory disorders with significant associated morbidity and mortality despite treatment. High-dose corticosteroids in addition to other interventions such as immunos...Dermatomyositis and polymyositis are rare chronic inflammatory disorders with significant associated morbidity and mortality despite treatment. High-dose corticosteroids in addition to other interventions such as immunosuppressants, immunomodulators, and more recently, biologics are commonly used in clinical practice; however, there are no clear guidelines directing their use. Our objective was to systematically review the evidence for immunotherapy in the treatment of dermatomyositis and polymyositis. Relevant studies were identified through Embase and PubMed database searches. Trials were selected using pre-determined selection criteria and then assessed for quality. Randomized controlled trials and experimental studies without true randomization and including adult patients with definite or probable dermatomyositis or polymyositis were evaluated. Any type of immunotherapy was considered. Clinical improvement, judged by assessment of muscle strength after 6 months, was the primary outcome. Secondary outcomes included IMACS definition of improvement, improvements in patient and physician global scores, physical function, and muscle enzymes. Twelve studies met eligibility criteria. Differences in trial design, quality, and variable reporting of baseline characteristics and outcomes made direct comparison impossible. Although no treatment can be recommended on the basis of this review, improved outcomes were demonstrated with a number of agents including methotrexate, azathioprine, ciclosporin, rituximab, and intravenous immunoglobulin. Plasmapheresis and leukapheresis were of no apparent benefit. More high-quality randomized controlled trials are needed to establish the role of immunosuppressive agents in the treatment of these conditions and the clinical context in which they are most likely to be beneficial.
Gutierrez M, Draghessi A, Bertolazzi C
… +7 more, Erre GL, Saldarriaga-Rivera LM, López-Reyes A, Fernández-Torres J, Audisio MJ, Pineda C, Pan-American League Against Rheumatisms (PANLAR) Ultrasound Study Group
Important advances from both therapeutic and clinical assessment have recently been reported in psoriatic arthritis (PsA). Moreover, the constant challenge to provide a more comprehensive assessment of this heterogeneous...Important advances from both therapeutic and clinical assessment have recently been reported in psoriatic arthritis (PsA). Moreover, the constant challenge to provide a more comprehensive assessment of this heterogeneous disease results in a variety of clinical instruments that help the clinician for a global evaluation of both disease activity and responsiveness. The current European League Against Rheumatism (EULAR) recommendations on the use of imaging suggest the use of ultrasound (US) in chronic arthritis to increase the diagnostic accuracy and improvement of its management as compared to clinical examination alone. Although US findings are not firmly established in daily clinical practice, it demonstrated several positive aspects such as good sensitivity and specificity, acceptable reliability, and adequate sensitivity to change, especially in the peripheral PsA. Additionally, recent works introduced the role of US in the assessment of skin and nails opening interesting area of research. The aim of this paper is to describe the potential role of US in the assessment of PsA and to discuss the current evidence supporting its application in daily clinical practice.
Best Pract Res Clin Rheumatol
· 2015 Feb · PMID 26266997
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Chronic pain is an important public health problem, and there is a need to understand the mechanisms that lead to pain chronification. From a neurobiological perspective, the mechanisms contributing to the transition fro...Chronic pain is an important public health problem, and there is a need to understand the mechanisms that lead to pain chronification. From a neurobiological perspective, the mechanisms contributing to the transition from acute to subacute and chronic pain are heterogeneous and are thought to take place at various levels of the peripheral and central nervous system. In the past decade, brain imaging studies have shed light on neural correlates of pain perception and pain modulation, but they have also begun to disentangle neural mechanisms that underlie chronic pain. This review summarizes important and recent findings in pain research using magnetic resonance tomography. Especially new developments in functional, structural and neurochemical imaging such as resting-state connectivity and γ-aminobutyric acid (GABA) spectroscopy, which have advanced our understanding of chronic pain and which can potentially be integrated in clinical practice, will be discussed.
Clin Rheumatol
· 2015 Mar · PMID 26198588
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To analyze characteristics of clinical practice guidelines (CPGs) for the management of rheumatoid arthritis (RA) developed in Latin American (LA) countries and to describe the knowledge, use, and barriers for their impl...To analyze characteristics of clinical practice guidelines (CPGs) for the management of rheumatoid arthritis (RA) developed in Latin American (LA) countries and to describe the knowledge, use, and barriers for their implementation perceived among LA rheumatologists, a comprehensive literature search including Medline, PubMed, Cochrane Library, LILACS and Scielo was performed. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was applied for evaluation. A survey was sent to PANLAR members containing questions related to knowledge about guidelines, application of the recommendations, and difficulties in implementing CPGs. Eight guidelines were identified. Most guidelines were evidence based (62 %), but in only 37 % a systematic literature search was done. None of the guidelines included patients' views and preferences, and only few of them stated an updating procedure. Funding body independence and disclosure of conflicts of interest were rarely reported. The survey was answered by 214 rheumatologists from all Latin American countries. Most rheumatologist reported knowledge and use of clinical guidelines, mainly international ones. In general, rheumatologist felt that guidelines apply to only a minority of patients seen in daily clinical practice. Limited access expensive drugs, suggested by the guidelines, was the most frequent barrier to guidelines implementation that was reported. A good number of guidelines on the treatment of rheumatoid arthritis have been developed in Latin America. Most of them are lacking some of the components recognized for high-quality clinical guidelines development. In spite that most rheumatologist know and apply guidelines, access to drugs is still a very important barrier to their implementation in Latin America.
Best Pract Res Clin Rheumatol
· 2014 Dec · PMID 26096094
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In rheumatic diseases, classification criteria have been developed to identify well-defined homogenous cohorts for clinical research. Although they are commonly used in clinical practice, their use may not be appropriate...In rheumatic diseases, classification criteria have been developed to identify well-defined homogenous cohorts for clinical research. Although they are commonly used in clinical practice, their use may not be appropriate for routine diagnostic clinical care. Classification criteria are being revised with improved methodology and further understanding of disease pathophysiology, but they still may not encompass all unique clinical situations to be applied for diagnosis of heterogenous, rare, evolving rheumatic diseases. Diagnostic criteria development is challenging primarily due to difficulty for universal application given significant differences in the prevalence of rheumatic diseases based on geographical area and clinic settings. Despite these shortcomings, the clinician can still use classification criteria for understanding the disease as well as a guide for diagnosis with a few caveats. We present the limits of current classification criteria, their use and abuse in clinical practice, and how they should be used with caution when applied in clinics.
Pineda C, Caballero-Uribe CV, de Oliveira MG
… +4 more, Lipszyc PS, Lopez JJ, Mataos Moreira MM, Azevedo VF
Clin Rheumatol
· 2015 Apr · PMID 25673060
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The use of biotechnology-derived medicines has significantly increased in recent decades. Although biosimilars undergo rigorous characterization as well as clinical studies to document their safety and effectiveness, the...The use of biotechnology-derived medicines has significantly increased in recent decades. Although biosimilars undergo rigorous characterization as well as clinical studies to document their safety and effectiveness, they are highly complex molecules and small changes in the purification and production process of a biosimilar can have major implications in its safety and effectiveness profile. In Latin America, regulatory authorities have begun to establish well-described and standardized pathways that permit a biosimilar to gain commercial licensure. In order to be certain that a biosimilar reaches its potential in ordinary clinical use, an intensive post-licensing monitoring system must be established since it is the only means to ascertain the true similarity between the original biologic and its biosimilar. Pharmacovigilance allows national authorities to determine a drug's performance in the marketplace. An effective tracking and pharmacovigilance system for biological medicines has many steps and processes. To aid policy makers in Latin American in addressing the many issues surrounding the establishment of an effective pharmacovigilance system, the Americas Health Foundation convened a group of experts to discuss the topic and develop recommendations for implementation. The group discussed current challenges and gaps in pharmacovigilance in Latin America, paying close attention to the major issues associated with traceability and pharmacovigilance of biosimilars following their approval. The recommendations developed should enable countries to accurately document the safety and performance of a biosimilar as experienced by patients under real-life conditions and have a significant impact on the successful implementation of pharmacovigilance of biosimilars throughout the region.
Soriano ER, Acosta-Felquer ML, Luong P
… +1 more, Caplan L
Best Pract Res Clin Rheumatol
· 2014 Oct · PMID 25488785
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This manuscript focuses on the pharmacologic treatment of psoriatic arthritis and axial spondyloarthritis - including ankylosing spondylitis - using traditional biologic and non-biologic disease-modifying antirheumatic d...This manuscript focuses on the pharmacologic treatment of psoriatic arthritis and axial spondyloarthritis - including ankylosing spondylitis - using traditional biologic and non-biologic disease-modifying antirheumatic drugs. Early treatment of psoriatic arthritis and axial spondyloarthritis/ankylosing spondylitis as well as the treat-to-target concept receive particular attention. This review also surveys recent national and international guidelines for the treatment of both psoriatic arthritis and couches practice recommendations for axial spondyloarthritis/ankylosing spondylitis within the context of various international guidelines.
Best Pract Res Clin Rheumatol
· 2014 Aug · PMID 25481548
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Rheumatoid Arthritis is characterized by autoimmune-mediated attack of the joint synovial lining resulting in destruction of bone and cartilage, and is a clinically and biologically heterogenous disease with respect to b...Rheumatoid Arthritis is characterized by autoimmune-mediated attack of the joint synovial lining resulting in destruction of bone and cartilage, and is a clinically and biologically heterogenous disease with respect to both course of disease and outcome to therapy. The current armamentarium of approved therapies does not result in complete clinical response in all patients. Improved techniques for imaging and performing biopsies on the rheumatoid synovium have facilitated multiple studies of the dysregulated cellular and molecular pathways in disease, and have provided evidence for a spectrum of pathogenic phenotypes across RA patients. These phenotypes are differentially affected by targeted therapies such as anti-TNFα and anti-CD20, and their presence prior to treatment impacts upon subsequent clinical outcomes. Ongoing histologic and molecular assessment of these synovial phenotypes through the implementation of routine synovial biopsy or using systemic biomarkers will improve targeting of therapies to specific patient subsets in both clinical trials and practice.
Speerin R, Slater H, Li L
… +6 more, Moore K, Chan M, Dreinhöfer K, Ebeling PR, Willcock S, Briggs AM
Best Pract Res Clin Rheumatol
· 2014 Jun · PMID 25481427
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With musculoskeletal conditions now identified as the second highest cause of the morbidity-related global burden of disease, models of care for the prevention and management of disability related to musculoskeletal cond...With musculoskeletal conditions now identified as the second highest cause of the morbidity-related global burden of disease, models of care for the prevention and management of disability related to musculoskeletal conditions are an imperative. Musculoskeletal models of care aim to describe how to operationalise evidence-based guidelines for musculoskeletal conditions and thus support implementation by clinical teams and their health systems. This review of models of care for musculoskeletal pain conditions, osteoarthritis, rheumatoid arthritis, osteoporosis and musculoskeletal injuries and trauma outlines health system and local implementation strategies to improve consumer outcomes, including supporting access to multidisciplinary teams, improving access for vulnerable populations and levering digital technologies to support access and self-management. However, the challenge remains of how to inform health system decision-makers and policy about the human and fiscal benefits for broad implementation across health services. Recommendations are made for potential solutions, as well as highlighting where further evidence is required.