Valat JP, Genevay S, Marty M
… +2 more, Rozenberg S, Koes B
Best Pract Res Clin Rheumatol
· 2010 Apr · PMID 20227645
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Sciatica is a symptom rather than a specific diagnosis. Available evidence from basic science and clinical research indicates that both inflammation and compression are important in order for the nerve root to be symptom...Sciatica is a symptom rather than a specific diagnosis. Available evidence from basic science and clinical research indicates that both inflammation and compression are important in order for the nerve root to be symptomatic. Tumour necrosis factor-alpha (TNF-alpha) is a key mediator in animal models, but its exact contribution in human radiculopathy is still a matter of debate. Sciatica is mainly diagnosed by history taking and physical examination. In general, the clinical course of acute sciatica is considered to be favourable. In the first 6-8 weeks, there is consensus that treatment of sciatica should be conservative. We review and comment on the levels of evidence of the efficacy of patient information, advice to stay active, physical therapy analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), epidural corticosteroid injections and transforaminal peri-radicular injections of corticosteroid. There is good evidence that discectomy is effective in the short term. but, in the long term, it is not more effective than prolonged conservative care. Shared decision making with regard to surgery is necessary in the absence of severe progressive neurological symptoms. Although the term sciatica is simple and easy to use, it is, in fact, an archaic and confusing term. For most researchers and clinicians, it refers to a radiculopathy, involving one of the lower extremities, and related to disc herniation (DH). As such, the term 'sciatica' is too restrictive as nerve roots from L1 to L4 may also be involved in the same process. However, even more confusing is the fact that patients, and many clinicians alike, use sciatica to describe any pain arising from the lower back and radiating down to the leg. The majority of the time, this painful sensation is referred pain from the lower back and is neither related to DH nor does it result from nerve-root compression. Although differentiating the radicular pain from the referred pain may be challenging for the clinician, it is of primary importance. This is because the epidemiology, clinical course and, most importantly, therapeutic interventions are different for these two conditions. It should, however, be emphasised that the quality of the available evidence is rather limited due to a considerable heterogeneity in the study populations included in the trials. This makes generalisation of findings across studies, and to routine clinical practice, a challenge. Prevalence estimates of radicular pain related to DH also vary considerably between studies, which is, in part, due to differences in the definitions used. A recent review showed that the prevalence of sciatic symptoms is rather variable, with values ranging from 1.6% to 43%. If stricter definitions of sciatica were used, for example, in terms of pain distribution and/or pain duration, lower prevalence rates were reported. Studies in working populations with physically demanding jobs consistently report higher rates of sciatica compared with studies in the general population.
Main CJ, Buchbinder R, Porcheret M
… +1 more, Foster N
Best Pract Res Clin Rheumatol
· 2010 Apr · PMID 20227643
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In this article, we specifically focus on the identification and management of patient beliefs and expectations during consultations with health-care professionals (HCPs). In examination of the nature and purpose of comm...In this article, we specifically focus on the identification and management of patient beliefs and expectations during consultations with health-care professionals (HCPs). In examination of the nature and purpose of communication during consultations, we evaluate the research relating to doctor-patient communication, present the Calgary-Cambridge framework and highlight the identification and management of the patient's beliefs and expectations as a key part of this process. Having identified what can go wrong, we identify the characteristics of effective consultations and consider strategies for improving communication. In recommending a clear and more focussed approach to the identification and management of patient beliefs and expectations, we consider not only the nature of the therapeutic climate, but also the style and content that could enhance the effectiveness of the communication. Having identified techniques for facilitating self-disclosure, we conclude by offering suggestions on how to 'close down' the consultation and hand over responsibility to the patient.
Best Pract Res Clin Rheumatol
· 2010 Apr · PMID 20227642
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In this article, we provide an evidence-based review of pain beliefs and their influence on pain perception and response to treatment. We examine the nature of pain perception and the role of cognitive and emotional proc...In this article, we provide an evidence-based review of pain beliefs and their influence on pain perception and response to treatment. We examine the nature of pain perception and the role of cognitive and emotional processes in the interpretation of pain signals, giving meaning to pain and shaping our response to it. We highlight three types of beliefs that have a particularly strong influence: fear-avoidance beliefs, pain self-efficacy beliefs and catastrophising. We examine the influence of beliefs, preferences and expectations on seeking consultation, interventions and treatment outcome from the perspective both of the patient and the health-care practitioner. We then adopt a broader societal perspective, considering secondary prevention and campaigns, which have attempted to change beliefs at a population level. The article concludes with a summary of the key messages for clinical management of patients presenting with painful conditions and suggestions for further research.
Kamper SJ, Maher CG, Hancock MJ
… +3 more, Koes BW, Croft PR, Hay E
Best Pract Res Clin Rheumatol
· 2010 Apr · PMID 20227640
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There has been a recent increase in research evaluating treatment-based subgroups of non-specific low back pain. The aim of these sub-classification schemes is to identify subgroups of patients who will respond preferent...There has been a recent increase in research evaluating treatment-based subgroups of non-specific low back pain. The aim of these sub-classification schemes is to identify subgroups of patients who will respond preferentially to one treatment as opposed to another. Our article provides accessible guidance on to how to interpret this research and determine its implications for clinical practice. We propose that studies evaluating treatment-based subgroups can be interpreted in the context of a three-stage process: (1) hypothesis generation-proposal of clinical features to define subgroups; (2) hypothesis testing-a randomised controlled trial (RCT) to test that subgroup membership modifies the effect of a treatment; and (3) replication-another RCT to confirm the results of stage 2 and ensure that findings hold beyond the specific original conditions. At this point, the bulk of research evidence in defining subgroups of patients with low back pain is in the hypothesis generation stage; no classification system is supported by sufficient evidence to recommend implementation into clinical practice.
Hayden JA, Dunn KM, van der Windt DA
… +1 more, Shaw WS
Best Pract Res Clin Rheumatol
· 2010 Apr · PMID 20227639
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Understanding prognosis is important in managing low back pain. In this article, we discuss the available evidence on low back pain prognosis and describe how prognostic evidence can be used to inform clinical decision m...Understanding prognosis is important in managing low back pain. In this article, we discuss the available evidence on low back pain prognosis and describe how prognostic evidence can be used to inform clinical decision making. We describe three main types of related prognosis questions: 'What is the most likely course?' (Course studies); 'What factors are associated with, or determine, outcome?' (Prognostic factor or explanatory studies); and 'Can we identify risk groups who are likely to have different outcomes?' (Risk group or outcome prediction studies). Most low back pain episodes are mild and rarely disabling, with only a small proportion of individuals seeking care. Among those presenting for care, there is variability in outcome according to patient characteristics. Most new episodes recover within a few weeks. However, recurrences are common and individuals with chronic, long-standing low back pain tend to show a more persistent course. Studies of mixed primary care populations indicate 60-80% of health-care consulters will continue to have pain after a year. Important low back pain prognostic factors are related to the back pain episode, the individual and psychological characteristics, as well as the work and social environment. Although numerous studies have developed prediction models in the field, most models/tools explain less than 50% of outcome variability and few have been tested in independent samples. We discuss limitations and future directions for research in the area of low back pain prognosis.
Best Pract Res Clin Rheumatol
· 2010 Feb · PMID 20129205
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We reviewed three recently published guidelines for the management of osteoarthritis (OA) and considered the evidence and potential for implementation. From this we propose a minimum standard of care, or a 'core set' of...We reviewed three recently published guidelines for the management of osteoarthritis (OA) and considered the evidence and potential for implementation. From this we propose a minimum standard of care, or a 'core set' of interventions, that should be offered to all patients with OA of the hip and/or knee. Eight core recommendations emerged where it is recommended that health-care professionals: Provide advice about, and offer access to appropriate information for OA self-management and lifestyle change; Provide advice about weight loss if patient is overweight or obese and refer to services as required; Provide advice for land-based exercises incorporating aerobic and strengthening components and refer to services as required; Recommend adequate paracetamol for pain relief; Make patients aware that non-steroid anti-inflammatory drugs (NSAIDs) or coxibs can improve symptoms in majority but this comes with potential for harm and that risk potential varies--be aware of and minimise the individual's risk potential; Offer intra-articular steroids for short-term relief of a flare or acute deterioration in symptoms; Offer stronger analgesic relief if prolonged severe symptoms; Offer access to assessment for arthroplasty for consumers with severe symptomatic OA not responding to conservative therapy. An integrated, chronic disease model of care is proposed to best implement OA management and a check list of clinical indicators/performance measures is provided.
Best Pract Res Clin Rheumatol
· 2010 Feb · PMID 20129203
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For the most part, non-pharmacological approaches are recommended for osteoarthritis treatment. This recommendation is based mainly on biomechanical observations leading to a modulation of the symptomatic loading joint....For the most part, non-pharmacological approaches are recommended for osteoarthritis treatment. This recommendation is based mainly on biomechanical observations leading to a modulation of the symptomatic loading joint. Approaches include orthoses, insoles, exercise, diet and patient education. The approach used for each osteoarthritis site must be adapted for the individual patient. Here, we use an evidence-based approach, including the European League Against Rheumatism (EULAR) and Osteoarthritis Research Society International (OARSI) recommendations, to summarise the non-pharmacological treatments available for knee, hip and hand osteoarthritis and to help the physician in daily clinical practice.
Best Pract Res Clin Rheumatol
· 2010 Feb · PMID 20129197
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Ultrasound (US) is a valuable tool for imaging musculoskeletal changes in osteoarthritis. It shows early and late findings related to inflammation and structural damage. Sonography is a safe tool, which has recently regi...Ultrasound (US) is a valuable tool for imaging musculoskeletal changes in osteoarthritis. It shows early and late findings related to inflammation and structural damage. Sonography is a safe tool, which has recently registered an increasing and widespread use, it being considered as a bedside procedure in the clinical assessment of rheumatic patients. Its applications in osteoarthritis are related to easy accessibility of equipment, low cost, short duration of single examinations and the possibility of performing a multiregional joint evaluation in the same scanning session. Permitting an extensive evaluation of most joint changes present in osteoarthritis, it gives the opportunity to monitor disease progression and perform a follow-up of the response to different local and systemic treatments. US-guided procedures are commonly performed with safety, reliability and optimal patient tolerance. Development in technology and technique with improvement of new research studies will further amplify the diagnostic role of ultrasound in osteoarthritis in the near future.
Best Pract Res Clin Rheumatol
· 2009 Dec · PMID 19945691
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In old age, 5-10% percent of all falls result in a fracture, and up to 90% of all fractures result from a fall. This article describes the link between fall risk and fracture risk in community-dwelling older persons. Whi...In old age, 5-10% percent of all falls result in a fracture, and up to 90% of all fractures result from a fall. This article describes the link between fall risk and fracture risk in community-dwelling older persons. Which factors attribute to both the fall risk and the fracture risk? Which falls result in a fracture? Which tools are available to predict falls and fractures? Directions for the use of prediction tools in clinical practice are given. Challenges for future research include further validation of existing prediction tools and evaluation of the cost-effectiveness of treatment after screening.
Best Pract Res Clin Rheumatol
· 2009 Dec · PMID 19945689
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Bone mineral density (BMD) measurements are recommended in some guidelines for monitoring osteoporosis treatment. However, evidence to support this approach is lacking, since treatment-induced changes in bone density may...Bone mineral density (BMD) measurements are recommended in some guidelines for monitoring osteoporosis treatment. However, evidence to support this approach is lacking, since treatment-induced changes in bone density may take up to 3 years to detect and do not predict fracture reduction. Biochemical markers of bone turnover have potential for monitoring since they change rapidly in response to treatment and are more predictive of fracture reduction, but variability of their measurement reduces their value in clinical practice. Neither approach has been shown to improve adherence to therapy. By contrast, there is evidence that discussion with a health-care professional improves treatment adherence, regardless of feedback about monitoring tests. At present, there is no justification for the use of bone-density measurement or bone-turnover markers in routine monitoring, but patients should be fully informed about their treatment and provided with the opportunity to discuss treatment-related issues with a health-care professional.
Kanis JA, McCloskey EV, Johansson H
… +3 more, Strom O, Borgstrom F, Oden A
Best Pract Res Clin Rheumatol
· 2009 Dec · PMID 19945684
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Fractures are the clinical consequence of osteoporosis and are a major cause of morbidity and mortality worldwide. Although treatments are available that have been shown to decrease the risk of fracture, problems arise i...Fractures are the clinical consequence of osteoporosis and are a major cause of morbidity and mortality worldwide. Although treatments are available that have been shown to decrease the risk of fracture, problems arise in identifying individuals at high risk of fracture so that intervention can be effectively targeted. Practice guidelines, available in many countries, differ markedly in approach, but generally recommend treatments on the basis of a previous fragility fracture and a defined threshold for bone mineral density (BMD). Recent developments in fracture risk assessment include the availability of the FRAX tool by the World Health Organization (WHO) Collaborating Centre for Metabolic Bone Diseases at Sheffield, UK, that integrates the weight of clinical risk factors for fracture risk with or without information on BMD and computes the 10-year probability of fracture. The tool increases sensitivity without trading specificity and is now being used in the re-appraisal of clinical guidelines.
Best Pract Res Clin Rheumatol
· 2009 Oct · PMID 19853825
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The evidence so far suggests that the paediatric inflammatory diseases encountered in rheumatology practice may be largely genetic in origin, where common single nucleotide polymorphisms (SNPs) in multiple genes contribu...The evidence so far suggests that the paediatric inflammatory diseases encountered in rheumatology practice may be largely genetic in origin, where common single nucleotide polymorphisms (SNPs) in multiple genes contribute to risk, with real but variable environmental components. As far as genetic susceptibility to common paediatric rheumatic diseases is concerned, only juvenile idiopathic arthritis (JIA) has been investigated in any substantial way so far. This article discusses susceptibility for different types of JIA, the different methods used and their advantages and disadvantages. The genetic code is also modifiable by epigenetic mechanisms and examples of these in immunity and rheumatoid arthritis are given to indicate another area of research in the elucidation of the genetics of paediatric rheumatic diseases.
Best Pract Res Clin Rheumatol
· 2009 Aug · PMID 19591782
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Between 20% and 40% of patients with systemic lupus erythematosus (SLE) have positive blood tests for antiphospholipid antibodies (aPLs). This article explains what tests are used to detect these antibodies and outlines...Between 20% and 40% of patients with systemic lupus erythematosus (SLE) have positive blood tests for antiphospholipid antibodies (aPLs). This article explains what tests are used to detect these antibodies and outlines the complexities of interpreting and acting upon a positive result. If aPLs are persistently positive, the patient may develop antiphospholipid syndrome (APS) characterised by vascular thrombosis, pregnancy morbidity or both. In patients with SLE who are aPL-positive but have not developed APS, there is some evidence that low-dose aspirin should be used prophylactically, but it is not conclusive. APS in patients with SLE is clinically similar to primary APS and should be treated in the same way, with anticoagulation to prevent recurrent thrombosis or with aspirin and sometimes heparin to prevent pregnancy loss. Current best practice in use of these treatments is discussed. However, these treatments are not ideal as they can have major side effects such as haemorrhage. Research which may lead to better, more targeted therapy for APS is discussed at the end of the article.
Best Pract Res Clin Rheumatol
· 2009 Apr · PMID 19393571
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All medical practice and research should aim to be evidence based, as far as this is possible. The first step to achieve this is to keep up with what is already known. With medical knowledge growing constantly, it has be...All medical practice and research should aim to be evidence based, as far as this is possible. The first step to achieve this is to keep up with what is already known. With medical knowledge growing constantly, it has become necessary to possess a high level of information literacy to be able to keep up with the literature. Furthermore, as patients can now search for information on the internet, clinicians must be able to respond to this type of information in a professional way when needed. Here, the development of viable search strategies for journal articles, books, book chapters and similar sources, selection of appropriate databases, search tools and selection methods are described and illustrated with examples from rheumatology. Further, the up-keep of skills over time, and the acquisition of literature just in time, are discussed.
Best Pract Res Clin Rheumatol
· 2008 Dec · PMID 19041076
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Magnetic resonance imaging (MRI) and ultrasonography (US) are useful adjuncts in the diagnosis of seronegative spondyloarthritides (SpA); a group of diseases that present early at a stage when radiographic assessment is...Magnetic resonance imaging (MRI) and ultrasonography (US) are useful adjuncts in the diagnosis of seronegative spondyloarthritides (SpA); a group of diseases that present early at a stage when radiographic assessment is invariably normal. This chapter will review how MRI and US can be used in the evaluation of early SpA. The diffuse osteitis/enthesitis on MRI may serve as a diagnostic hallmark for SpA spinal disease, but needs confirmatory studies for comparison with other spinal pathologies. MRI is the modality of choice for monitoring axial disease in anti-tumour necrosis factor (TNF) therapy responses in the research environment, but it is not yet certain whether this will be relevant in clinical practice. Anti-TNF therapy may be associated with regression of MRI-determined osteitis, but retardation of associated bony fusion is debatable. MRI and US are still undergoing evaluation for the diagnosis of enthesitis of the appendicular skeleton; US, in particular, shows promise at these sites.
In this study, patients with ankylosing spondylitis (AS) were assessed both by patient and physician using two enthesitis indices and the relationship between these indices and disease activity parameters was investigate...In this study, patients with ankylosing spondylitis (AS) were assessed both by patient and physician using two enthesitis indices and the relationship between these indices and disease activity parameters was investigated. The study involved 100 AS patients. The patients were evaluated with 10-cm visual analog scale (VAS) for spinal pain (VAS-S), peripheral joint pain (VAS-P), global assessment of patient, and global assessment of doctor. In the laboratory evaluations, the erythrocyte sedimentation rates (ESR) and serum C-reactive protein levels of the patients were determined. Bath AS disease activity index (BASDAI), Bath AS functional index (BASFI), Bath AS metrology index, and Bath AS radiology index were calculated. The severity of enthesitis was evaluated according to Mander enthesitis index (MEI) and Maastricht ankylosing spondylitis enthesitis score applied by both the patient (MASES-P) him/herself and the physician (MASES-D). There was a correlation between BASDAI and BASFI as well as MEI, MASES-D, and MASES-P indices (r = 0.447, r = 0.342, r = 0.663, r = 0.530, r = 0.464, and r = 0.435, respectively). No correlation between the laboratory parameters and enthesitis indices were detected. In multiple linear regression analysis, BASFI, VAS-S, and female gender (41.3%) were the best predictors of MEI-D, whereas BASFI, VAS-S, female gender, and ESR (32.5%) were the best predictors for MASES-D and BASFI (18.9%) was the best predictor of MASES-P. The assessment of simple and easily applicable MASES score by a patient may be expected to help the physician in clinical practice. When the disease activity of the patients with AS are evaluated, both BASDAI, the clinical importance of which has been confirmed in numerous studies and which is recommended by ASAS, and BASFI, which is valued by patients, should be considered.
BACKGROUND: Complementary-alternative medicine (CAM) has been widely used by rheumatic patients for many years, but doctors are often unaware of the actual use. OBJECTIVES: This study aimed at patients' experience and pe...BACKGROUND: Complementary-alternative medicine (CAM) has been widely used by rheumatic patients for many years, but doctors are often unaware of the actual use. OBJECTIVES: This study aimed at patients' experience and perceptions of CAM as a way for long-term coping with illness. METHODS: Fifteen in-depth interviews were conducted with patients sampled by contact with voluntary patient-driven rheumatic disease societies, outside of any treatment settings. Strategically, the sampling included a variety of rheumatic diseases and CAM-treatments, but strived otherwise to be typical of CAM-users. Interviews were taped and fully transcribed; coding and analysis of themes were assisted by computer software. RESULTS: Rheumatic disease patients expressed use of CAM as methods of regulation of discomforts, the feeling of the body, and self-empowerment, not for unrealistic healing of their rheumatic disease. They experienced a variety of effects, most often expressed in terms of mind-body interrelated experiences, such as "lightness of the body" rather than relief in specific symptoms. They expressed the feeling of "have been helped" when leaving a CAM-session and appreciated to have more than 1 way to understand their disease and symptoms. They were usually not naive, but were critical consumers. The patients typically believed in the alternative viewpoints of "natural is best" and in "energy meridians," but they were otherwise not believers in any alternative, "new age"-type worldview. CONCLUSION: These findings suggest that clinical practice may be enriched by listening to or asking rheumatic disease patients' CAM-experiences in a nonpatronizing way.
Hypoxemia has been associated with low bone mineral density (BMD) in animal and human models. We assessed the association of haemoglobin levels with ultrasound-derived (UD) T score, Z score and the stiffness index in all...Hypoxemia has been associated with low bone mineral density (BMD) in animal and human models. We assessed the association of haemoglobin levels with ultrasound-derived (UD) T score, Z score and the stiffness index in all 358 subjects aged 75+ living in Tuscania (Italy). Also, we searched for the haemoglobin cutoff levels that might best identify participants with osteoporosis. In the multivariable linear regression analysis, haemoglobin levels were associated among participants with the UD T score [beta = 0.13; 95% confidence interval (CI) = 0.01-0.25; p = 0.030], Z score (beta = 0.11; 95% CI = 0.01-0.22; p = 0.045) and stiffness index (beta = 1.87; 95% CI = 0.51-3.21; p = 0.007) after adjusting for potential confounders. Haemoglobin levels <140 g/L in men and <130 g/L in women best predicted osteoporosis in linear discriminant analysis. Haemoglobin is independently associated with all UD-BMD parameters. Haemoglobin levels <140 g/L in men and 130 g/L in women might be adopted in clinical practice to identify older subjects in whom screening for osteoporosis might yield higher effectiveness.