Showing papers in "Best Practice & Research: Clinical Rheumatology in 2010"

The Epidemiology of low back pain.

Abstract: Low back pain is an extremely common problem that most people experience at some point in their life. While substantial heterogeneity exists among low back pain epidemiological studies limiting the ability to compare and pool data, estimates of the 1 year incidence of a first-ever episode of low back pain range between 6.3% and 15.4%, while estimates of the 1 year incidence of any episode of low back pain range between 1.5% and 36%. In health facility- or clinic-based studies, episode remission at 1 year ranges from 54% to 90%; however, most studies do not indicate whether the episode was continuous between the baseline and follow-up time point(s). Most people who experience activity-limiting low back pain go on to have recurrent episodes. Estimates of recurrence at 1 year range from 24% to 80%. Given the variation in definitions of remission and recurrence, further population-based research is needed to assess the daily patterns of low back pain episodes over 1 year and longer. There is substantial information on low back pain prevalence and estimates of the point prevalence range from 1.0% to 58.1% (mean: 18.1%; median: 15.0%), and 1 year prevalence from 0.8% to 82.5% (mean: 38.1%; median: 37.4%). Due to the heterogeneity of the data, mean estimates need to be interpreted with caution. Many environmental and personal factors influence the onset and course of low back pain. Studies have found the incidence of low back pain is highest in the third decade, and overall prevalence increases with age until the 60-65 year age group and then gradually declines. Other commonly reported risk factors include low educational status, stress, anxiety, depression, job dissatisfaction, low levels of social support in the workplace and whole-body vibration. Low back pain has an enormous impact on individuals, families, communities, governments and businesses throughout the world. The Global Burden of Disease 2005 Study (GBD 2005) is currently making estimates of the global burden of low back pain in relation to impairment and activity limitation. Results will be available in 2011. Further research is needed to help us understand more about the broader outcomes and impacts from low back pain.

The Epidemiology of neck pain

Abstract: Neck pain is becoming increasingly common throughout the world. It has a considerable impact on individuals and their families, communities, health-care systems, and businesses. There is substantial heterogeneity between neck pain epidemiological studies, which makes it difficult to compare or pool data from different studies. The estimated 1 year incidence of neck pain from available studies ranges between 10.4% and 21.3% with a higher incidence noted in office and computer workers. While some studies report that between 33% and 65% of people have recovered from an episode of neck pain at 1 year, most cases run an episodic course over a person's lifetime and, thus, relapses are common. The overall prevalence of neck pain in the general population ranges between 0.4% and 86.8% (mean: 23.1%); point prevalence ranges from 0.4% to 41.5% (mean: 14.4%); and 1 year prevalence ranges from 4.8% to 79.5% (mean: 25.8%). Prevalence is generally higher in women, higher in high-income countries compared with low- and middle-income countries and higher in urban areas compared with rural areas. Many environmental and personal factors influence the onset and course of neck pain. Most studies indicate a higher incidence of neck pain among women and an increased risk of developing neck pain until the 35-49-year age group, after which the risk begins to decline. The Global Burden of Disease 2005 Study is currently making estimates of the global burden of neck pain in relation to impairment and activity limitation, and results will be available in 2011.

Why is osteoarthritis an age-related disease?

Abstract: Although older age is the greatest risk factor for osteoarthritis (OA), OA is not an inevitable consequence of growing old. Radiographic changes of OA, particularly osteophytes, are common in the aged population, but symptoms of joint pain may be independent of radiographic severity in many older adults. Ageing changes in the musculoskeletal system increase the propensity to OA but the joints affected and the severity of disease are most closely related to other OA risk factors such as joint injury, obesity, genetics and anatomical factors that affect joint mechanics. The ageing changes in joint tissues that contribute to the development of OA include cell senescence that results in development of the senescent secretory phenotype and ageing changes in the matrix including formation of advanced glycation end-products that affect the mechanical properties of joint tissues. An improved mechanistic understanding of joint ageing will likely reveal new therapeutic targets to slow or halt disease progression. The ability to slow progression of OA in older adults will have enormous public health implications given the ageing of our population and the increase in other OA risk factors such as obesity.

Exercise therapy for chronic nonspecific low-back pain

Abstract: Exercise therapy is the most widely used type of conservative treatment for low back pain. Systematic reviews have shown that exercise therapy is effective for chronic but not for acute low back pain. During the past 5 years, many additional trials have been published on chronic low back pain. This articles aims to give an overview on the effectiveness of exercise therapy in patients with low back pain. For this overview, existing Cochrane reviews for the individual interventions were screened for studies fulfilling the inclusion criteria, and the search strategy outlined by the Cochrane Back Review Group (CBRG) was followed. Studies were included if they fulfilled the following criteria: (1) randomised controlled trials,(2) adult (> or =18 years) population with chronic (> or =12 weeks) nonspecific low back pain and (3) evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery or return to work). Two reviewers independently selected studies and extracted data on study characteristics, risk of bias and outcomes at short-term, intermediate and long-term follow-up. The GRADE approach (GRADE, Grading of Recommendations Assessment, Development and Evaluation) was used to determine the quality of evidence. In total, 37 randomised controlled trials met the inclusion criteria and were included in this overview. Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. The authors conclude that evidence from randomised controlled trials demonstrated that exercise therapy is effective at reducing pain and function in the treatment of chronic low back pain. There is no evidence that one particular type of exercise therapy is clearly more effective than others. However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment.

Measuring the global burden of low back pain

Abstract: Low back pain is a major cause of morbidity in high-, middle- and low-income countries, yet to date it has been relatively under-prioritised and under-funded. One important reason may be the low ranking it has received relative to many other conditions included in the previous Global Burden of Disease studies, due in part to a lack of uniformity in how low back pain is defined and a paucity of suitable data. We present an overview of methods we have undertaken to ensure a more accurate estimate for low back pain in the Global Burden of Disease 2005 study. This will help clinicians to contextualise the new estimates and rankings when they become available at the end of 2010. It will also be helpful in planning further population-based epidemiological studies of low back pain to ensure their estimates can be included in the future Global Burden of Disease studies.

Lumbar Spinal Stenosis

Abstract: Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to advanced imaging and to an ageing population. This review focusses on radicular symptoms related to degenerative central and lateral stenosis and updates knowledge of LSS pathophysiology, diagnosis and management. Since patients with anatomic LSS can range from asymptomatic to severely disabled, the clinical diagnosis focusses on symptoms and examination findings associated with LSS. Imaging findings are helpful for patients with persistent, bothersome symptoms in whom invasive treatments are being considered. There is limited information from high-quality studies about the relative merits and demerits of commonly used treatments. Interpreting and comparing results of available research are limited by a lack of consensus about the definition of LSS. Nevertheless, evidence supports decompressive laminectomy for patients with persistent and bothersome symptoms. Recommendations favour a shared decision-making approach due to important trade-offs between alternative therapies and differences among patients in their preferences and values.

How important are back pain beliefs and expectations for satisfactory recovery from back pain

Abstract: 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.

What is the prognosis of back pain

Abstract: 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.

Epidemiology of gout: an update

Abstract: Gout is the most common inflammatory joint disease in men, characterised by formation of monosodium urate (MSU) crystals in the synovial fluid of joints and in other tissues. The epidemiology of gout provides us with the understanding of the disease distribution and its determinants. In an attempt to update the knowledge on the topic, more recent research reports on the descriptive epidemiology of gout are reviewed in this article. The review describes clinical characteristics and case definitions of gout, including the Rome and New York diagnosis criteria of gout, '1977 American Rheumatism Association (ARA) criteria' and the 10 key propositions of the European League Against Rheumatism (EULAR) recommendations. Gout incidence, prevalence, morbidity and mortality, geographical variation of the disease, relevant risk factors for both the occurrence and outcome of gout and trends of the disease over time are then described. Difficulties in obtaining the information and data reported are also discussed.

Targeting subchondral bone for treating osteoarthritis: what is the evidence?

Abstract: Over the past few decades, significant progress has been made with respect to new concepts about the pathogenesis of osteoarthritis (OA). This article summarises some of the knowledge we have today on the involvement of the subchondral bone in OA. It provides substantial evidence that changes in the metabolism of the subchondral bone are an integral part of the OA disease process and that these alterations are not merely secondary manifestations, but are part of a more active component of the disease. Thus, a strong rationale exists for therapeutic approaches that target subchondral bone resorption and/or formation, and data evaluating the drugs targeting bone remodelling raise the hope that new treatment options for OA may become available.

The role of biomechanics in the initiation and progression of OA of the knee

Abstract: The knee is one of the most common joints affected by osteoarthritis (OA), frequently with clinical presentation by middle age or even earlier. Accumulating evidence supports that knee OA progression is often driven by biomechanical forces, and the pathological response of tissues to such forces leads to structural joint deterioration, knee symptoms and reduced function. Well-known biomechanical risk factors for progression include joint malalignment and meniscal tear. The high risk of OA after knee injury demonstrates the critical role of biomechanical factors also in incident disease in susceptible individuals. However, our knowledge of the contributing biomechanical mechanisms in the development of early disease and their order of significance is limited. Part of the problem is our current lack of understanding of early-stage OA, when it starts and how to define it.

Treatment-based subgroups of low back pain: A guide to appraisal of research studies and a summary of current evidence

Abstract: 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.

Prevention and management of chronic back pain.

Abstract: Low back pain is prevalent, and both debilitating for the patient and costly for society if it becomes a chronic condition. The initial prognosis at the onset of low back pain is positive, however the rate of recurrence is high and about 20% of patients seeking care develop a chronic problem that may or may not lead to disability. The main message, based on the best evidence, is that keeping active despite low back pain is "healthy". A large portion of patients seeking care can manage their short term and even longer term incapacity. However, for those who cannot manage their pain, significant relief can be found in a variety of conservative treatments. Passive treatment should be kept to a minimum as evidence shows that active treatments are more effective for improving function and return to work. There is evidence that identifying psychosocial symptoms and barriers, and referral to appropriate interventions improves outcomes. There are currently no clear indications for surgery in nonspecific low back pain.

Inhibition of JAK kinases in patients with rheumatoid arthritis: scientific rationale and clinical outcomes

Abstract: CP-690,550 is an orally active and selective inhibitor of the janus kinase (JAK) molecules. The molecular pathways through which the JAK moieties function are described along with the clinical mechanisms associated with their inhibition. Animal models of JAK inhibition are reviewed as a background for the possible inhibition of JAK in humans. The pharmacokinetics of CP-690,550 in humans is described, and the Phase IIA and IIB trials are reviewed in some detail. These trials were dose-ranging and showed a general dose response with relatively robust American College of Rheumatology 20 (ACR20) responses. A proof-of-concept 6-week trial in which CP-690,550 was given as monotherapy was associated with highly efficacious responses at the mid and higher twice-daily dose ranges employed. A subsequent 24 week dose-ranging trial in which CP-690,550 was administered in combination with methotrexate showed ACR20 responses, which were also statistically significant versus placebo interventions. CP-690,550 treatment was associated with side effects, which included headache and nausea. Infections were more common versus placebo as were elevations in transaminase enzymes when administered in combination with methotrexate, and increases in low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol. Decreases in haemoglobin and white blood cell (WBC) counts were also observed along with small increases in serum creatinine. Occasional significant decreases of haemoglobin (>2gdl −1 ) were observed, although decreases of WBC to less than 1000 per mm 3 were not seen. Plans for long-term follow-up of the described trials are described along with the features of five presently ongoing Phase III trials of the CP-690,550 janus kinase (JAK) inhibitor. Future directions include completion and publication of these trials along with study of JAK inhibition for other indications.

Epidemiology of systemic sclerosis

Abstract: Systemic sclerosis (SSc) is a multisystem auto-immune disease. The two main subtypes of SSc (limited and diffuse) typically have differing courses and prognoses. New classification criteria have been proposed to identify SSc in the earliest stages, before skin involvement. Over the past three decades, there has been an apparent increase in the incidence of SSc to approximately 20 per million, possibly due to improved diagnosis. The most extensively studied environmental associations of SSc are organic solvents and silica but no single risk factor has emerged. Recent genetic studies have identified new susceptibility factors including human leucocyte antigen (HLA) haplotypes and polymorphisms in immune regulatory genes. Despite earlier disease recognition and effective treatment for some of its complications, SSc still carries a high mortality, particularly due to cardiorespiratory complications. Although some predictors of organ involvement and outcomes have been identified, novel biomarkers are greatly needed. Due to low disease prevalence, large multicentre research collaborations are required.

Non-pharmacological approaches for the treatment of osteoarthritis

Abstract: 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.

Systemic lupus erythematosus.

Abstract: Systemic lupus erythematosus (SLE) is one of the most diverse autoimmune diseases as it may affect any organ in the body and display a broad spectrum of clinical and immunological manifestations. Epidemiological studies have identified marked differences in the prevalence and course of SLE between genders, and across different ages, races and geographic locations. Methodological differences between studies may account for some of the disparity seen. Additionally, some insights into possible environmental risk factors for SLE have also been provided. As this condition is relatively uncommon, multifactorial, and largely influenced by genetic predisposition, it is inherently difficult to confirm or exclude infectious or environmental contributors to its etiology. Movement of people between communities and defining specific exposures can also be problematic. Despite these limitations, ongoing observation of SLE cohorts in multiple countries and settings, along with large international cooperative efforts in recent years, have helped clarify the risks of SLE in various groups and have defined marked differences in the worldwide occurrence of the disease.

Osteoporosis and fragility fractures

Abstract: The prevalence of osteoporosis is expected to increase with the ageing of the world’s population. This article reviews the epidemiology, risk factors and health burden of osteoporosis. In the Global Burden of Disease (GBD) Study 2005, osteoporosis is studied as a risk factor for fracture by considering the bone-mineral-density (BMD) measurement as the continuous exposure variable. We have performed a systematic review seeking population-based studies with BMD data measured by dual-X-ray absorptiometry (DXA). The femoral neck was selected as the unique location and all values were converted into Hologic® to enable inclusion of worldwide data for analysis. Provisional results on mean BMD values for different world regions are shown in age breakdowns for males and females 50 years or over, as well as mean T-scores using the young, white, female reference of National Health and Nutrition Examination Survey (NHANES) III. Results show remarkable geographical differences and a time trend towards improvement of the BMD values in Asian and European populations.

Classification criteria for psoriatic arthritis and ankylosing spondylitis/axial spondyloarthritis

Abstract: The concept of spondyloarthritides (or spondyloarthropathies, SpAs) that comprises a group of interrelated disorders has been recognised since the early 1970s. While the European Spondyloarthropathy Study Group (ESSG) criteria and the Amor criteria have been developed to embrace the entire group of SpAs, new criteria for psoriatic arthritis have been developed recently. The Classification of Psoriatic Arthritis (CASPAR) study, a large one of more than 1000 patients, led to a new set of validated classification criteria for psoriatic arthritis. Since their publication in 2006 the CASPAR criteria are widely used in clinical studies. In ankylosing spondylitis, the 1984 modified New York criteria have been used widely in clinical studies and daily practice but are not applicable in early disease when the characteristic radiographical signs of sacroiliitis are not visible but active sacroiliitis is readily detectable by magnetic resonance imaging (MRI). This led to the concept of axial SpA that includes patients with and without radiographical damage; candidate criteria for axial SpA were developed based on proposals for a structured diagnostic approach. These criteria were validated in the Assessment of Spondyloarthritis International Society (ASAS) study on new classification criteria for axial SpA, a large international prospective study. In this new criteria, sacroiliitis showing up on MRI has been given as much weight as sacroiliitis on radiographs, thereby also identifying patients with early axial SpA. Both the CASPAR and the ASAS criteria for axial SpA are likely to be of use as diagnostic criteria.

Targeting the synovial tissue for treating osteoarthritis (OA): where is the evidence?

Abstract: Osteoarthritis (OA) is often a progressive and disabling disease, which occurs in the setting of a variety of risk factors--such as advancing age, obesity and trauma--that collude to incite a cascade of pathophysiological events within joint tissues. An important emerging theme in OA is a broadening of focus from a disease of cartilage to one of the 'whole joint.' The synovium, bone and cartilage are each involved in pathological processes that lead to progressive joint degeneration. Additional themes that have emerged over the past decade are novel mechanisms of cartilage degradation and repair, the relationship between biomechanics and biochemical pathways, the importance of inflammation and the role of genetics. In this article, we review the molecular, clinical and imaging evidence that synovitis is not an 'incidental finding of OA', but plays a significant role in disease pathogenesis, and could therefore represent a target for future treatments.

Back pain and work

Abstract: Low back pain is a leading cause of work disability and constitutes a significant socioeconomic burden worldwide. In an attempt to stem the serious consequences of long-term disability, a new approach for back pain in primary care is being disseminated. It mainly focusses on identifying the relationship between pain/disability and work, recognising important workplace and psychosocial issues, providing patients reassuring messages about activity, facilitating the return to work process and engaging other resources as needed. This article examines current expert opinion and available evidence on work issues for effective back pain management. In general, return to work, if safe, is beneficial for recovery and well-being. Some cases might require physicians to actively communicate with employers, claims managers and others in order to achieve safe and sustained return to work, while in most instances, simple efforts to identify and discuss work issues directly with the patient can lead to better work outcomes.

Addressing patient beliefs and expectations in the consultation

Abstract: 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.

Imaging the joint in osteoarthritis: a place for ultrasound?

Abstract: 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.

Evidence-based management of rapidly progressing systemic sclerosis.

Abstract: Systemic sclerosis has the highest case-specific mortality of any of the auto-immune rheumatic diseases, as well as causing major morbidity. It is a major clinical challenge and one that has previously provoked substantial nihilism due to the limited therapeutic options available and the perceived lack of evidence for clinical effectiveness of those treatments that are currently in use. However, this situation is changing; there are emerging data supporting efficacy for some treatment approaches for this patient group together with a growing number of exciting potential novel approaches to treatment that are moving into the clinical arena. Some of the recent clinical trials are reviewed and discussed in detail.

Can we stop progression of ankylosing spondylitis

Abstract: Ankylosing spondylitis is characterised by inflammation of the spine and the entheses followed by bone formation. Excessive bone formation in ankylosing spondylitis leads to the formation of bone spurs, such as syndesmophytes and enthesiophytes, which contribute to ankylosis of joints and poor physical function. This process is based on increased differentiation of osteoblasts from their mesenchymal precursors, which allows to rapidly build up new bone. Prostaglandins, bone morphogenic proteins and Wnt proteins play an essential role in this process. By contrast, tumour necrosis factor (TNF) does not appear to be the direct trigger for osteophyte formation in ankylosing spondylitis. The article reviews the current knowledge regarding the mechanisms and clinical role of ankylosis and explains strategies on how to prevent it in patients with ankylosing spondylitis.

Epidemiology of large-vessel vasculidities.

Abstract: The systemic vasculitides are multisystem disorders characterised by the inflammation of blood vessels and tissue necrosis. Classified by the size of the vessels affected, the large vessel vasculitides include giant cell arteritis (GCA) and Takayasu's arteritis (TA). These are anatomically, epidemiologically and clinically distinct conditions. They are often associated with considerable morbidity and mortality. The classification of vasculitis has been an area of controversy for many years and current classification criteria remain suboptimal. Although intensive efforts are under way to improve them, a further understanding of the aetiology and pathogenesis of these diseases is required to develop more sensitive and specific diagnostic tests. These efforts, however, have been hampered by the low prevalence of these diseases. The establishment of national and international registries is encouraged to enhance valuable data collection. These are anatomically, epidemiologically and clinically distinct conditions. This article summarises the current classification systems for systemic vasculitis and their limitations. We also review the presently known epidemiology, risk factors and morbidity and mortality associated with GCA and TA.

How to measure the impact of musculoskeletal conditions.

Abstract: Musculoskeletal conditions are universally prevalent among all age and gender groups, across all socio-demographic strata of society. Their impact is pervasive yet this is not widely recognised at the level of health policy and priority. Musculoskeletal conditions are a diverse group of disorders with regard to pathophysiology but are linked anatomically and by their association with pain and impaired physical function; encompassing a spectrum of conditions, including inflammatory diseases such as rheumatoid arthritis or gout; age-related conditions such as osteoporosis and osteoarthritis; common conditions of unclear aetiology such as back pain and fibromyalgia; and those related to activity or injuries such as occupational musculoskeletal disorders, sports injuries or the consequences of falls and major trauma. The increasing number of older people and the changes in lifestyle throughout the world with increasing obesity and reduced physical activity mean that the burden on people and society will increase dramatically. The growing awareness of the burden increases the need for accurate measurement and assessment of the burden as well as measurement of the impact of any public health action. This chapter considers theoretical and practical issues relevant to measuring the buden of musculoskeltal conditions in populations, societies and individuals.

Inflammatory osteoarthritis of the hand

Abstract: Inflammatory or erosive are terms used interchangeably to define a clinical subset of osteoarthritis of the hand (HOA), targeting interphalangeal joints and characterised by an abrupt onset, marked pain and functional impairment, inflammatory symptoms and signs, including stiffness, soft tissue swelling, erythema, paraesthesiae, mildly elevated C-reactive protein and a worse outcome than non-erosive HOA This subset is defined radiographically by subchondral erosion, cortical destruction and subsequent reparative change, which may include bony ankylosis Although the presence of both clinical and radiographic aspects are very suggestive for the diagnosis in most cases, doubts have been recently raised from some studies which, by means of sensitive imaging techniques such as magnetic resonance imaging (MRI) and sonography, had found erosive changes in most patients with HOA, including those without signs of erosions at conventional radiography However, many findings suggest that subjects with erosive HOA exhibit more inflammatory features than those with non-erosive HOA in different ways, including clinical, laboratory and sonographic aspects Thus, it is probably preferable to use the double term inflammatory/erosive to better define this particular subset of HOA

Arthroscopy as a Treatment for Knee Osteoarthritis

Abstract: Since surfaces become irregular and debris from cartilage and meniscus gets released into the joint cavity of osteoarthritic joints, washing away this debris and attendant crystals, smoothing rough surfaces and repairing tears might help patients with disease. Such interventions are accomplished during an arthroscopy, when a fibre-optic endoscope and surgical instruments are inserted into the knee. While initial uncontrolled case series suggested that arthroscopy alleviated pain in patients with osteoarthritis, large randomised trials have suggested that arthroscopy has a limited role as a treatment of osteoarthritis.

Developing a minimum standard of care for treating people with osteoarthritis of the hip and knee.

Abstract: 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.